Trust-building factors in Patient‒Physician relationship: a qualitative study

Trust-building factors in Patient‒Physician relationship: a qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Trust-building factors in Patient‒Physician relationship: a qualitative study Milad Gharehbaghi, Pooneh Salari, Shahriar Hasannia, Amirahmad Shojaei This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6115413/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Apr, 2025 Read the published version in Middle East Research Journal of Medical Sciences → Version 1 posted You are reading this latest preprint version Abstract Trust-building factors in Patient‒Physician relationship: a qualitative study. Background : Trust plays a significant role in establishing patient‒physician relationships. This study, as part of a deeper investigation, aimed to determine trust-building factors in patient‒physician relationships. Methods: This qualitative study included a literature review, group discussions, semistructured interviews, and data analysis. From spring 2019 to 2022, we conducted literature reviews, focus group discussions (FGDs), semistructured interviews, and thematic analysis. In the summer of 2021, we conducted 8 FGDs and interviewed 42 participants from Tehran University of Medical Sciences. The data were analyzed, and the results were classified. Results: The statements were categorized into internal and external factors affecting trust. Internal factors arise directly from patient‒physician interactions. External factors include global trust, media influence, the Ministry of Health and other sources. Hence, 12 internal factors and three external factors were identified. Conclusion: Internal and external factors influencing trust in the patient‒physician relationship were identified. Improving external factors requires societal efforts, whereas internal factors can be addressed through enhanced academic courses. Moreover, these 15 factors could inform future questionnaires measuring trust. Interpersonal relationship Iranian patients Medical ethics Relationship factors Tehran trust evaluation Figures Figure 1 Introduction Why do we trust? The significance of trust in interpersonal relationships cannot be overstated. It is often said that without trust, society cannot thrive. In healthcare, trust is crucial, as it reflects patients' willingness to rely on their physicians for medical care. Patients must trust healthcare providers, even if they do not have strong personal bonds. This enables doctors to provide accurate information, safeguard personal data, deliver good care, and act in patients’ best interests. Without trust, patients may not feel comfortable sharing sensitive information or following medical advice, potentially leading to poor health outcomes. 1 , 2 Acknowledging the critical role of trust in healthcare interactions raises the following question: When do we trust a doctor? Several factors contribute to establishing trust in the patient‒physician relationship, including honesty, competency, and communication. Effective communication goes beyond conveying information accurately; it also entails actively listening and showing empathy. 2 , 3 Measuring trust in a clinical setting is challenging because of its subjective nature, which heavily relies on patients’ perceptions and expectations. 4 Many studies have investigated healthcare trust and developed tools to measure trust levels. Qualitative research methods such as focus group discussions and personal interviews are valuable for understanding aspects of trust. 5 The historical and cultural context of healthcare in Iran is deeply rooted in ancient traditions and religious practices. Nonetheless, much of the ancient knowledge about the trust between patients and physicians and its teaching was lost in Iran during the early Islamic period because of the destruction of non-Koranic texts. During the Islamic period, Iranian physicians such as Avicenna allocated parts of their books to discussing medical ethics. The modernization of medical education in Iran, particularly with the establishment of the Faculty of Medicine at Tehran University in 1934, led to the integration of medical ethics into formal training. The establishment of the Medical Ethics Research Center and Medical Ethics Research Committees at the national level in the 1990s significantly increased the emphasis on ethical practices, especially within universities across Iran. Recent reforms in medical ethics courses for undergraduate students underscore the evolving recognition of ethical considerations in medical education throughout the country. Currently, Iranian medical universities are offering 2 credit courses in medical ethics to their students. However, challenges persist, including a historical paternalistic approach among Iranian physicians, which negatively impacts trust. 6 , 7 Additionally, research has reported low levels of public trust in the healthcare system during crises such as the COVID-19 pandemic in Iran. 8 , 9 Studies have highlighted the need to address these trust-related issues effectively through a comprehensive revision of the curriculum across undergraduate medical courses. 10 Despite its historical and cultural richness, Iran's healthcare system faces significant challenges in maintaining public trust. Although extensive research on trust in patient‒physician relationships exist globally, studies focusing on Iran are lacking. This gap is critical, given the unique cultural and social dynamics affecting healthcare trust in the region. By identifying key trust factors in Iran's healthcare system, this study aims to inform targeted interventions, ultimately improving patient outcomes and healthcare quality. Methods 1. Procedure This study aims to identify and analyze trust-building factors in patient‒physician relationships through an exploratory qualitative design. 11 This process included four phases of literature review 12 , focus group discussions (FGDs), 13 semistructured interviews, 14 and thematic analysis, 15 which were conducted from the spring of 2019–2022. 2. Researcher characteristics The research team consisted of medical students (MG, SH) and academic members (PS, AS) from a research institute. The team included one female member. All the researchers were involved in all the phases of the study except for the interviews, which were performed by AS and MG. To facilitate this, MG received training supervised by AS. The training included attending preparation sessions for open-ended interviews and conducting practice interviews with members of the institute. The research team explored the diverse aspects of trust-building factors in the patient‒physician relationship. Selection and identification of cases 1. Context and sampling strategy Physicians, medical ethicists, and psychologists were selected from the attending professors at the university. Nonmedical experts were eligible if they 1) had at least a bachelor’s degree and 2) worked at medical centers. Patient interviewees were chosen randomly during their visits to Tehran University hospital clinics (Imam Khomeini Hospital and Sina Hospital) over two months. The sample included outpatients who were not cognitively impaired. The exclusion criteria were children and patients who could not make health-related decisions due to their age-related illness and mental or neurologic disorders. All participants were chosen through convenience sampling. A convenience sample is taken from a source that is easily available. Research carried out on a convenience sample can exhibit strong internal validity if the results are trustworthy. However, such a study’s external validity might be restricted because the findings may not accurately reflect the entire population. 16 We chose convenience sampling because, despite its disadvantages, it is appropriate for exploratory research, where the goal is to gain an initial understanding, and it is cost- and time-efficient. The interviews continued until data saturation was achieved. Data saturation is a standard approach in qualitative research to determine the required sample size for sufficient data. This occurs when new data collection stops producing new information, indicating redundancy. This means that when the data have been analyzed, no new information is found, and further data collection is unnecessary. Its stopping criterion was conducted on the basis of the sample size suggestion of Francis et al. 17 2. Ethical issues Before each phase, we explained the study's purpose and reassured participants of their confidentiality and voluntary participation. Verbal informed consent was obtained, and participants' voices were recorded with permission and then transcribed and deleted to ensure anonymity. Ethical approval was obtained from the ethics committee. Technical Information 1. Data collection instrument We searched Google Scholar and PubMed via combinations of keywords such as 'patient', 'physician', 'doctor', and 'trust'. We limited our search to journal articles published in English from 2010–2021, resulting in 116 relevant articles after screening abstracts for relevancy. Our goal was to extract factors affecting trust to build our knowledge to discuss trust and the factors affecting it in FGDs and consequently sharpen our focus on the interview questions. The Wake-Forest Trust Scale 18 dimensions, including fidelity, competence, honesty, and confidentiality, were used as the primary aspects of trust discussed in the subsequent phases. This scale is a tool designed to measure patients’ trust in their healthcare provider and consists of items that are rated on a 10-point Likert scale. 