Practical Strategies to Build Trust With Diverse Patient Populations

Very nice to meet you all. It is lovely to have you all here this evening. As I said for those who missed it, I am Dr. Itunu Johnson Sogbetun, and this evening we are going to be talking about practical strategies to build trust with diverse populations. A little about me: I have not put all of my CV, but I have been a doctor for 15 years, which is absolutely crazy. I qualified in 2011 and I am a GP (in some countries, a family doctor or family practitioner), which is a primary care specialist. I am also a specialist in women's health, sexual health, and menopause. I teach medical students at Queen Mary's, which is part of the University of London. I also do equity, diversity, and inclusion at the Royal College of GPs for the Faculty of Northwest London. I am also co-chair of the Women's Health Special Interest Group at the Royal College of General Practitioners. I am really excited to be here to talk about something that is really important to me, which is building trust. Even though I am a clinician sitting in front of you as a doctor, I have also been a patient. I was diagnosed with hypertension at age 27. At the time, my blood pressure was so high it was around 190 over 110. It was crazy. I was privileged because I am a clinician, so I could figure out: I have headaches, I need to check my blood pressure. The GP who saw me at the time thought this was probably a fluke. I was privileged enough to be referred for 24-hour blood pressure monitoring, and they picked up that my blood pressure was very high. I could have had a stroke. I could have not known and developed complications like kidney problems, as many people who are Black like me, but who do not have some of the privileges that I have, have experienced. That was just the beginning of my journey. I have had other healthcare experiences. I combine my personal insight with professional expertise as a clinician, and as a passionate clinician, to ensure that the care I provide is tailored to the patient and that I can build trust with patients. It is from these joint lenses that we are going to have this conversation today. A time to reflect. Many of you will be at the beginning of your medical career. Some of you might be a little bit more established. This is a time to honestly reflect, and you can write in the chat: have you ever thought, "This patient is difficult"? We have terms that are used in the UK that are somewhat derogatory, like "heart-sink patient" and "frequent flyer." I remember when I was working in the emergency department a few years ago as a junior doctor. We had patients who would come in with all-over body pain. Many of these were women in their 40s to 50s, and many were from ethnic minority backgrounds. At the time, I was not a menopause specialist. It took me several years to reflect and realize: many of these women, because we would do blood tests and not know what was going on, may have been presenting with menopausal symptoms, but we were not thinking about it. We were labeling them as difficult, but they were not difficult. They were presenting in a different way to what we were expecting. Have you ever judged a patient's choices or beliefs? They say, "I do not want to take my blood pressure medication. I want to take herbal medication." This can be common in certain communities. Have you judged that and thought, "That is ridiculous"? Or patients who say, "I do not want vaccinations." Have you thought, "Oh my gosh, you are making other people sick"? You might not say it out loud, but have you thought it? Have you ever assumed a patient is not going to listen, or if they have not listened, have you challenged why? Or do you just label, "They missed the appointment" or "They are non-compliant"? Have you ever felt awkward talking to someone different from you? Maybe you do not understand their nuances, or English is their second language, or you are speaking through an interpreter and you feel the conversation is difficult. Have you skipped a patient because you think the conversation is going to be really long because English is not their first language, and you would rather speak to a patient who is more fluent in English? Have you ever felt awkward talking to someone, maybe a patient who wears a hijab, and you do not understand anything about Muslim culture and you are worried you will offend them? As human beings, we all have our own ingrained biases and personal judgments. That is not necessarily wrong. It is what you do about it and how it can impact trust in the patient consultation. I am not saying this to make you feel judged. We have all done this at some point, and we will still do it. It is about thinking about it. Why is this patient difficult? That is where we can change the narrative, and we are going to talk about this in a minute. Why are they choosing not to have vaccines? Rather than just judging the choice, we need to think about the why. How do we know they are non-compliant? Why will they not follow advice? Could there be something else going on? Maybe they cannot follow the advice because they cannot afford to pay the prescription charge. We do not know if we do not ask, or if we do not push beyond. We all come from different cultural backgrounds. Remember: everybody has culture. Being American, being Caucasian American, you have your own culture, and there are different subcultures. You could be from Italian American heritage or Irish American heritage. Everybody has their own culture. You could be African-American. You could be African who is American. You could be African-American descended from slaves. You could be Caribbean American and classed as African-American. There are many cultural lenses in that. As Asian-American, you could be from China or Japan. It is all different cultures. We are always going to have someone who is different. The question is: how do we approach difference? Are we afraid of it, or do we embrace the fact that we are all different and we all come with a beautiful flavor? There is beauty in our diversity. Let us think about these two patients. The patient on the left side of the screen is labeled, "She keeps missing appointments." This is a 50-year-old woman with type 2 diabetes. She is not coming for her appointments, and her HbA1c is through the roof. It is frustrating as a clinician because you know you can help her get better, but you need to look into what the issue is. This is the reality of her life. She needs to work. She is working zero-hour jobs; if she does not work, she does not get paid. She is also caring for her grandchildren because her children have difficulties in their personal lives and she has to support her grandchildren. Where she lives, there is limited access to fresh food, and she struggles financially. So she buys what is available, which is not always the healthier option. When she eventually comes in, she feels the doctor is not