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Qualitative
Health Research
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Mandates of Trust in the DoctorPatient Relationship

Helge Skirbekk, Anne-Lise Middelthon, Per Hjortdahl and Arnstein Finset

Qual Health Res published online 15 April 2011
DOI: 10.1177/1049732311405685
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5Skirbekk et al.Qualitative Health Research

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Qualitative Health Research

XX(X) 19
The Author(s) 2011
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Mandates of Trust in the

DoctorPatient Relationship
Helge Skirbekk,1 Anne-Lise Middelthon,1
Per Hjortdahl,1 and Arnstein Finset1

Abstract
We examine the conditions for trust relationships between patients and physicians. A trust relationship is not normally
negotiated explicitly, but we wanted to discuss it with both patients and physicians. We therefore relied on a combination
of interviews and observations. Sixteen patients and 8 family physicians in Norway participated in the study. We found
that trust relationships were negotiated implicitly. Physicians were authorized by patients to exercise their judgment
as medical doctors to varying degrees. We called this phenomenon the patients mandate of trust to the physician.
A mandate of trust limited to specific complaints was adequate for many medical procedures, but more open
mandates of trust seemed necessary to ensure effective and humane treatment for patients with more complex and
diffuse illnesses. More open mandates of trust were given if the physician showed an early interest in the patient,
was sensitive, gave time, built alliances, or bracketed normal behavior.
Keywords
communication, medical; interviews, semistructured; observation; relationships, patient-provider; trust
Trust is an important quality of the doctorpatient relationship (Fugelli, 2001). In recent years, the phenomenon of
trust has been researched in a number of empirical studies, and instruments to measure trust have been developed (Anderson & Dederick, 1990; Thom, Hall, &
Pawlson, 2004). Findings from these studies indicate relatively high trust in medicine in general (Calnan & Sanford,
2004), and in the patients specific physicians (Mechanic,
2004). Patient trust has an impact on patient satisfaction, adherence, and continued enrollment (Anderson
& Dederick; Hall 2006; Hall, Dugan, Zheng, & Mishra,
2001; Safran et al., 1998; Thom et al.).
We wished to examine and present a model of the
conditions of trust relations between patients and their
physicians. There is little research on trust as a dynamic
phenomenon, exploring how patients and medical doctors view and change the conditions and content of their
trust relationship. Most of the studies reviewed were based
on questionnaires given to patients and physicians after
consultation, but patients view trust in their physicians
holistically (Hall et al.; Kao, Green, Zaslavsky, Koplan, &
Cleary, 1998). This means that even if trust can be viewed
as a construct with many dimensions, for the purpose of
survey questions, trust is treated as if it only had one dimension. In an article by Mechanic & Meyer (2000), the authors
argued that it is hard for patients to explain why they
trust their respective physician. Often, patients say they
respond to their gut feeling. The physicians interpersonal

competence, through caring, concern, and compassion,

was reported to be very important for the patients trust,
but this also had an effect on the evaluation of the physicians technical competence. This means that even
though patients can separate impressions of the physicians technical and interpersonal competence, it is harder
for patients to separate how the two impressions color
their trust relations.
According to many theories of trust, a central aspect of
trust relationships is the trusters lack of precautionary
measures against the trustee (Hertzberg, 1988; Lagerspetz,
1998; Skirbekk, 2009; Wittgenstein, 1980). Patients are
vulnerable because of their illness, and the asymmetrical
knowledge of medicine (Calnan & Rowe, 2008). Thus trust
always entails a leap of faith (Brownlie, 2005; Kierkegaard,
1992; Mllering, 2006; Simmel, 1978). Patients are
whether they like it or not, whether they think of it or
notat risk regarding the competence and goodwill of
the physician (Baier, 1994).
A challenge for trust research is that trust is normally
taken for granted, without being introduced in the dialogue
1

