Nurturing Trust and Equity in Patient Spaces

I grew up in one world, but I’ve spent most of my life working in another. I grew up in white-world, where everyone looked like me and spoke English. From birth to medical school, I lived in a world where our white Anglo norms were society’s norms. Other people’s perspectives were “ethnic” or “cultural.” Our sense of “normal” set the boundaries between us and others. And then the boundaries moved. Or I moved.

There came a moment when I decided that I needed to make a difference in the world. My own insecurities, my family dysfunction, and my college roommate’s suicide all left me questioning my choices and my value as a person. All I had was this vague, poorly defined sense that I wanted to help people, especially the people who needed help most.

So, I moved. I switched first from being an English major at Harvard to being a premed chemistry major at the University of Miami. I learned about yogurt and Boston accents and arrogance at Harvard and about Cuban coffee and Jesus at the U.

Today, America is in transition. A white-majority population accustomed to setting the norms is moving into a new minority-majority reality. I’ve lived and practiced amidst this transition in urban Chicago and in the small-town Deep South. In Chicago, I worked with immigrant doctors at Cook County Hospital and immigrant patients at our South Lawndale/La Villita clinic. In the 1980s in Central Florida, I served six years as medical director of the West Orange Farmworkers Health Association. I practiced in our smallest migrant clinic, on Highway 50 in Groveland, Florida. I did home visits on dirt roads on the Black side of town.

I moved from Groveland to Atlanta, to the then-relatively new Morehouse School of Medicine. It took a quarter century of working in a historically Black medical school to help me find my soul, to make peace with myself, and in some ways to become comfortable in my own skin.

In my current faculty position at Florida State University, I am a teacher, a researcher, and a tenured professor; I also chaired the Council on Diversity and Inclusion (now the Council on Engagement) at our College of Medicine. But I am outlawed from teaching that systemic racism and institutionalized inequities are root causes of health disparities. As a public health physician, I am not supposed to promote vaccinations that could save lives. By order of the state surgeon general, no one in the Florida Department of Health is ever supposed to use the phrase health equity. To say it would require us to acknowledge that we still have systemic inequities. My colleagues and I are also handcuffed in the care we may provide to trans individuals or even to women making reproductive choices.

Here’s the dilemma for white people who want to do the right thing and be on the right side of history. How do we come to grips with our own whiteness? For many of us, the opposite of being a white nationalist has meant denying race or pretending that we live in a post-racial world. We have good intentions. But to deny our own racial identity or pretend that we don’t see race is to gaslight the real everyday lived experience of people of color. It also denies our own lived experience of privilege.

But I wonder—is there a third path, one that boldly rejects white nationalism or white identity politics but also avoids the color-blind racism of claiming that race doesn’t matter? Over the past few decades, I have paid attention to my own journey attempting to forge this “third path.” I have tried to encourage others to see their own true selves, including their own whiteness, through nonwhite eyes.

I see the dysfunction, and I wonder how and when the healing can begin.

The march of progress is often slow and uneven, two steps forward and sometimes two steps back. But it marches on. Changing demographics are driving us forward. Communicating openly about who we are as diverse humans is driving us forward. The complexity of modern families is driving us forward. Civil rights advocates and social justice warriors and democratic socialists and allies and woke people are all leading us forward. And the status quo, anti-woke, shrinking minority will have the same experience as all those who came before. They will live to see the progress. Perhaps one day they may see this brave new world as an opportunity for learning and growth. It is our moment for both giving and receiving love and grace. It is our moment for healing. If we so choose.

At Morehouse, one way that I found healing was by striving to understand racial and cultural differences that impact healthcare. A critical realization—that came to me much too slowly, over several years—was that I had a radically different perspective on trust, and on respect, than my Black colleagues. While I delve into many more cultural differences in my book, Healing in a Changing America, here I share how I learned to earn my patients’ and colleagues’ trust.

Questioning My Trustworthiness

“Why should I trust you?” she asked. I was shocked and hurt and offended all at the same time. What had I done?

I had recently taken a leadership position as medical director of the Morehouse Family Practice Center, where she was a nurse educator on the clinical faculty. To give context, the older physicians on faculty were all Black, while the recent hires (including me) were white. The nurses were all Black women. The front desk staff were all Black women. The nonphysician faculty (nutritionist, psychologist, etc.) were all Black women. A new, young white-guy physician (me) had been put in charge of the clinic. To a small extent, I had been given control over my colleague’s schedule and her workload.