19 2. Data collection methods 2.1 Group Discussions Each group participated in two focused group discussions (FGDs), so 8 FGD sessions were conducted. Two principal investigators facilitated the meetings. In all the FGDs, the purpose of the study was illuminated, and the participants could respond spontaneously. FGDs aimed to explore the nature of trust in the patient‒physician relationship, the factors affecting it, and the measurements that could improve patient‒physician trust. The participants evaluated each other’s viewpoints and discussed the dimensions affecting trust. In addition, some mentioned which approach might improve or impair patient‒physician trust and the current trust situation in Iran. Each session continued until data saturation, which lasted approximately 2 hours, and each group took part in 2 sessions (each group cooperated for 4 hours). 2.2. Interviews The interviews included in-depth semistructured interviews, starting with open-ended questions that aimed to assess major components of establishing trust. The interviewers had two principal investigators and a medical student as a research assistant. At the beginning of each interview, the purpose of the study was clarified, explaining the importance of extracting trust-building factors. Each interview session usually lasted 90–120 minutes. Table 1 shows the five sets of questions presented in the questionnaire. Table 1 Questionnaire Q1 Which factors influence patients’ trust in physicians in Iran? Which ones do you think are the most important? Q2 Which characteristics [of physicians] affect patient trust? Which of them might have a negative or positive influence on the patient‒physician relationship? Q3 Which organizations could affect patient trust? How are they affecting trust? Q4 What can physicians do to increase patient trust levels? Q5 What should we ask the participants if we want to evaluate and measure trust in Iran in the future? We conducted probes to clarify the questions and asked the participants to provide more details and speak about their personal experiences, if any. The interviews continued until data saturation was reached. 3. Units of study The interview participants included 23 physicians, 9 nonmedical experts, and 10 patients visiting Tehran University of Medical Sciences hospitals in the fall of 2021. The participants ranged in age from 35 to 68 years, and their demographic details are provided in Table 2. In the 8 FGDs, 22 participants formed separate groups of physicians, medical ethicists, psychologists, and nonmedical experts with at least a bachelor’s degree who worked at medical centers, and the sessions were held at the Medical Ethics and History of Medicine Research Center. Table 2 Demographic characteristics of the interview participants Participants Female (No.) Male (No.) Age (mean ± SD) Doctors 45.65 ± 8.59 Internists 1 1 Surgeons 1 1 Pediatricians 1 1 Ophthalmologists 1 1 Otolaryngologists 1 1 Dermatologists 1 1 Gynecologists 1 1 Physiotherapists 1 1 General Practitioners 1 1 Medical Ethics Specialists 2 3 Non-Medical Experts 5 4 45.37 ± 5.56 Patients 5 5 58.20 ± 8.17 Statistical analyses 1. Data processing and analysis We used a hybrid approach (deductive/inductive) to code the gathered information. This method involves employing predetermined themes derived from the literature, representing the deductive aspect. Additionally, it involves identifying themes directly from the collected data, reflecting the inductive element. 20 The contents discussed in the interviews were analyzed by a team of Tehran University professors, including a medical ethics specialist, four physicians, and two sociologists. After the FGDs and interviews were transcribed verbatim, 484 sentences were obtained. The data from the FGDs and interviews were transcribed and subjected to thematic analysis to identify recurring themes and patterns related to trust-building factors. We assigned codes to segments of text that represented similar ideas or concepts. A coding framework was developed on the basis of these patterns, covering factors such as physician expertise, empathy and trust-building strategies. Afterward, related codes were grouped into broader themes to capture overarching concepts within the data. Furthermore, subthemes were developed to categorize themes into specific aspects, providing additional detail to the analysis. Figure 1 illustrates how we categorized a quote from the interview by coding. Finally, the findings were reported by summarizing the main themes and subthemes. Table 3 shows a summary of these and their key quotes. Table 3 The internal and external factors of trust Internal factors Key quotes Themes Subthemes Competence 1- Expertise “Competency is the most vital factor affecting trust.” “Not listening is a terrible habit which makes me - and I think everyone - feel like left out…” 2- Communication skills Empathy Compassion “He greeted me with a warm smile and took time to sit down and listen to my concerns and questions.” Allocating appropriate time to patients “Because of the low visit cost, doctors might not pay enough attention in their visit.” Accountability Responsibility “Some doctors don’t answer patients’ questions” Respectfulness 1- Caring about patients’ time “Respect plays a vital role in developing trust.” “A doctor’s fame is based on the number of patients in their waiting room. They sometimes do it deliberately.” 2- Inconveniently high waiting time Unprofessional relationship 1- Romantic relationship “Some of the physicians might abuse and manipulate patients.” 2- Sexual harassment 3- Paying more attention to wealthier patients Confidentiality Privacy “The information must be kept confidential and rarely shared with authorized individuals.” Honesty “Instead of painting an overly optimistic picture, doctors should choose honesty.” Conflict of interest Receiving gifts “Many physicians cooperate with a specific lab; It’s important to clarify this ‘cooperation’.” Autonomy Giving sufficient information to patients “Autonomy is generally accepted worldwide and always leads to a better trust-building” Unnecessary diagnostic equipment and treatment “The number of cesarean sections and rhinoplasty operations has increased.” Medical errors “Not only physicians usually don’t accept their mistakes, they rarely admit to them.” External factors The Media Social media National TV “Sharing doctors’ medical errors [on social media] isn’t necessarily bad since most of them apologize and try to make amends for their actions.” Medical organizations Medical Council The Ministry of Health “The Medical Council usually punishes the liable physicians much less than they should be.” Global trust “Patients’ trust is influenced by how people think about the doctors in that region.” 2. Techniques to enhance trustworthiness To increase the trustworthiness of our data, we employed “member checking”. During member checking, researchers share their findings with participants to ensure that they are accurate. This helps show that the research reflects different viewpoints, and it is a vital technique to ensure the credibility of the data. 21 Although we could only check in half of the interviewees, as the other half had busy schedules, everyone in the FGDs took part in member checking and reviewing the research work. 3. Reporting Our reporting followed the Standards for Reporting Qualitative Research (SRQR) guidelines, which ensure transparency, rigor, and comprehensive reporting in qualitative research. 22 Results/Discussion This study was conducted as part of a broader investigation aimed at measuring patient‒physician trust and understanding the influencing factors from physicians’ perspective. We conducted interviews with a total of 64 participants, including 22 members of FGDs and 42 interviewees. Through our analysis, we identified 15 factors affecting trust. To enhance clarity, we categorized these factors as either internal or external, depending on their associations with doctors’ behaviors and actions. This process allowed us to distill the themes into 12 internal and 3 external factors, as elaborated in Table 3 . Internal aspects revolve around physician traits such as fidelity, honesty, competency, and confidentiality. These factors are fundamental in building and maintaining trust between patients and healthcare providers. Academic courses focusing on medical ethics can significantly contribute to enhancing these traits among medical students and physicians. In Iran, medical ethics have always held a prominent position. This is evident from the Sassanian era (3rd to 7th AD), when Iranian medicine experienced notable advancements. The establishment of Gondishapur Academy during this period marked a significant milestone in medical education in the region. Ethics holds a significant place in academics, emphasizing the importance of ethical conduct among students. 23 During the Islamic period, noteworthy figures such as Razi (865–925 AD) and Abu Ali Sina (Avicenna) (981–1037) contributed significantly through their works and writings to the understanding and promotion of ethics in medicine in Iran. 24 , 25 The evolution of medical education in Iran continued with the establishment of the first college of medicine, Dar ul-Funoon, in the nineteenth century. This marked a significant development in structured medical training within the country. 