University of Oslo, Oslo, Norway

Corresponding Author:
Helge Skirbekk, University of Oslo, Medical Faculty,
Institute of Health and Society, Centre for Medical Ethics,
P.O. Box 1130 Blindern, N-0318 Oslo, Norway
Email: helge.skirbekk@medisin.uio.no

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Qualitative Health Research XX(X)

as an explicit topic. The first author recently discussed the

implicit nature of trust in medical consultations (Skirbekk,
2009). He suggests that trust is normally discussed explicitly
only when asked, or when close to breaking down. This lack
of explicit discussion of trust in medical consultations
makes the phenomenon of trust both hard to define and
difficult to study empirically. Inspired by previous studies, we have interpreted trust as the patients implicit
willingness to accept the physicians judgment in matters
of concern to the patient. Our empirical study was focused
on the implicit conditions of the patients trust.

Methods
We wanted to use methods to observe the patients trust
even if it remained implicit in the consultations. We also
wanted to be able to validate and discuss the trust relationship with both participants. Therefore, we decided to
triangulate our methods (Denzin, 1970). We used both
video observations and qualitative interviews. We wanted
to relate what happened during the consultations to the
comments of the participants afterwards.

Participants
Invitation letters about a study on the trust relationship
between physicians and patients were sent to 42 general
practitioners/family physicians in urban and suburban
areas in Norway. Six family physicians responded positively, and another 2 were recruited at a later stage. The
physicians were asked to recruit two patients between 50
and 75 years of age willing to participate in a study consisting of both observations and interviews. This age group
was chosen for two reasons. There are few studies focusing on older patients, and we wanted patients who could be
expected to fall into two categories: illnesses that were easy
to diagnose and treat, and illnesses that were more diffuse
and difficult to diagnose and treat. The two groups of
patients were chosen to observe expected differences
in physicianpatient communication (Skirbekk, 1999).
A total of 8 family physicians (5 men, 3 women) and 16
patients (4 men, 12 women) participated in the study.
They were between 33 and 80 years of age (mean = 58
years), and all were ethnic Norwegians. All of the patients
were already familiar with their physicians through undergoing at least a few years of consultation.

Procedures
Sixteen consultations were videotaped at eight different
practices in family medicine. The first author installed the
camera and microphone, but was not present during
the consultations. Both the patient and the physician
were informed in advance of the purpose and design
of the study in both verbal and written form. Immediately

after the consultation, the patient and the physician were

shown the consultation videotape together with the
researcher, and were asked for comments and reactions.
This was done to verify our understanding of what happened during the consultation.
In-depth, semistructured interviews were conducted
later with physicians and patients separately, usually after
a few days. Interviewees were encouraged to reflect on
the trust relationship, to assert their own opinions, and to
tell their own stories concerning the phenomena discussed.
We were inspired by a procedure called active interviewing, allowing for discussion on phenomena that were of
common interest (Gubrium & Holstein, 1997; Kvale,
1996; Middelthon, 2005). The study was cross-sectional,
but we conducted some follow-up interviews for clarifying
and ethical purposes.

Analysis
Analysis was done continuously, with new observations
and interviews supplementing our sample. In general,
analysis followed the principles of Kvale (1996), and
Gubrium and Holstein (1997). We followed these stages
(Skirbekk, 2008):
1. We read interview notes and viewed observation
videos to obtain an overall impression. Abbreviated versions of field notes and transcripts were
handed out among coauthors for comments and
control (Heath, 2004).
2. We noted patterns in physicians and patients
descriptions of the trust relationship. Particularly interesting or telling comments were noted
(Denzin, 1970; Miles & Huberman, 1994). We
were especially attentive to phenomena and concepts relevant for both clinical and theoretical
views on trust relationships between physicians
and patients (Hammersley & Atkinson, 1983).
3. We compared interviews and observation videos
looking for both similarities that strengthened
our impressions and differences that weakened
them. Whenever interpretations reached a level
where hypotheses could be formed, remaining
videos and interviews were reviewed to find
opposing interpretations (Silverman, 2001).
4. Based on these analyses, we reread some of the
theories of trust (Baier, 1986; Hertzberg, 1988;
Lagerspetz, 1998; Luhmann, 1979; Wittgenstein,
1980). A number of key concepts were developed.
5. When we felt the key concepts no longer were
challenged by seeing or hearing more information (data saturation), key observation videos
were shown to a panel of two psychologists
from outside the medical faculty to assess
interpretations.