The instinct to distrust a white man with power was deep and visceral. It was a distrust that had been earned by many white men in positions of power before me. It was distrust built up over generations and reinforced almost every day. Of course, people of color shouldn’t give their trust freely to white people. Let white people earn it. Do I frame the problem as hers, as a problem of her distrust? Or is it my challenge for me to become and to be known as trustworthy?

This was the beginning of a new insight that took a while to grow. I had done nothing to lose her trust, but I also had done nothing to gain her trust. I was starting from an assumption that trust was something I already had but could lose if I behaved badly. She (and many of our colleagues of color) started from an instinct of caution and skepticism. Some scholars call it “a hermeneutic of suspicion.”¹

Mistrust was the logical conclusion of knowing that they’ve been burned too many times before. Think of all the historic reasons to mistrust white people. Start from slavery. Move on to Jim Crow oppression to lynchings to race massacres² to voting suppression (then³ and now⁴). Think of redlining in housing⁵ and of employment discrimination.⁶ Wrap your head around the massive attempt to dehumanize African Americans. Think about it in healthcare, from torturous surgical experiments on enslaved people⁷ to the psychological diagnosis of “runaway slave syndrome.”⁸ We segregated hospital wards⁹ and doctors’ offices.¹⁰ We ran government-funded syphilis experiments.¹¹ We still have disparities in treatment for pain¹² and cancer¹³ and heart disease.¹⁴ Then multiply those by a thousand demeaning experiences and microaggressions that people of color experience every day.¹⁵ Why should they trust me?

At Morehouse, I had to work to earn the trust of patients and staff and fellow physicians. In many ways, this trust/distrust dynamic was the opposite side of the respect/disrespect coin in how we related to each other. My colleague’s unwillingness to start from a baseline of trusting people she didn’t know was similar to how I thought people should have to earn my respect. Her assumption was that showing respect to all people was a given. Showing disrespect was an assault on one’s humanity. It was fascinating to me in that moment when my trust was questioned that neither of us was aware of how the other perceived issues of trust/distrust and respect/disrespect. We had polar opposite racial and cultural lenses.

This trust/distrust dynamic plays out in medical care every day. It manifests as one of the many root causes of unequal health outcomes. There is a growing body of research designed simply to find valid measures of the various domains of trust, including trust in physicians, trust in institutions, and more generalized cultural mistrust.¹⁶ Unfortunately, much of this research blames patients by framing the issue as a problem of “those people,” of the minority group. Much less research has been devoted to the measurement of white trustworthiness or institutional trustworthiness.¹⁷

Personal, Relational Trust

Early in my career, I joined the medical staff of the West Orange Farmworkers Health Association, caring for patients in the smallest, most remote clinic. Groveland, Florida, was a town with two stoplights, no Dairy Queen, and a dark history of racial animus. My patients were not just farmworkers but also low-income and uninsured people of all backgrounds. Maybe a third were African American, a third white, and a third Hispanic or Latine. Our other clinics served Haitian and Chinese immigrants as well. All too often, my heart was broken by seeing preventable suffering. We saw late-stage cancers (as described in “The Need for Healing” on page 60) and extreme complications of treatable diseases that doctors serving the well-insured and well-off rarely saw. Sometimes the barriers were financial or structural and sometimes cultural or psychological. Sometimes the barrier to getting the right care was mistrust.

Patients who have more trust in their healthcare professionals are more satisfied with their treatment, have fewer symptoms, and pursue healthier behaviors.¹⁸ Patients see nuance and have a keen sense of whom to trust. For example, one group of researchers found that people might mistrust white Anglo doctors and even the whole healthcare system but still trust their nurse practitioner.¹⁹ Maybe doctors should put on our humble hats and learn about building trust from our nursing colleagues. Nurses are often more competent in relational skills. (Sadly, medical schools do not select future doctors for their emotional intelligence.)

The power dynamics are also different for nurses than for doctors. Power and control are central to issues of white trustworthiness. As physicians, especially white-guy physicians, we must give up the need to control. Instead of the usual push-pull of trying to get my patient to make the healthy choice (i.e., what I want them to do), I’ve learned to practice my motivational interviewing skills. I come alongside my patient and see the world through their eyes. I walk with them toward their goals, not mine.