26 During the Pahlavi dynasty (1925–1979), Iran underwent significant modernization and Westernization across various aspects of society, including medicine and healthcare. This period included reforms in medical education, healthcare systems, and the establishment of new medical schools and hospitals. Ethical codes and principles became integral to medical practice, and medical students were expected to adhere to these codes and principles in their interactions with patients, colleagues, and the healthcare system. 27 In 1963, Dr. M.N. Etemadian authored “Medical Ethics and Customs,” which provided a comprehensive exploration of ethical issues in healthcare. The book delved into various topics, such as the doctor‒patient relationship, confidentiality, abortion, and euthanasia, and offered thorough discussions and insights into these ethical considerations. Following the Islamic Revolution in 1979, there was an emphasis on Islamic principles in various sectors, including medicine. This led to changes in the healthcare system and medical education to align with Islamic values. The National Committee of Ethics in Education of Medical Sciences, established in 2016, oversees ethics education in medical sciences across Iran. There are significant shortcomings in ethics education within the medical curriculum, including the absence of ethics in some curricula and a shortage of qualified ethics instructors. 10 We discuss the themes and trust-building factors with quotes that our interviewers provided. More quotes can be found in Table 3 . Competence, empathy and spending enough time A doctor’s experience and ability to explain medical conditions in a clear manner impacts my trust in them greatly. Almost everyone indicated that competency is crucial in building trust; however, our respondents perceived a decline in physicians’ skills and knowledge. “Communication skills”, including listening, are also linked to competence and better outcomes. Howe et al. also emphasized the importance of competence and warmth in patient‒physician interactions: competence may establish trust between patients and providers, and it is so effective that it boosts the placebo response in patients. 28 Doctors don’t understand patients’ situation sometimes… When doctors take the time to listen to me and examine me, I feel more confident in their skills. Iranian culture values interpersonal relationships and empathy. Additionally, medical education typically includes training in communication skills and patient-centered care. However, as in many other countries, Iranian doctors face challenges such as heavy workloads, time constraints, and resource limitations. The respondents believed that these factors impact the delivery of empathetic care. A study in China revealed that patients’ perceptions of a physician’s empathy directly affect their evaluation of the relationship. 29 This highlights how crucial it is for patients to believe that their doctor is kind and understanding to build trust. Accountability, autonomy and conflicts of interest Her (the doctor’s) willingness to take responsibility and keep me informed throughout the process made a significant difference. Accountability is considered an aspect of excellence in social interactions, including in the healthcare environment. In recent years, the emphasis on accountability in the healthcare system of advanced countries has increased because of its effect on performance and quality of care. 30 , 31 The respondents believed that when physicians become irresponsible or unaccountable, their trust in the patient‒physician relationship decreases. In addition, involving patients in their treatment management, while debated, was valuable, especially for physicians during interviews. Autonomy improves care quality, even though some patients might find it confusing. One physician said: I sometimes give them (patients) options to opt for, and then they seem confused, and I’m told, ‘You’re the doctor. How should I know which one is better?’ The health system in Iran is currently advocating for a shared decision-making approach between physicians and patients. However, national TV sometimes promotes TV series or movies that depict paternalistic patient‒physician relationships. 32 Another challenge is cancer diagnosis disclosure: a significant distinction between the Iranian protocol and those employed in Western societies in “Breaking bad news” is the importance of family-centered disclosure culture in Iran. Healthcare professionals often mention that family members pose the primary challenge to diagnosis disclosure, and despite the prevailing culture of nondisclosure, many physicians have a positive stance on directly disclosing a diagnosis to patients. 33 “Some physicians put their interest first, and it is neither acceptable nor delightful… It makes you wonder whether the physician even cares for patients’ needs.” Public disclosure of physician conflicts of interest is a common method for managing financial conflicts; patients desire information on conflicts of interest. Nevertheless, based on this information—for example, increased payment transparency—is associated with decreased patient trust in some studies. 34 , 35 Our respondents were convinced that the physicians should disclose conflicts of interest. Respect, unprofessional behavior and confidentiality … The lack of empathy and respect from the doctor left me feeling frustrated, unheard, and even belittled… I left the appointment with more questions than answers… The bond between patients and healthcare providers is built on trust, where patients not only rely on healthcare providers for care but also share personal and psychological details. Maintaining appropriate boundaries and respecting patient privacy are vital for building trust. In contrast, sharing confidential information without consent can lead to anxiety and distrust. This relationship is, however, fragile due to power imbalances, differing knowledge levels, and the vulnerability of patients. As a result, sexual interaction between a physician and a patient cannot be considered consensual. 36 Our participants believed that an unprofessional patient‒physician relationship, such as a romantic relationship, is a risk of trust and should be avoided. Honesty, unnecessary diagnostic procedures and medical errors “Whatever the reason is to lie, trust gets affected badly… It’s not sincere. It makes the patient feel like they have been manipulated… I think it’s patients’ right to know what’s happening to them”. A range of studies have highlighted the importance of honesty and trust in the patient‒physician relationship. Brenner et al. and Montgomery et al. both underscored the critical role of honesty and transparency in promoting patient safety and trust. 37 , 38 They (operations) usually cost high and are not necessarily indicated. Unnecessary tests have become a common practice in medicine, despite evidence suggesting that they are unnecessary. Doctors may order these tests out of habit or safeguard themselves, particularly in developing countries. 39 However, this can cause misinterpretation, unwarranted suspicions and legal challenges. Moreover, patient mistrust in healthcare can lead to both excessive and insufficient use of medical services, with patients seeking multiple opinions and costly treatments. 40 Medical errors aren’t uncommon in the clinic. Even with advancements in medical education and diagnostic procedures, errors are unavoidable. It is crucial to communicate openly with patients after such incidents to maintain trust. Although the extent of medical errors in Iran has not been well studied, failure to disclose errors is believed to erode trust. External factors Medical students aren’t being screened on the basis of their morality and motivation… The graduate doctors are not efficiently observed. External factors, which are not related to doctors’ individual traits, play a role in influencing trust in healthcare. Healthcare organizations and generalized trust are influenced by cultural, governmental, and administrative factors. Therefore, they need more radical approaches to enhance their level of trust. External factors, such as media, including social media, influence trust by shaping communication and doctor‒patient interactions. Our participants agreed that increased internet accessibility and online content facilitated the evaluation of doctors and the medical system, but its effect on trust was limited. 41 Although the national media has recently praised medical staff’s efforts against COVID-19, it often shows negative images of physicians. Moreover, better accountability and monitoring by the Medical Council and the Ministry of Health are needed to address patient complaints and restore trust in the healthcare system. Generalized trust plays an essential role in how we perceive and judge others. 