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Skirbekk et al.

Ethics
Observing medical consultations meant the researcher also
observed confidential situations; some patients undressed,
others cried. Discussing the consultation with both the
physician and the patient present could have led to
unwanted confrontations, disturbing ongoing relations or
treatments. It was therefore necessary to handle the interviews and the observations in a truthful, careful, and
respectful manner. Participation in the study was based
on the written informed consent of all participants. The
research project was submitted to and approved by the
Committee for Medical Research Ethics of Norway.

Results
Implicit Trust
The patients degree of trust in the physician was never
explicitly mentioned during the consultations. Trust
remained implicit throughout the observation videos.
However, both patients and physicians thoughts on the
trust relationship were prompted by watching the video
of the consultation.

Mandates of Trust
All of the patients in the study told the interviewer they
had some sort of trust in their physician; however, this trust
was always limited to a certain degree. Trust was never
what Skirbekk has described as blind faith (Skirbekk,
2008), but rather situated somewhere between acceptance and critical trust (Poortinga & Pidgeon, 2003), a
kind of conditional trust (Calnan & Sanford, 2004). In
general, the patients in our study trusted the well-meaning
intention of their physicians advice, but they also restricted
the trust relationship if they felt uncertain. Not all patients
were willing to comply without checking other sources.
One patient said, I am not skeptical, but it is good to keep
oneself oriented. Trust was thus both implicit and conditional, and we wanted to study what phenomena constituted the patients conditions.
The patients expectations regarding their physicians
varied. Some patients emphasized thorough examinations
and clear explanations, others wanted the consultation to
end quickly. Most patients, and all of the patients with
chronic illnesses, said they considered the physicians
involvement in their particular illness as important for
their trust, i.e., being interested in you as a person.
During analysis we observed that patients trust in the
physician seemed related to what topics the physician and
the patient considered appropriate to discuss during the
consultation. These implicit rules seemed to be based partly
on the nature of the illnesses presented by the patient
(e.g., simple or complex, acute or chronic), partly on the

expectations related to the roles of physician and patient,

and partly on the relationship between the physician and
the patient as persons. We found the implicit limitations
to the openness of the discussion to be connected with the
trust relationship in the consultation.
Our findings indicate that patients implicitly authorize
physicians (and vice versa) according to what the patient
considers appropriate restrictions to the physicians
judgment. During an interview, one physician was very
explicit in his description of a phenomenon very similar
to the one we tried to describe, actually applying the word
mandate:
The patient must have a right to give you a mandate,
in a way. . . . It is quite important that the patient is
confident that he is in charge . . . and that they have
a right to, sort of, define the mandate that you have.
To go in and almost drag out the patients hidden
symptoms. . . . It requires trust, and a sort of reciprocal understanding of trust. The patient is often in
a quite vulnerable position, and it is easy to drag out
something, and if you show it afterwards there can
be an ecstatic atmosphere and, Oh, so fantastic,
opening up, and so forth, but then the patient often
regrets it afterwards. Patients are incredibly easy to
seduce.
On the basis of this interview we adopted the term mandates of trust as a category to describe the degree of openness, and in what areas the physician is authorized to
exercise his or her judgment in matters of concern to the
patient.
Limited mandates of trust. Patients give mandates of trust
to their physician with different degrees of openness, and
for different reasons. All patients in our study had certain
expectations with regard to the medical consultation. We
use patients role expectations of physicians as a term for
the patients generalized expectations of medical practitioners in a consultation. The trust relationship between
physician and patient was perceived as relatively uncomplicated by the patients as long as their role expectations
of physicians (and to some extent, the physicians role
expectations of patients) were followed. In the interviews, it was revealed that every patient expected his or
her respective physician to listen to their problems and
help find a solution to these problems (not necessarily
solve them). One patient appreciated that her physician
took her illnesses seriously . . . and was honest about
what she did not know. Patients expected medical competency, thoroughness, and benevolence, but not all
patients expected anything beyond responding to what
was perceived as relevant for the medical examination.
Most of these consultations were limited to specific biomedical topics, but we also saw instances of mandates of
trust limited to specific psychosocial problems. We call