When I took over as medical director of all the clinics in the association (mere months after starting), my predecessor took me out to lunch. Dr. Otilia Mariña is an incredibly dedicated family physician. I think she was worried that I didn’t quite get it. As we were eating, she tried to pass along some of her passion and wisdom. “George,” she said, “when I’m in the exam room with a patient, they tell me things they wouldn’t even tell their spouse or their best friend.” She paused. “I feel like a priestess.” There was a sacredness in this moment as well. She went on. “Sometimes I can’t fix it. But all they expect, all they hope for, is that I will hold their hand and walk with them on their journey.” I don’t know if I ever got it in the same way that Oti did, but I took it all to heart. I share her words with every class of medical students that comes my way.

In Groveland, the Latine community we served in our migrant/community health center was mostly of Mexican origin. We saw out-of-control diabetes every day. And we saw all the long-term consequences of high blood sugars and poorly controlled diabetes. Working in this community taught me one thing about helping people manage their own health. It’s relational, not informational. It’s about dignity and respect. It’s not about facts or graphs or data. Instead, it’s about personal, relational trust. Our front desk team comprised wonderful young women who had grown up in the community and had only a high school education. They were part of the extended families of many of our patients. If I couldn’t be trusted, at least I could build a team that had trust. I could be trust-adjacent. These were the core values. Familismo. Personalismo. Respeto. Confianza.

Earning Trust

In a Hastings Center Report, Laura Specker Sullivan, a philosophy professor who studies trust, writes: “For those who have faced exploitation and discrimination at the hands of physicians, ... and medical institutions, trust is a tall order and, in many cases, would be naive.”²⁰ Our task is not just to get patients to trust us but to become trustable. In Sullivan’s words, we face the daunting task of “establishing trust in an unjust environment.”²¹ This is a key point. If we frame this as a problem of Black or African American mistrust,²² we are getting it wrong. The problem is the white failure to be trustworthy, played out over centuries. It gets repeated in healthcare settings and communities every day. White untrustworthiness breeds Black mistrust. The Association of American Medical Colleges recently released its 10 “Principles of Trustworthiness” to guide community engagement.²³ They tell us to stop trying to educate the community. In fact, their first principle is that “The community is already educated; that’s why it doesn’t trust you.”

We begin to make progress when we are willing to do the hard work of dismantling the untrustworthiness of historically white institutions and of white people. I earn trust when I honestly acknowledge a historic pattern of abuse and bias that is still present.²⁴ I earn trust when I see things through the eyes of minoritized patients and colleagues. I earn trust when I acknowledge (and repent of) my own easy acceptance of white privilege. I have to own the fact that I still benefit from systems that favor me. I earn trust when I seek to change my own implicit and explicit biases and prejudice. I earn trust when I find my voice and overcome my own silence in the face of inequity.

If I’m just a white guy trying to avoid race and treat each patient as a unique individual, then I am discounting others’ racialized experience. I am pretending that race doesn’t matter, while they experience the abuse of racism every day. And if my healthcare system is producing racially unequal outcomes, I need to own it. Either it has structures and processes that bias those outcomes, or else somehow the victims are to blame for all the inequalities they experience.

Individual “cultural competency” is not enough. We must diagnose and fix the brokenness. Can you say the word racism? Can you say it out loud in front of your peers or your leadership? If not, can you at least have practical, strategic, and tactical discussions about actions to eliminate bias and discrimination? Can you strategize on how to reverse power/resource inequities and health outcome disparities? Can you make a long-term commitment to actively engage in antiracism action? If not, why should people on the receiving end of racial inequities trust you?

How do patients experience racism in your clinic or hospital? Ask them, but be ready to act on what you hear. Have the right person ask them, in a setting where it is safe to express true feelings, including pain and rage. Dig into the hard, marathon work of undoing racism in your organization or practice.* What would it take to achieve perfect equality of outcomes across all racial/ethnic/gender and socioeconomic strata of patients? What would it take to achieve vertically proportionate diversity, with minorities oversampled in positions of leadership and power and budget authority? The days when organizations can just hire a VP for Diversity are long past.