42 For example, if a region’s view of doctors is positive, people will easily trust them, and vice versa. It varies on the basis of cultural beliefs and organizations in different regions. In conclusion, although external factors might require arduous actions and prolonged time at the social and cultural levels to enhance trust, internal factors can be trained and improved individually and through academic courses. This makes practicing and maintaining internal factors a reasonable goal in an academic environment to be tutored. Limitations The study’s outcomes are limited since it was restricted to Iran, specifically Tehran. Nonetheless, we selected our participants from different faculties and clinics at Tehran University. The study’s generalizability to other populations was limited because of the inclusion of nonrandomized participants and a relatively small population. The convenience sampling of this study restricts the generalizability of the results, and the lack of verification by some of the members may undermine the data’s credibility. To obtain the perfect benefit from the study, it should be further developed. Our final goal is to use the factors affecting trust to investigate trust between patients and physicians in a quantitative study and to comprehend how the factors affect the relationship, especially from physicians’ perspective. Conclusion Trust in medical settings is crucial for a healthy patient‒physician relationship, as it reflects our perceptions of others’ intentions and abilities. This study identified 12 internal factors related to physicians’ traits and 3 external factors affecting trust. The internal factors, rooted in medical professionalism, significantly impact patients’ trust. Increasing physicians’ awareness of these factors and their potential influence is crucial for building trust. This highlights the importance of strengthening medical ethics education for undergraduates. On the other hand, external factors, including organizations and global trust, call for broader measures to effectively uphold trust. Declarations Ethics approval and consent to participate Ethical approval was acquired from the Tehran University of Medical Sciences (TUMS) research ethics committee (approval code IR.TUMS.VCR.REC.1397.957). Verbal informed consent was obtained before the interviews. Consent for publication Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Authors’ contributions MG composed the article, gathered the data, and participated in designing study, analyzing and data interpretation. 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Does Missing Trust Lead to Overuse or Underuse of Health Care Services? Am J Manag Care ; 29, https://www.ajmc.com/view/does-missing-trust-lead-to-overuse-or-underuse-of-health-care-services- (2023). Lu LY, Sheikholeslami N, Alokozai A, et al. The Role of Patient Research in Patient Trust in Their Physician. J Hand Surg Am 2019; 44: 617.e1-617.e9. Evans AM, van de Calseyde PPFM. The Reputational Consequences of Generalized Trust. Pers Soc Psychol Bull 2018; 44: 492–507. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Apr, 2025 Read the published version in Middle East Research Journal of Medical Sciences → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6115413","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":423817776,"identity":"319d9ffa-e3f2-4b82-bafa-4c39e2850359","order_by":0,"name":"Milad Gharehbaghi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYDACZuYGBh6GA0AWDwMDY4OEHEjwwAO8WhhRtRiDtSTgtQZVC0NiA0gQnxbddsbGD29+3ZE3bz978OPXHRbp88MOPwTaYien24Bdi9lhxmbJuX3PDOecyUuWlj0jkbvxdpoBUEuysdkBnFoapHl7DjPOYMgxkJZsA2qZnQDSciBxG24tzb+BWuxn8L8x/g3Ukm44O/0DIS1t0jw/DifOkMgxk/zYJpEgL51D0JY2y7kNh5NnSLxLs2ZskzDcIJ1TcCDBAI9fzh8+fOPNn8O2M/hzD9/82VYnLz87ffOHDxV2cri0gAFjG4RmBkYNgwFYpQEe5WDwB6r1B5CQbyCkehSMglEwCkYaAAAN0GqufNVAuAAAAABJRU5ErkJggg==","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Milad","middleName":"","lastName":"Gharehbaghi","suffix":""},{"id":423817777,"identity":"1f8f6773-0c08-4f07-94a6-4162ea2b31ec","order_by":1,"name":"Pooneh Salari","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Pooneh","middleName":"","lastName":"Salari","suffix":""},{"id":423817778,"identity":"f3d3c3b3-0963-4d55-b244-c01ad3802d4e","order_by":2,"name":"Shahriar Hasannia","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Shahriar","middleName":"","lastName":"Hasannia","suffix":""},{"id":423817779,"identity":"0ebb96b5-806e-4d27-91ea-e6b99a5d607d","order_by":3,"name":"Amirahmad Shojaei","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Amirahmad","middleName":"","lastName":"Shojaei","suffix":""}],"badges":[],"createdAt":"2025-02-26 18:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6115413/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6115413/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.36348/merjms.2025.v05i02.009","type":"published","date":"2025-04-24T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":78246338,"identity":"e2c7c6cc-c86a-4646-976b-43d1147a5c26","added_by":"auto","created_at":"2025-03-11 09:27:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":196391,"visible":true,"origin":"","legend":"\u003cp\u003eAn example of coding.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6115413/v1/52989291c6557d6732bbf297.png"},{"id":82392700,"identity":"762bd734-1c99-4057-9b89-ce44e46a5f61","added_by":"auto","created_at":"2025-05-09 18:53:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":893205,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6115413/v1/d4bc7c8c-d129-4f08-94cd-bf8fae62957c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTrust-building factors in Patient‒Physician relationship: a qualitative study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWhy do we trust? The significance of trust in interpersonal relationships cannot be overstated. It is often said that without trust, society cannot thrive. In healthcare, trust is crucial, as it reflects patients' willingness to rely on their physicians for medical care. Patients must trust healthcare providers, even if they do not have strong personal bonds. This enables doctors to provide accurate information, safeguard personal data, deliver good care, and act in patients’ best interests. Without trust, patients may not feel comfortable sharing sensitive information or following medical advice, potentially leading to poor health outcomes.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Acknowledging the critical role of trust in healthcare interactions raises the following question: When do we trust a doctor?\u003c/p\u003e \u003cp\u003eSeveral factors contribute to establishing trust in the patient‒physician relationship, including honesty, competency, and communication. Effective communication goes beyond conveying information accurately; it also entails actively listening and showing empathy.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMeasuring trust in a clinical setting is challenging because of its subjective nature, which heavily relies on patients’ perceptions and expectations.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Many studies have investigated healthcare trust and developed tools to measure trust levels. Qualitative research methods such as focus group discussions and personal interviews are valuable for understanding aspects of trust.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe historical and cultural context of healthcare in Iran is deeply rooted in ancient traditions and religious practices. Nonetheless, much of the ancient knowledge about the trust between patients and physicians and its teaching was lost in Iran during the early Islamic period because of the destruction of non-Koranic texts. During the Islamic period, Iranian physicians such as Avicenna allocated parts of their books to discussing medical ethics.\u003c/p\u003e \u003cp\u003eThe modernization of medical education in Iran, particularly with the establishment of the Faculty of Medicine at Tehran University in 1934, led to the integration of medical ethics into formal training. The establishment of the Medical Ethics Research Center and Medical Ethics Research Committees at the national level in the 1990s significantly increased the emphasis on ethical practices, especially within universities across Iran. Recent reforms in medical ethics courses for undergraduate students underscore the evolving recognition of ethical considerations in medical education throughout the country. Currently, Iranian medical universities are offering 2 credit courses in medical ethics to their students.\u003c/p\u003e \u003cp\u003eHowever, challenges persist, including a historical paternalistic approach among Iranian physicians, which negatively impacts trust.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Additionally, research has reported low levels of public trust in the healthcare system during crises such as the COVID-19 pandemic in Iran.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Studies have highlighted the need to address these trust-related issues effectively through a comprehensive revision of the curriculum across undergraduate medical courses.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDespite its historical and cultural richness, Iran's healthcare system faces significant challenges in maintaining public trust. Although extensive research on trust in patient‒physician relationships exist globally, studies focusing on Iran are lacking. This gap is critical, given the unique cultural and social dynamics affecting healthcare trust in the region.\u003c/p\u003e \u003cp\u003eBy identifying key trust factors in Iran's healthcare system, this study aims to inform targeted interventions, ultimately improving patient outcomes and healthcare quality.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e1. Procedure\u003c/p\u003e\u003cp\u003eThis study aims to identify and analyze trust-building factors in patient‒physician relationships through an exploratory qualitative design. \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e This process included four phases of literature review\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, focus group discussions (FGDs),\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e semistructured interviews,\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e and thematic analysis,\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e which were conducted from the spring of 2019–2022.