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Qualitative Health Research XX(X)

these phenomena limited mandates of trust, and they

seemed adequate for most consultations. The following
example is from such a consultation with an easily diagnosed patient:
A woman patient came to the physician with a fractured hand that had previously been treated and
plastered [casted]. The physician and patient discussed and reviewed the plastering process, the
healing process, the different bones in the hand,
and the movements in the hand. At no time did any
of them discuss anything except the bones in the
hand, problems related to specific questions of treatment, and a medical certificate for the patient. At no
time did it seem that the patient or the physician
wanted to discuss anything else. This was later confirmed by both physician and patient.
We found that if the patients concern seemed obvious for
both patient and physician, often very little discussion
was necessary before diagnosis could be given and treatment could be recommended. These relatively simple
consultations could be adequately performed based on a
mandate of trust which was limited to specific patient
concerns.
Open mandates of trust. In other consultations, the topics of discussion were not limited to specific concerns or
specific diseases. The patient would discuss how his or
her illness affected his or her lifestyle and beliefs in ways
that were more concerned with the patients personal
understanding of the situation than with specific medical
treatment; for example:
A female patient had been given the diagnosis of
fibromyalgia by a rheumatologist. In the interview
after the consultation, she said that she was afraid to
look stupid during consultation, but she claimed she
felt completely calm when speaking with this particular physician. She felt she had enough time to
say what she wanted to say, and did not have to
pull herself together when she spoke with this
physician. She told the interviewer that she believed
he [the physician] is a good human being. She
also said the physician spoke in a way she could
understand easily, emphasizing that she preferred
to hear it from him, even though other physicians
could have performed the same services.
This patient emphasized having something other than generalized role expectations of a physician. Of course she
expected her physician to perform as a medical practitioner, but she also wanted to feel that she knew the physician as a person. She wanted to discuss personal matters
with someone she trusted as a good human being, and

not just as a competent representative of the medical profession. Like other patients who permitted the physician
to be more invasive in the dialogue, she said she felt she
could tell the physician anything.
Another woman patient emphasized the importance of
speaking to someone of her own gender. She also said that
she felt like her physician understood her problems better
because she experienced a kind of resonance of life experience. . . . You feel like you can say what you want, and,
sort of be yourself 100 percent. We labeled such relationships as characterized by more open mandates of trust. In
these consultations, fewer professional issues and more
personal matters were prominent. In our study, the patients
who expressed the importance of what we have called open
mandates of trust all had complex complaints, often diffuse
and multifactorial symptoms, and chronic illnesses. These
patients put great emphasis on being taken seriously, or
even specified being taken seriously as a human being
for a trustful relationship to develop. They also expressed
the importance of being able to be themselves and not
having to watch [their] tongue. This could mean that the
patients wanted the physician to understand them as being
as truthful and honest as they could be. The patients wanted
to trust their physician as a person with whom they could
speak openly, and expect to be respected as a fellow human
being. Some patients in our study told stories of serious
maltreatment, often resulting in distrust in health care professionals. However, personal and continual involvement
from their particular physician had made them feel taken
care of and seen as human beings.