Can we teach doctors and nurses and healthcare executives to do better? The jury is still out. In one review of interventions designed to enhance patient trust, researchers found no effect.²⁵ Clearly, short-term cultural competence workshops are not enough. We might raise awareness, but building trust requires a deep soul commitment to being trustworthy. It means acknowledging racism and injustice while using our privilege to confront the root causes of inequity.

So how can a white guy earn trust in a nonwhite world? Trust is earned every day in the interactions that show respect or disrespect. Trust is earned in learning to offer that respect in the form and manner in which each person receives respect. These may be quite different from the ways in which I would feel respected. And when trust is given before we’ve earned it, we must honor that gift as an act of grace.

Many of us are not in charge of anything. We feel like we have no power to make justice blossom. But where we do not have control, we often have influence. We can speak up when we see injustice. We can ask the naive question: How could we make things better? We can reflect bias or ugliness back to the speaker: “What did you mean when you said that?”

We can stand with those who have authentic lived experience or who are effective advocates for their community. We can notice when hierarchy or systems of power or a culture of denial are making it too risky for them to speak up. In those moments, we can step into that danger and speak as an ally.

Imagine thousands of us across this country and millions around the world committed to nurturing gardens of equity in all the spaces we touch. Imagine those vibrant, colorful gardens becoming the ecosystem of our nation and injustice merely the weeds that we must occasionally dig out.

Wouldn’t that be worth doing? Wouldn’t you want to play your part? We don’t have to be perfect. We just have to do our best to grow and tend the garden. And we have to be intentional. 

George Rust, MD, MPH, is a professor at the Florida State University (FSU) College of Medicine and codirector of the FSU Center for Medicine and Public Health Policy and Practice. His previous positions include serving as public health medical director for six counties in Florida and as the founding director of the National Center for Primary Care at Morehouse School of Medicine. In 2017, he won the American College of Preventive Medicine’s President’s Award for Contributions to Health Equity. This article is excerpted and adapted from Healing in a Changing America: Doctoring in a Nation of Needless Suffering © 2025 Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press.

*For guidance on how to undertake this work, see “Brave Spaces: Community-Driven Anti-Racism Partnerships” in the Fall 2021 issue of AFT Health Care. (return to article)

Endnotes

1. B. Cooper, Eloquent Rage: A Black Feminist Discovers Her Superpower (Picador, 2018), 262; and B. Cooper, “I Was Wrong About Gaza: Why We Can No Longer Ignore the Horrors in Palestine,” Salon, August 5, 2014, salon.com/2014/08/05/i_was_wrong_about_gaza_why_we_can_no_longer_ignore_the_horrors_in_palestine.

2. P. Woll, “America: How Did We Get Here?,” in Healing History: Where History Meets Behavioral Health Equity for African Americans (African American Behavioral Health Center of Excellence, National Center for Primary Care, Morehouse School of Medicine, April 2021), africanamericanbehavioralhealth.org/documents/HealingHistory-ChapterTwo.pdf.

3. M. Darling, “A Right Deferred: African American Voter Suppression After Reconstruction,” History Now 51 (Summer 2018), gilderlehrman.org/history-resources/essays/right-deferred-african-american-voter-suppression-after-reconstruction.

4. Lawyers’ Committee for Civil Rights Under Law, “Trump Executive Order Would Disenfranchise Millions of Black Voters,” March 27, 2025, lawyerscommittee.org/trump-executive-order-would-disenfranchise-millions-of-black-voters; M. Waldman, “People of Color Are Being Deterred from Voting,” Brennan Center for Justice, March 6, 2024, brennancenter.org/our-work/analysis-opinion/people-color-are-being-deterred-voting; and Thurgood Marshall Institute, “Project 2025’s Threats Voting Rights and Black Political Power,” tminstituteldf.org/threats-to-voting-rights-project-2025.

5. R. Rothstein, “Suppressed History: The Intentional Segregation of America’s Cities,” American Educator 45, no. 1 (Spring 2021): 32–37.

6. K. Schaeffer, “Black Workers’ Views and Experiences in the U.S. Labor Force Stand Out in Key Ways,” Pew Research Center, August 31, 2023, pewresearch.org/short-reads/2023/08/31/black-workers-views-and-experiences-in-the-us-labor-force-stand-out-in-key-ways; V. Wilson and W. Darity, Understanding Black-White Disparities in Labor Market Outcomes Requires Models That Account for Persistent Discrimination and Unequal Bargaining Power (Economic Policy Institute, March 25, 2022), epi.org/unequalpower/publications/understanding-black-white-disparities-in-labor-market-outcomes; and D. Solomon, C. Maxwell, and A. Castro, Systematic Inequality and Economic Opportunity (Center for American Progress, August 2019), americanprogress.org/article/systematic-inequality-economic-opportunity.