\u003c/p\u003e\u003cp\u003e2. Researcher characteristics\u003c/p\u003e\u003cp\u003eThe research team consisted of medical students (MG, SH) and academic members (PS, AS) from a research institute. The team included one female member. All the researchers were involved in all the phases of the study except for the interviews, which were performed by AS and MG. To facilitate this, MG received training supervised by AS. The training included attending preparation sessions for open-ended interviews and conducting practice interviews with members of the institute.\u003c/p\u003e\u003cp\u003eThe research team explored the diverse aspects of trust-building factors in the patient‒physician relationship.\u003c/p\u003e\u003cp\u003eSelection and identification of cases\u003c/p\u003e\u003cp\u003e1. Context and sampling strategy\u003c/p\u003e\u003cp\u003ePhysicians, medical ethicists, and psychologists were selected from the attending professors at the university. Nonmedical experts were eligible if they 1) had at least a bachelor’s degree and 2) worked at medical centers. Patient interviewees were chosen randomly during their visits to Tehran University hospital clinics (Imam Khomeini Hospital and Sina Hospital) over two months. The sample included outpatients who were not cognitively impaired. The exclusion criteria were children and patients who could not make health-related decisions due to their age-related illness and mental or neurologic disorders.\u003c/p\u003e\u003cp\u003eAll participants were chosen through convenience sampling. A convenience sample is taken from a source that is easily available. Research carried out on a convenience sample can exhibit strong internal validity if the results are trustworthy. However, such a study’s external validity might be restricted because the findings may not accurately reflect the entire population.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e We chose convenience sampling because, despite its disadvantages, it is appropriate for exploratory research, where the goal is to gain an initial understanding, and it is cost- and time-efficient.\u003c/p\u003e\u003cp\u003eThe interviews continued until data saturation was achieved. Data saturation is a standard approach in qualitative research to determine the required sample size for sufficient data. This occurs when new data collection stops producing new information, indicating redundancy. This means that when the data have been analyzed, no new information is found, and further data collection is unnecessary. Its stopping criterion was conducted on the basis of the sample size suggestion of Francis et al.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e2. Ethical issues\u003c/p\u003e\u003cp\u003eBefore each phase, we explained the study's purpose and reassured participants of their confidentiality and voluntary participation. Verbal informed consent was obtained, and participants' voices were recorded with permission and then transcribed and deleted to ensure anonymity. Ethical approval was obtained from the ethics committee.\u003c/p\u003e\u003cp\u003eTechnical Information\u003c/p\u003e\u003cp\u003e1. Data collection instrument\u003c/p\u003e\u003cp\u003eWe searched Google Scholar and PubMed via combinations of keywords such as 'patient', 'physician', 'doctor', and 'trust'. We limited our search to journal articles published in English from 2010–2021, resulting in 116 relevant articles after screening abstracts for relevancy.\u003c/p\u003e\u003cp\u003eOur goal was to extract factors affecting trust to build our knowledge to discuss trust and the factors affecting it in FGDs and consequently sharpen our focus on the interview questions. The Wake-Forest Trust Scale\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e dimensions, including fidelity, competence, honesty, and confidentiality, were used as the primary aspects of trust discussed in the subsequent phases. This scale is a tool designed to measure patients’ trust in their healthcare provider and consists of items that are rated on a 10-point Likert scale.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e2. Data collection methods\u003c/p\u003e\n\u003cp\u003e2.1 Group Discussions\u003c/p\u003e\n\u003cp\u003eEach group participated in two focused group discussions (FGDs), so 8 FGD sessions were conducted. Two principal investigators facilitated the meetings. In all the FGDs, the purpose of the study was illuminated, and the participants could respond spontaneously. FGDs aimed to explore the nature of trust in the patient‒physician relationship, the factors affecting it, and the measurements that could improve patient‒physician trust. The participants evaluated each other\u0026rsquo;s viewpoints and discussed the dimensions affecting trust. In addition, some mentioned which approach might improve or impair patient‒physician trust and the current trust situation in Iran. Each session continued until data saturation, which lasted approximately 2 hours, and each group took part in 2 sessions (each group cooperated for 4 hours).\u003c/p\u003e\n\u003cp\u003e2.2. Interviews\u003c/p\u003e\n\u003cp\u003eThe interviews included in-depth semistructured interviews, starting with open-ended questions that aimed to assess major components of establishing trust. The interviewers had two principal investigators and a medical student as a research assistant. At the beginning of each interview, the purpose of the study was clarified, explaining the importance of extracting trust-building factors. Each interview session usually lasted 90\u0026ndash;120 minutes. Table\u0026nbsp;1 shows the five sets of questions presented in the questionnaire.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eQuestionnaire\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQ1 Which factors influence patients\u0026rsquo; trust in physicians in Iran?\u003c/p\u003e\n \u003cp\u003eWhich ones do you think are the most important?\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ2 Which characteristics [of physicians] affect patient trust?\u003c/p\u003e\n \u003cp\u003eWhich of them might have a negative or positive influence on the patient‒physician relationship?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ3 Which organizations could affect patient trust?\u003c/p\u003e\n \u003cp\u003eHow are they affecting trust?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ4 What can physicians do to increase patient trust levels?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ5 What should we ask the participants if we want to evaluate and measure trust in Iran in the future?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eWe conducted probes to clarify the questions and asked the participants to provide more details and speak about their personal experiences, if any. The interviews continued until data saturation was reached.\u003c/p\u003e\n\u003cp\u003e3. Units of study\u003c/p\u003e\n\u003cdiv\u003e\n \u003cp\u003eThe interview participants included 23 physicians, 9 nonmedical experts, and 10 patients visiting Tehran University of Medical Sciences hospitals in the fall of 2021. The participants ranged in age from 35 to 68 years, and their demographic details are provided in Table\u0026nbsp;2.\u003c/p\u003e\n \u003cp\u003eIn the 8 FGDs, 22 participants formed separate groups of physicians, medical ethicists, psychologists, and nonmedical experts with at least a bachelor\u0026rsquo;s degree who worked at medical centers, and the sessions were held at the Medical Ethics and History of Medicine Research Center.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eDemographic characteristics of the interview participants\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eParticipants\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFemale (No.)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMale (No.)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDoctors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.65\u0026thinsp;\u0026plusmn;\u0026thinsp;8.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInternists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgeons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePediatricians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOphthalmologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOtolaryngologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDermatologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGynecologists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysiotherapists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGeneral Practitioners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical Ethics Specialists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNon-Medical Experts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.37\u0026thinsp;\u0026plusmn;\u0026thinsp;5.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58.20\u0026thinsp;\u0026plusmn;\u0026thinsp;8.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003eStatistical analyses\n\u003c/div\u003e\n\u003cp\u003e1. Data processing and analysis\u003c/p\u003e\n\u003cp\u003eWe used a hybrid approach (deductive/inductive) to code the gathered information. This method involves employing predetermined themes derived from the literature, representing the deductive aspect. Additionally, it involves identifying themes directly from the collected data, reflecting the inductive element.\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe contents discussed in the interviews were analyzed by a team of Tehran University professors, including a medical ethics specialist, four physicians, and two sociologists. After the FGDs and interviews were transcribed verbatim, 484 sentences were obtained. The data from the FGDs and interviews were transcribed and subjected to thematic analysis to identify recurring themes and patterns related to trust-building factors. We assigned codes to segments of text that represented similar ideas or concepts. A coding framework was developed on the basis of these patterns, covering factors such as physician expertise, empathy and trust-building strategies.