Elements Associated With

Establishing Open Mandates of Trust
During analysis, we looked for hints of what could open
up the physicians implicit mandate of trust. This process
of authorization seemed to be initialized after the patient,
in one way or another, had tested the physician for trustworthiness beyond what could normally be expected
through generalized role expectations. Patients seemed to
depend on signs from the physician to initiate opening up
limited mandates of trust, perhaps because appropriate
medical limitations to the mandate of trust are usually not
known to the patient.
Most patients who had given their physician a more
open mandate of trust could (and often did) tell stories
illustrating how the trust relationship had developed.
Several patients mentioned how trust had developed after
the physician had made a phone call to their home, after
working hours, to ask about their well-being. The patients
said this made them feel as if the physician took a personal interest in them, going beyond the patients normal
expectations of a physician. Likewise, some physicians
asked patients directly about their uncertainties, and if

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Skirbekk et al.
the patients responded positively, the physicians said they
felt free to open up their mandate of trust.
Analyzing these patients stories, we found five specific elements that were associated with open mandates
of trust in the consultation, although there are, of course,
probably many more. These elements are presented here
because they were emphasized by the patients: (a) the physician showing an early interest in the patient, (b) the
physician showing sensitivity to patient emotion, (c) the
physician giving the patient and the relationship time,
(d) establishing alliances against a common adversary,
and (e) instances of bracketing normal role behavior,
e.g., through a shared sense of humor.
Showing early interest in the patient. In practically all
consultations based on what we conceptualized as open
mandates of trust, the physicians expressed some interest
in the patients well-being early on. A sentence like, You
were here 14 days ago could be sufficient to demonstrate
knowledge of the patients history. Even a question like,
What did we talk about the last time? could function
well, as it ensured that both physician and patient had the
same understanding of the situation. One particular physician opened his consultations with this sentence: Now
Im excited [to hear what you have to tell me]. The patient
told the interviewer that she perceived this as open and
inviting, creating an atmosphere in which an adequately
open mandate of trust could be maintained.
Sensitivity to patient emotions. In a number of consultations patients indicated that they had emotional concerns
that were directly or indirectly related to the complaint that
brought them to the physician. The physicians sensitivity
to these cues could function to open up the mandate of
trust; for example:
A woman patient had recently received a diagnosis
of Parkinsons disease. Her mother had died from
the same disease earlier, so she knew well the illnesses
that awaited her. She was depressed, and discussed
her condition with her physician: Sometimes I get
overwhelmed with emotions. . . . I also know that it
is important that I get to work, that I have something
to do. At this point she stopped saying anything
and started crying. The physician rose without
speaking, walked over to the washing sink, and
picked up a paper towel. As he handed it to the
patient he continued the consultation.
This patient expressed a need for support in the interview,
and she was happy for the physicians calm understanding of this need. The physicians action seemed in the
context of the consultation to imply respect and honesty,
as well as belief in the good will of the other.
Giving time/continuity. In the interviews, the importance
of giving the patient and the relationship enough time was

often mentioned. Giving time was conceptualized both in

terms of time spent in each consultation, and time passed
through years of consultations (continuity); for example:
One patient had had contrast fluids (used for X-ray
scans) injected into her cerebellum during a hospital
procedure more than 20 years previously. She had
been paralyzed on her entire left side for months, and
still had a very stiff neck; she believed this was the
result of maltreatment. This had naturally shaken her
trust in medicine and in physicians, but her trust in
her particular physician was strong. Over time, he
had proven that he took an interest in the patient,
and she felt that she could speak to him about
everything. She felt that he cared about more than
just the thing you visited him for: he cared about
you as a human being.
Most of the patients interviewed expressed an understanding of physicians busy schedules, but they disliked
being rushed. If they felt they were in a hurry, they rarely
felt they had time to tell the story they wanted to tell about
their illness. Many of the physicians also expressed the
importance of giving patients time to tell their stories. One
physician said, You save a lot of time when you let
the patient speak his mind. . . . If you have not understood
the patients agenda, it will be impossible to give any sensible treatment. This physician encouraged his first
patient to speak for more than four minutes before he
uttered any questions. He said this gave him the patients
own perspective on what the real problems were through
accurate descriptions of the patients symptoms.
Building alliances. Normally, the physician and the patient
are allied against the patients illnesses, but alliances can
also be directed against other adversaries. Many patients
expressed horrible experiences with hospitals and the social
security system in Norway. Very often the experiences
turned sour because the patients did not feel their diffuse
symptoms were believed. These patients felt the suspicion
from hospital specialists or health bureaucrats to be highly
unreasonable, and very often completely draining on their
already strained health. One patient phrased the problem
paradoxically: You must be well to be ill. The following
is an example of an alliance between a patient and a
physician:
A woman patient shared a long story of illnesses.
Sixteen years previously she had developed breast
cancer. One breast was removed, and she had
recently undergone breast reconstruction with transplants from her stomach. She had been informed
about how much trouble it would be not to use silicone, but through the support of her family physician, she decided to stick with her original plan.