7. K. Marsh and H. White, “‘Racialized Myths,’ Medical Exploitation, and Dire Results,” Pulitzer Center, August 31, 2024, pulitzercenter.org/stories/racialized-myths-medical-exploitation-and-dire-results.

8. H. Fischer, “Drapetomania: A ‘Disease’ That Never Was,” Hektoen International (Fall 2022), hekint.org/2022/10/06/drapetomania-a-disease-that-never-was.

9. E. Largent, “Public Health, Racism, and the Lasting Impact of Hospital Segregation,” Public Health Reports 133, no. 6 (September 17, 2018): 715–20.

10. M. Andrews, “1965: The Year That Brought Civil Rights to the Nation’s Hospitals,” KFF Health News, August 9, 2016, kffhealthnews.org/news/1965-the-year-that-brought-civil-rights-to-the-nations-hospitals.

11. F. Fletcher et al., “Newly Released Documents from Untreated Syphilis Study: Ethical, Just, and Respectful Use of Archival Materials,” Hastings Center for Bioethics, November 27, 2023, thehastingscenter.org/newly-released-documents-from-untreated-syphilis-study-ethical-just-and-respectful-use-of-archival-materials.

12. J. Sabin, “How We Fail Black Patients in Pain,” AAMC, January 6, 2020, aamc.org/news/how-we-fail-black-patients-pain; and M. Morales and R. Yong, “Racial and Ethnic Disparities in the Treatment of Chronic Pain,” Pain Medicine 22, no. 1 (January 2021): 75–90.

13. J. Vo et al., “Health Disparities,” Clinical Journal of Oncology Nursing 25, no. 5 (October 2021): 17–24.

14. A. Faloye, B. Houston, and A. Milam, “Racial and Ethnic Disparities in Cardiovascular Care,” Journal of Cardiothoracic and Vascular Anesthesia 38, no. 8 (August 2024): P1623–1626.

15. D. Sue, “What to Know About Microaggressions,” Health Matters, November 10, 2020, healthmatters.nyp.org/what-to-know-about-microaggressions.

16. J. Platt and L. Taylor, Measuring Trust: Where Are We and Where Do We Need to Go? (AcademyHealth, 2024), academyhealth.org/sites/default/files/publication/%5Bfield_date%3Acustom%3AY%5D-%5Bfield_date%3Acustom%3Am%5D/trust_measures_compendium.pdf.

17. A. Anderson and D. Griffith, “Measuring the Trustworthiness of Health Care Organizations and Systems,” Milbank Quarterly 100 (June 2022): 345–64.

18. J. Birkhäuer et al., “Trust in the Health Care Professional and Health Outcome: A Meta-Analysis,” PLOS ONE 12, no. 2 (2017): e0170988.

19. R. Benkert et al., “Trust, Mistrust, Racial Identity and Patient Satisfaction in Urban African American Primary Care Patients of Nurse Practitioners,” Journal of Nursing Scholarship 41, no. 2 (June 2009): 211–19.

20. L. Sullivan, “Trust, Risk, and Race in American Medicine,” Hastings Center Report 50, no. 1 (January/February 2020): 18–26.

21. Sullivan, “Trust, Risk, and Race.”

22. M. Hostetter and S. Klein, “Understanding and Ameliorating Medical Mistrust Among Black Americans,” Commonwealth Fund, January 14, 2021, commonwealthfund.org/publications/newsletter-article/2021/jan/medical-mistrust-among-black-americans.

23. AAMC Center for Health Justice, “The Principles of Trustworthiness Toolkit,” aamc.org/trustworthiness#principles; and Sullivan, “Trust, Risk, and Race.”

24. Sullivan, “Trust, Risk, and Race.”

25. J. Graham et al., “Influence of Trust on HIV Diagnosis and Care Practices: A Literature Review,” Journal of the International Association of Providers of AIDS Care 9, no. 6 (November 2010): 346–52.

[Illustrations By Jesse Zhang]