\u003c/p\u003e\n\u003cp\u003eAfterward, related codes were grouped into broader themes to capture overarching concepts within the data. Furthermore, subthemes were developed to categorize themes into specific aspects, providing additional detail to the analysis. Figure\u0026nbsp;1 illustrates how we categorized a quote from the interview by coding.\u003c/p\u003e\n\u003cp\u003eFinally, the findings were reported by summarizing the main themes and subthemes. Table\u0026nbsp;3 shows a summary of these and their key quotes.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eThe internal and external factors of trust\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eInternal factors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eKey quotes\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eThemes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSubthemes\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCompetence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e1- Expertise\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026ldquo;Competency is the most vital factor affecting trust.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;Not listening is a terrible habit which makes me - and I think everyone - feel like left out\u0026hellip;\u0026rdquo;\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e2- Communication skills\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmpathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompassion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;He greeted me with a warm smile and took time to sit down and listen to my concerns and questions.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAllocating appropriate time to patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Because of the low visit cost, doctors might not pay enough attention in their visit.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAccountability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResponsibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Some doctors don\u0026rsquo;t answer patients\u0026rsquo; questions\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eRespectfulness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1- Caring about patients\u0026rsquo; time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u0026ldquo;Respect plays a vital role in developing trust.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;A doctor\u0026rsquo;s fame is based on the number of patients in their waiting room. They sometimes do it deliberately.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2- Inconveniently high waiting time\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eUnprofessional relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1- Romantic relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003e\u0026ldquo;Some of the physicians might abuse and manipulate patients.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2- Sexual harassment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3- Paying more attention to wealthier patients\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConfidentiality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrivacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;The information must be kept confidential and rarely shared with authorized individuals.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHonesty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Instead of painting an overly optimistic picture, doctors should choose honesty.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConflict of interest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReceiving gifts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Many physicians cooperate with a specific lab; It\u0026rsquo;s important to clarify this \u0026lsquo;cooperation\u0026rsquo;.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAutonomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGiving sufficient information to patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Autonomy is generally accepted worldwide and always leads to a better trust-building\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnnecessary diagnostic equipment and treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;The number of cesarean sections and rhinoplasty operations has increased.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical errors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Not only physicians usually don\u0026rsquo;t accept their mistakes, they rarely admit to them.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eExternal factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe Media\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial media\u003c/p\u003e\n \u003cp\u003eNational TV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Sharing doctors\u0026rsquo; medical errors [on social media] isn\u0026rsquo;t necessarily bad since most of them apologize and try to make amends for their actions.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical organizations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedical Council\u003c/p\u003e\n \u003cp\u003eThe Ministry of Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;The Medical Council usually punishes the liable physicians much less than they should be.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGlobal trust\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026ldquo;Patients\u0026rsquo; trust is influenced by how people think about the doctors in that region.\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e2. Techniques to enhance trustworthiness\u003c/p\u003e\n\u003cp\u003eTo increase the trustworthiness of our data, we employed \u0026ldquo;member checking\u0026rdquo;. During member checking, researchers share their findings with participants to ensure that they are accurate. This helps show that the research reflects different viewpoints, and it is a vital technique to ensure the credibility of the data.\u003csup\u003e21\u003c/sup\u003e Although we could only check in half of the interviewees, as the other half had busy schedules, everyone in the FGDs took part in member checking and reviewing the research work.\u003c/p\u003e\n\u003cp\u003e3. Reporting\u003c/p\u003e\n\u003cp\u003eOur reporting followed the Standards for Reporting Qualitative Research (SRQR) guidelines, which ensure transparency, rigor, and comprehensive reporting in qualitative research.\u003csup\u003e22\u003c/sup\u003e\u003c/p\u003e"},{"header":"Results/Discussion","content":"\u003cp\u003eThis study was conducted as part of a broader investigation aimed at measuring patient‒physician trust and understanding the influencing factors from physicians\u0026rsquo; perspective. We conducted interviews with a total of 64 participants, including 22 members of FGDs and 42 interviewees. Through our analysis, we identified 15 factors affecting trust. To enhance clarity, we categorized these factors as either internal or external, depending on their associations with doctors\u0026rsquo; behaviors and actions. This process allowed us to distill the themes into 12 internal and 3 external factors, as elaborated in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eInternal aspects revolve around physician traits such as fidelity, honesty, competency, and confidentiality. These factors are fundamental in building and maintaining trust between patients and healthcare providers. Academic courses focusing on medical ethics can significantly contribute to enhancing these traits among medical students and physicians.\u003c/p\u003e \u003cp\u003eIn Iran, medical ethics have always held a prominent position. This is evident from the Sassanian era (3rd to 7th AD), when Iranian medicine experienced notable advancements. The establishment of Gondishapur Academy during this period marked a significant milestone in medical education in the region. Ethics holds a significant place in academics, emphasizing the importance of ethical conduct among students.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e During the Islamic period, noteworthy figures such as Razi (865\u0026ndash;925 AD) and Abu Ali Sina (Avicenna) (981\u0026ndash;1037) contributed significantly through their works and writings to the understanding and promotion of ethics in medicine in Iran.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe evolution of medical education in Iran continued with the establishment of the first college of medicine, Dar ul-Funoon, in the nineteenth century. This marked a significant development in structured medical training within the country.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e During the Pahlavi dynasty (1925\u0026ndash;1979), Iran underwent significant modernization and Westernization across various aspects of society, including medicine and healthcare. This period included reforms in medical education, healthcare systems, and the establishment of new medical schools and hospitals. Ethical codes and principles became integral to medical practice, and medical students were expected to adhere to these codes and principles in their interactions with patients, colleagues, and the healthcare system.