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Qualitative Health Research XX(X)

The patient was very grateful for the support she

had been given from friends, family, and a support
group. Fifteen years previously she had a prolapsed
disc. Ten years previously the right side of her face
had become paralyzed after influenza, and 2 days
later she was sent to a hospital. The hospital claimed
they could not do anything but give her muscle relaxants. After fighting in the courts for a year, with the
support of her physician, she was sent to the
national hospital and given plastic surgery around
the eyes. At the time of the interview she had applied
for a follow-up face lift, again with the support of
her physician.
The patient knew how hard it could be to argue with the
health bureaucracy, often referring to it as a menace to
humanity. She said that it hurt to feel accused of lying,
claiming that things could have gotten really bad if she
had not had a kind and helpful physician. She spoke of her
physician as my angel, claiming that she really cared
about you. Of course, such alliances might be highly
problematic for health care systems in general, but in this
particular dyad the patient felt such an alliance was necessary for an open trust relationship to develop.
Bracketing normal role behavior. Some physicians
opened up limited mandates of trust by stepping outside
their expected roles, if only for very short periods of time
(Skirbekk, 2007). By bracketing role expectations, physicians and patients could see each other on a more personal
level than staying in their roles would allow. Sometimes
the power imbalance could temporarily be set aside, and
the normal role relations reviewed, just through sharing a
laugh. The benefits of a shared sense of humor were
emphasized by some physicians and patients as a way of
creating common ground. One patient expressed it as
being in the same boat. The following is an example of
shared humor:
The patienta manwas a former alcoholic and
cancer patient with a number of illnesses. He suffered from anxiety among other people. He said that
he missed the smoking room in his coin collectors
club. The smoking room disappeared when Norway
instituted stricter smoking prohibition laws. Then he
added, I dont believe for a second that it [smoking]
is unhealthy. He elaborated by criticizing the inadequacies of smoking research, and claimed that
heavy smokers in the Caucasus and in Greenland
live until they are 150 years old: One hundred and
twenty is quite common. The physician seemed a
bit uncertain about how to respond, but ended up
expressing her belief in the hazards of smoking,
even though some people could withstand it well:
But claiming that it is healthy, I cannot agree with
you there. The patient continued: Perhaps that was

a bit exaggerated. They both laughed. Later the

patient brought the subject up again, claiming that
no one has embolism in Greenland. Then he said
that in Denmark he got many questions asking him
if he was from Greenland. The physician laughed.
So now you are taking a chance on your having
Greenlandic ancestry, believing that is why you can
withstand tobacco so well. Is that how you are
thinking? The patient laughed.
The humor present in this consultation confirmed a sense
of respect between the patient and physician, as an expression of common humanity. This seemed to create an atmosphere in which normal role relations could be put aside
for a short period of time. The patient said that he
appreciated people who did not take themselves, or him,
too seriously. He added that his physician never spoke as
from a pedestal. The patient can be understood as testing
the physician through humor to see if she could be trusted.
The physician was reluctant at first, but quickly understood
and used the humor present in the situation.
Bracketing role relations is something that rarely is
functional unless it is done within a limited time span.
Patients visit their physicians to see a medical practitioner,
not just for fun. Furthermore, humor can easily lead to
negative consequences, to ridicule or mockery, or it
can be used instrumentally to create a common ground
that is false.

Discussion
We observed consultations in family medicine and interviewed physicians and patients about the patients trust in
the physicianpatient relationship. As expected, the
patients trust in the physician remained implicit throughout all consultations; this did not mean that trust was not
negotiated. The conditions of trust varied with the consultation, the patients medical history, and the doctor
patient relationship. Trust is not unidimensional, and
patients do not necessarily trust physicians in a way that
can be scaled from high to low. Patients test their physicians
both to see if their mandate of trust is justified, and to
see if it can be more open.
The main focus of our study thus became to discover
what phenomena constituted different kinds of relations
between patients and physicians. The topics discussed and
the extent to which the physician was authorized to listen,
respond, and exercise his or her judgment as a physician in
matters of concern to the patient emerged as important
themes. We found that the patients kept some sort of control of these phenomena through varying limitations to
the trust relationship. We called this phenomenon the
patients mandate of trust to the physician.
The patients trust was never absolute in our study.
Patients often seemed to test their physician implicitly,

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Skirbekk et al.
which could result in modifications in the patients acceptance of their physicians judgment. Physicians were
given limited mandates of trust by the patient when the
patient accepted (e.g., by showing up at the physicians
office) or had to accept (e.g., in an emergency situation)
the physicians role as a doctor of medicine (Parsons &
Shils, 1962). We found that a mandate of trust limited to
specific patient complaints was adequate as a basis for
many medical procedures, but not necessarily for all.
More open mandates of trust seemed necessary to
ensure effective and humane treatment for patients with
more complex and diffuse illnesses. Our study showed that
it was important for patients to feel they could speak
openly, and were treated with respect as human beings, for
more open mandates of trust to be given to the physician.
We found that an early interest in the patients well-being,
sensitivity, giving time/continuity, building alliances, and
bracketing normal role behavior for short periods of time
were elements associated with open mandates of trust.
More open mandates of trust could give the physician an
opportunity to confront the patient rather directly with
medical and psychological perspectives that the patient
otherwise perhaps would not have been either willing to
receive or capable of receiving. Relationships based on
open mandates of trust can be more resilient to challenges, but also more vulnerable to feelings of betrayal,
than relationships based on limited mandates of trust.
Some elements of our model have been demonstrated
by other researchers. Wilson, Morse, and Penrod (1998)
demonstrated how caregivers might be tested in situations
in which reciprocal trust is developed. Mechanic and
Meyer (2000) also found that patients with chronic diseases test their physicians against their knowledge and
expectations. Fiscella et al. (2004) found that active physician exploration of the patients experience of their illnesses, as well as longer consultation time, were associated
with greater patient trust. Hsieh, Ju, and Kong (2010)
showed how competence, shared goals, professional
boundaries, and established patterns of collaboration can
strengthen or compromise trust relations. Manderson and
Warren (2010) showed how competence is often the most
important dimension of trust relations with health care
professionals, but social skills and caring play important
roles when patients negotiate their trust relations. Our
work builds on and sometimes replicates these findings
in an ongoing attempt to describe what phenomena constitute trust relations.
In clinical situations, patients with medically unexplained symptoms are unfortunately often met by less
patient-centered communication than patients with more
classic symptoms: Physicians, facing lack of time, the
anxiety of uncertainty, and frustrated patients, often retreat
into physician-centered behavior that is likely to be counterproductive (Epstein, Shields, Meldrum, & Duberstein,