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn 1963, Dr. M.N. Etemadian authored \u0026ldquo;Medical Ethics and Customs,\u0026rdquo; which provided a comprehensive exploration of ethical issues in healthcare. The book delved into various topics, such as the doctor‒patient relationship, confidentiality, abortion, and euthanasia, and offered thorough discussions and insights into these ethical considerations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFollowing the Islamic Revolution in 1979, there was an emphasis on Islamic principles in various sectors, including medicine. This led to changes in the healthcare system and medical education to align with Islamic values. The National Committee of Ethics in Education of Medical Sciences, established in 2016, oversees ethics education in medical sciences across Iran. There are significant shortcomings in ethics education within the medical curriculum, including the absence of ethics in some curricula and a shortage of qualified ethics instructors.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWe discuss the themes and trust-building factors with quotes that our interviewers provided. More quotes can be found in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eCompetence, empathy and spending enough time\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eA doctor\u0026rsquo;s experience and ability to explain medical conditions in a clear manner impacts my trust in them greatly.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlmost everyone indicated that competency is crucial in building trust; however, our respondents perceived a decline in physicians\u0026rsquo; skills and knowledge. \u0026ldquo;Communication skills\u0026rdquo;, including listening, are also linked to competence and better outcomes. Howe et al. also emphasized the importance of competence and warmth in patient‒physician interactions: competence may establish trust between patients and providers, and it is so effective that it boosts the placebo response in patients.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eDoctors don\u0026rsquo;t understand patients\u0026rsquo; situation sometimes\u0026hellip; When doctors take the time to listen to me and examine me, I feel more confident in their skills.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIranian culture values interpersonal relationships and empathy. Additionally, medical education typically includes training in communication skills and patient-centered care. However, as in many other countries, Iranian doctors face challenges such as heavy workloads, time constraints, and resource limitations. The respondents believed that these factors impact the delivery of empathetic care. A study in China revealed that patients\u0026rsquo; perceptions of a physician\u0026rsquo;s empathy directly affect their evaluation of the relationship.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e This highlights how crucial it is for patients to believe that their doctor is kind and understanding to build trust.\u003c/p\u003e \u003cp\u003eAccountability, autonomy and conflicts of interest\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHer (the doctor\u0026rsquo;s) willingness to take responsibility and keep me informed throughout the process made a significant difference.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAccountability is considered an aspect of excellence in social interactions, including in the healthcare environment. In recent years, the emphasis on accountability in the healthcare system of advanced countries has increased because of its effect on performance and quality of care.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e The respondents believed that when physicians become irresponsible or unaccountable, their trust in the patient‒physician relationship decreases. In addition, involving patients in their treatment management, while debated, was valuable, especially for physicians during interviews. Autonomy improves care quality, even though some patients might find it confusing. One physician said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI sometimes give them (patients) options to opt for, and then they seem confused, and I\u0026rsquo;m told, \u0026lsquo;You\u0026rsquo;re the doctor. How should I know which one is better?\u0026rsquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe health system in Iran is currently advocating for a shared decision-making approach between physicians and patients. However, national TV sometimes promotes TV series or movies that depict paternalistic patient‒physician relationships.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Another challenge is cancer diagnosis disclosure: a significant distinction between the Iranian protocol and those employed in Western societies in \u0026ldquo;Breaking bad news\u0026rdquo; is the importance of family-centered disclosure culture in Iran. Healthcare professionals often mention that family members pose the primary challenge to diagnosis disclosure, and despite the prevailing culture of nondisclosure, many physicians have a positive stance on directly disclosing a diagnosis to patients.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Some physicians put their interest first, and it is neither acceptable nor delightful\u0026hellip; It makes you wonder whether the physician even cares for patients\u0026rsquo; needs.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePublic disclosure of physician conflicts of interest is a common method for managing financial conflicts; patients desire information on conflicts of interest. Nevertheless, based on this information\u0026mdash;for example, increased payment transparency\u0026mdash;is associated with decreased patient trust in some studies.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e Our respondents were convinced that the physicians should disclose conflicts of interest.\u003c/p\u003e \u003cp\u003eRespect, unprofessional behavior and confidentiality\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026hellip; The lack of empathy and respect from the doctor left me feeling frustrated, unheard, and even belittled\u0026hellip; I left the appointment with more questions than answers\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe bond between patients and healthcare providers is built on trust, where patients not only rely on healthcare providers for care but also share personal and psychological details. Maintaining appropriate boundaries and respecting patient privacy are vital for building trust. In contrast, sharing confidential information without consent can lead to anxiety and distrust. This relationship is, however, fragile due to power imbalances, differing knowledge levels, and the vulnerability of patients. As a result, sexual interaction between a physician and a patient cannot be considered consensual.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e Our participants believed that an unprofessional patient‒physician relationship, such as a romantic relationship, is a risk of trust and should be avoided.\u003c/p\u003e \u003cp\u003eHonesty, unnecessary diagnostic procedures and medical errors\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Whatever the reason is to lie, trust gets affected badly\u0026hellip; It\u0026rsquo;s not sincere. It makes the patient feel like they have been manipulated\u0026hellip; I think it\u0026rsquo;s patients\u0026rsquo; right to know what\u0026rsquo;s happening to them\u0026rdquo;.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA range of studies have highlighted the importance of honesty and trust in the patient‒physician relationship. Brenner et al. and Montgomery et al. both underscored the critical role of honesty and transparency in promoting patient safety and trust.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey (operations) usually cost high and are not necessarily indicated.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUnnecessary tests have become a common practice in medicine, despite evidence suggesting that they are unnecessary. Doctors may order these tests out of habit or safeguard themselves, particularly in developing countries.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e However, this can cause misinterpretation, unwarranted suspicions and legal challenges. Moreover, patient mistrust in healthcare can lead to both excessive and insufficient use of medical services, with patients seeking multiple opinions and costly treatments.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMedical errors aren\u0026rsquo;t uncommon in the clinic.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEven with advancements in medical education and diagnostic procedures, errors are unavoidable. It is crucial to communicate openly with patients after such incidents to maintain trust. Although the extent of medical errors in Iran has not been well studied, failure to disclose errors is believed to erode trust.\u003c/p\u003e \u003cp\u003eExternal factors\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMedical students aren\u0026rsquo;t being screened on the basis of their morality and motivation\u0026hellip; The graduate doctors are not efficiently observed.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eExternal factors, which are not related to doctors\u0026rsquo; individual traits, play a role in influencing trust in healthcare. Healthcare organizations and generalized trust are influenced by cultural, governmental, and administrative factors. Therefore, they need more radical approaches to enhance their level of trust.\u003c/p\u003e \u003cp\u003eExternal factors, such as media, including social media, influence trust by shaping communication and doctor‒patient interactions. Our participants agreed that increased internet accessibility and online content facilitated the evaluation of doctors and the medical system, but its effect on trust was limited.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e Although the national media has recently praised medical staff\u0026rsquo;s efforts against COVID-19, it often shows negative images of physicians. Moreover, better accountability and monitoring by the Medical Council and the Ministry of Health are needed to address patient complaints and restore trust in the healthcare system.\u003c/p\u003e \u003cp\u003eGeneralized trust plays an essential role in how we perceive and judge others.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e For example, if a region\u0026rsquo;s view of doctors is positive, people will easily trust them, and vice versa. It varies on the basis of cultural beliefs and organizations in different regions.\u003c/p\u003e \u003cp\u003eIn conclusion, although external factors might require arduous actions and prolonged time at the social and cultural levels to enhance trust, internal factors can be trained and improved individually and through academic courses. This makes practicing and maintaining internal factors a reasonable goal in an academic environment to be tutored.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study\u0026rsquo;s outcomes are limited since it was restricted to Iran, specifically Tehran. Nonetheless, we selected our participants from different faculties and clinics at Tehran University. The study\u0026rsquo;s generalizability to other populations was limited because of the inclusion of nonrandomized participants and a relatively small population. The convenience sampling of this study restricts the generalizability of the results, and the lack of verification by some of the members may undermine the data\u0026rsquo;s credibility.\u003c/p\u003e \u003cp\u003eTo obtain the perfect benefit from the study, it should be further developed. Our final goal is to use the factors affecting trust to investigate trust between patients and physicians in a quantitative study and to comprehend how the factors affect the relationship, especially from physicians\u0026rsquo; perspective.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTrust in medical settings is crucial for a healthy patient‒physician relationship, as it reflects our perceptions of others\u0026rsquo; intentions and abilities. This study identified 12 internal factors related to physicians\u0026rsquo; traits and 3 external factors affecting trust. The internal factors, rooted in medical professionalism, significantly impact patients\u0026rsquo; trust. Increasing physicians\u0026rsquo; awareness of these factors and their potential influence is crucial for building trust. This highlights the importance of strengthening medical ethics education for undergraduates. On the other hand, external factors, including organizations and global trust, call for broader measures to effectively uphold trust.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was acquired from the Tehran University of Medical Sciences (TUMS) research ethics committee (approval code IR.TUMS.VCR.REC.1397.957).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eVerbal informed consent was obtained before the interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMG composed the article, gathered the data, and participated in designing study, analyzing and data interpretation.\u003c/p\u003e\n\u003cp\u003ePS cooperated in data analysis and interpretation and supervised substantially in revising the article for its contents.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSH made contributions to study conception and revision of contents.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAS supervised the study design and the data interpretation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLuo Y, Liu Y, Chen H, et al. 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The Relationship Between the Physician-Patient Relationship, Physician Empathy, and Patient Trust. \u003cem\u003eJ Gen Intern Med\u003c/em\u003e 2022; 37: 1388\u0026ndash;1393.\u003c/li\u003e\n\u003cli\u003eAhmed M, Abdalla M, Taha M. Why social accountability of medical schools in Sudan can lead to better primary healthcare and excellence in medical education? \u003cem\u003eJ Family Med Prim Care\u003c/em\u003e 2020; 9: 3820.\u003c/li\u003e\n\u003cli\u003eChurch J, Skrypnek R, Smith N. Improving Physician Accountability through Primary Care Reform in Alberta. \u003cem\u003eHealthc Pap\u003c/em\u003e 2018; 17: 48\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eRiahi H, Bazmi S, Enjoo SA, et al. The Physician-Patient Relationship: How It Is Represented in Iranian National Television. \u003cem\u003eJ Med Educ\u003c/em\u003e 2020; 19: e107905.\u003c/li\u003e\n\u003cli\u003eAl-Bishi N. 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Truth, Trust, and Transparency\u0026mdash;The Highly Complex Nature of Patients\u0026rsquo; Perceptions of Conflicts of Interest in Medicine. \u003cem\u003eJAMA Netw Open\u003c/em\u003e 2019; 2: e191929.\u003c/li\u003e\n\u003cli\u003eClemens V, Br\u0026auml;hler E, Fegert JM. #patientstoo \u0026ndash; Professional sexual misconduct by healthcare professionals towards patients: a representative study. \u003cem\u003eEpidemiol Psychiatr Sci\u003c/em\u003e 2021; 30: e50.\u003c/li\u003e\n\u003cli\u003eMontgomery T, Berns JS, Braddock III CH. Transparency as a Trust-Building Practice in Physician Relationships With Patients. \u003cem\u003eJAMA\u003c/em\u003e 2020; 324: 2365\u0026ndash;2366.\u003c/li\u003e\n\u003cli\u003eBrenner MJ, Hickson GB, Rushton CH, et al. Honesty and Transparency, Indispensable to the Clinical Mission\u0026mdash;Part II. \u003cem\u003eOtolaryngol Clin North Am\u003c/em\u003e 2022; 55: 63\u0026ndash;82.\u003c/li\u003e\n\u003cli\u003eMurmu L, Murmu S. Avoid unnecessary tests. \u003cem\u003eBMJ\u003c/em\u003e 2022; 379: o2689.\u003c/li\u003e\n\u003cli\u003eWarda E, Taye A, Perskin M, et al. Does Missing Trust Lead to Overuse or Underuse of Health Care Services? \u003cem\u003eAm J Manag Care\u003c/em\u003e; 29, https://www.ajmc.com/view/does-missing-trust-lead-to-overuse-or-underuse-of-health-care-services- (2023).\u003c/li\u003e\n\u003cli\u003eLu LY, Sheikholeslami N, Alokozai A, et al. The Role of Patient Research in Patient Trust in Their Physician. \u003cem\u003eJ Hand Surg Am\u003c/em\u003e 2019; 44: 617.e1-617.e9.\u003c/li\u003e\n\u003cli\u003eEvans AM, van de Calseyde PPFM. The Reputational Consequences of Generalized Trust. \u003cem\u003ePers Soc Psychol Bull\u003c/em\u003e 2018; 44: 492\u0026ndash;507.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Interpersonal relationship, Iranian patients, Medical ethics, Relationship factors, Tehran trust evaluation","lastPublishedDoi":"10.21203/rs.3.rs-6115413/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6115413/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTrust-building factors in Patient‒Physician relationship: a qualitative study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Trust plays a significant role in establishing patient‒physician relationships. This study, as part of a deeper investigation, aimed to determine trust-building factors in patient‒physician relationships.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis qualitative study included a literature review, group discussions, semistructured interviews, and data analysis. From spring 2019 to 2022, we conducted literature reviews, focus group discussions (FGDs), semistructured interviews, and thematic analysis. In the summer of 2021, we conducted 8 FGDs and interviewed 42 participants from Tehran University of Medical Sciences. The data were analyzed, and the results were classified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe statements were categorized into internal and external factors affecting trust. Internal factors arise directly from patient‒physician interactions. External factors include global trust, media influence, the Ministry of Health and other sources. Hence, 12 internal factors and three external factors were identified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eInternal and external factors influencing trust in the patient‒physician relationship were identified. Improving external factors requires societal efforts, whereas internal factors can be addressed through enhanced academic courses. Moreover, these 15 factors could inform future questionnaires measuring trust.\u003c/p\u003e","manuscriptTitle":"Trust-building factors in Patient‒Physician relationship: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-11 09:19:42","doi":"10.21203/rs.3.rs-6115413/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"284f8cdd-64ed-4fc6-88bf-172de3d7b20b","owner":[],"postedDate":"March 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-09T18:53:03+00:00","versionOfRecord":{"articleIdentity":"rs-6115413","link":"https://doi.org/10.36348/merjms.2025.v05i02.009","journal":{"identity":"middle-east-research-journal-of-medical-sciences","isVorOnly":true,"title":"Middle East Research Journal of Medical Sciences"},"publishedOn":"2025-04-24 00:00:00","publishedOnDateReadable":"April 24th, 2025"},"versionCreatedAt":"2025-03-11 09:19:42","video":"","vorDoi":"10.36348/merjms.2025.v05i02.009","vorDoiUrl":"https://doi.org/10.36348/merjms.2025.v05i02.009","workflowStages":[]},"version":"v1","identity":"rs-6115413","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6115413","identity":"rs-6115413","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}