2006, p. 274). Lack of patient-centered communication

has also been demonstrated by Brown (2008). He found
that management regulations in clinical health care greatly
reduce the time available to talk with patients. The four
minutes before asking questions offered by one of the
physicians in our study was thus clearly extraordinary.
On average, physicians interrupt patients after 18 seconds
(Beckman & Frankel, 1984).
From a sociologists perspective, mandates of trust
point toward a need for sharing power. Weber (1978)
defined power as the ability to impose ones will, even in
the face of opposition. Following this definition, the
doctorpatient relationship is asymmetrical with regard
to power and vulnerability. Although the patient has knowledge of his or her own illness, and the subjective experiences of pain, the physician has knowledge of the disease,
objective knowledge of diagnoses, and modern medicine in
general (Kleinman, 1988). Speaking metaphorically, the
physician draws the map of diseases, illustrating the terrain
of the patients illnesses. The physician has what Brten
(1988) called model power, and therefore controls what
diagnosis and treatment the patient will receive.
Patients expectations of physicians have changed.
Modern patients have demands, and have been described
as consumers (Calnan & Rowe, 2008). Patients expectations are, of course, linked to the physicians role as
being knowledgeable in modern medicine, and his or her
ability to act on behalf of this knowledge, but this is no
longer necessarily enough. Parsons thoughts on the traditional physicians role exemplify this view: To assure
functional health care the physician should be oriented
toward affective neutrality, collectivity, universalism,
specificity, and achievement (Parsons, 1951). Parsons pattern variables are important for the efficacy of the knowledge base of modern medicine, what has been described as
system trust (Luhmann, 1979), but as Giddens (1991)
pointed out, role expectations for a physician are also connected to phenomena more visible to the patient, even if
these are as superficial as a white coat, medical posters on
the wall, a certain way of asking questions, and being
able to diagnose and treat the patient. The physician is a
representative of what Giddens (1990, p. 83) called access
points of abstract systems, immediately recognizable and
far less abstract than the system itself.
Being taken seriously as a human being in modern
complex societies demands power sharing. Traditional,
asymmetrical power relations in doctorpatient relationships (the expert/lay divide) are challenged as medical
knowledge is spread through mass media such as the
Internet and through a diffusion of traditional authorities.
Brown (2008) claimed that physicians standing as caring
and competent now depends to a great degree on communicating with and involving the patient before trust can
be earned. Our findings indicate that more open trust

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Qualitative Health Research XX(X)

relationships depend on more personal involvement with

the patient. A physician showing reciprocal humanity creates common ground with the patient. It is important that
mandates of trust are given and received bilaterally, and
in a balanced fashion, for mandates of trust to grow more
open.

Conclusion
Mandates of trust could be seen as a model describing the
implicit conditions of trust relationships between patients
and their physicians. Being aware of the phenomenon,
what situations demand open mandates of trust, and what
actions are likely to open up or limit the patients mandates
of trust, should be beneficial for any practitioner striving
for good medical communication. We found that an early
interest in the patients well-being, sensitivity, giving
time/continuity, building alliances, and bracketing normal
role behavior for short periods of time were all elements
associated with open mandates of trust. More research is
needed to identify adequate and balanced limitations of
mandates of trust in different clinical situations.
Acknowledgments
We are grateful for the advice and support we received from
Harald Grimen, Oslo University College, and Kristine Lillestl,
University of Bergen.

Declaration of Conflicting Interests

The authors declared no conflicts of interest with respect to the
authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/
or authorship of this article.

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Bios
Helge Skirbekk, PhD, is a senior research fellow in the Center
for Medical Ethics, Institute of Health and Society, Medical
Faculty, University of Oslo, Oslo, Norway.
Anne-Lise Middelthon, PhD, is an associate professor in the
Section for Medical Anthropology, Institute of Health and Society,
Medical Faculty, University of Oslo, Oslo, Norway.
Per Hjortdahl, PhD, is a professor in the Department of General
Practice and Community Medicine, Institute of Health and
Society, Medical Faculty, University of Oslo, Oslo, Norway.
Arnstein Finset, PhD, is a professor in the Department of
Behavioral Sciences, Institute of Basic Medical Sciences, Medical
Faculty, University of Oslo, Oslo, Norway.

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