listening to her. She has questions about medication. She is having side effects. She has been put on metformin and is having GI side effects, but she feels that when she mentions it, she is not being listened to. As a result of her chaotic lifestyle, much of which is not her fault, she is missing appointments, her HbA1c is through the roof, and she is almost giving up. This is a situation where trust is breaking down in the clinical relationship. We could just label it as "She misses appointments" (in the UK we say DNA, did not attend), but if you want to go the extra mile, you can think: how can I support her better? Is there social services support that might help with vouchers for fresh food? Is there a way to be more flexible, such as appointments by telephone so she does not have to miss work? Depending on where you work, is there an opportunity to prescribe physical activity, such as a charity or volunteer sector program that could support her with manageable physical activity? You will not have all the answers, but it is about thinking: how can I support this patient and overcome the realities to help her have better care? That is what we call trying to achieve equitable healthcare. The patient on the right is a 28-year-old woman with pelvic pain. She has had investigations. Her periods are really, really painful. Her scan was normal. Blood tests are normal. You want her to try a hormonal contraceptive to see if it helps improve her pelvic pain because you think it could improve her quality of life. She is missing days of work because of her heavy and painful periods. The pelvic pain is impacting her relationship because sex is painful. You are explaining: we have not found anything on the scan, we have done blood tests, surgery is high risk because it could damage the bladder and bowels, but if you try the medication, we can use it as part of the diagnostic context to see if symptoms improve. That could make us think there is underlying endometriosis or something we have not picked up on scan, and it could improve her quality of life. That is your thinking. But she is saying, "No, I do not want hormones. No, no, no. Doctors always come with hormones. You are medically gaslighting me. You are not taking my concerns seriously." She has fear because she has family members who have had breast cancer, and she has been told the narrative that it was the pill or hormones that caused it. She has been watching TikTok videos from so-called experts telling her not to use hormones, that they are unnatural, and pushing supplements. The algorithm keeps feeding her more of the same. She lives in the US but was not born there. She can speak English, but it is not her first language, and there is nuance she might not fully understand. You might label her as someone who Googles everything and is not listening, but underneath this is fear, and that fear has broken trust. How often do we expect trust without first checking if the patient feels safe? Our clinical rooms and consultations should be a place of safety, not a place where patients feel judged. That can be tricky because how we communicate, our nonverbal communication, our verbal communication, our pre-existing bias, and even how we present ourselves as clinicians can contribute to, or undermine, that feeling of safety. Why does this matter? It is about outcomes. We want equitable outcomes for everybody. We want everybody to have good quality care, but we know some people have worse quality care, and low trust is a massive contributor. Low trust means missed appointments, non-compliance, delayed care, and poorer outcomes. If people do not trust healthcare, they are more likely to stop treatment early, less likely to come for follow-ups, and less likely to engage. This leads to poorer outcomes, and it does not affect all groups equally. Here are general examples across groups that might struggle with equitable healthcare. In the Black community, Black women are up to four times more likely to die in pregnancy and childbirth, in the US and the UK. In a country with access to top-level care, it is extremely sad that we still see these outcomes. Black men are twice as likely to die of prostate cancer. Black women get breast cancer less often but are more likely to die from it. Black children are twice as likely to die at birth than White children. In Asian populations, there are higher risks of stomach cancer. If you are not thinking about it, you may not push further when someone presents with symptoms. I had a patient with Chinese ancestry who came in with vague abdominal symptoms. The initial tests were normal, but I pushed further because of higher risk and family history. In addition, within many Asian communities, there may be difficulty engaging with mental health treatment depending on generation, and there may be difficulty with English proficiency or nuance. Someone can speak the language but not fully understand the nuance of how we explain things, and that can impact shared decision making and outcomes. In the Hispanic population in the US, 18 percent are uninsured, making it more difficult to access care. There can be increased food insecurity. We know the pressures Hispanic communities are experiencing across the United States at the moment; many are struggling to go to work. Mental health services can be underused. There can be mistrust and language barriers. Feeling safe is a huge issue, especially now. In the American Indian and Native American population, life expectancy is the lowest of any US racial group. There are huge barriers to accessing care. Some communities are uninsured and struggling to access care, and that impacts outcomes. It is about building trust and building ways to reach these communities rather than thinking of them as hard to reach. There are also communities with genetic heritage that increases the risk of certain health problems. BRCA mutations can affect about one in 40 people of Ashkenazi Jewish background, so breast and prostate cancer risk is extremely high. For people with a Celtic background, conditions like cystic fibrosis can be higher risk. If you are not thinking about these risks, you are not thinking about how to provide equitable care. What erodes trust? You see the tip of the iceberg: mistrust and disengagement. But at the bottom is systemic neglect, bias, systemic racism, institutional racism, and people feeling their symptoms are minimized or missed. Language matters, not only whether someone speaks English, but also nuance, jargon, and clarity. People may not understand the plan. When I can see it is difficult for a patient to understand, I send them a text: one, this is the plan; two, this is the outline. Sometimes I print it out so they can take it home and tick off the boxes. You do everything you can to ensure understanding and follow-up, especially when you know there is a high chance it might not happen because of other challenges. Some patients get everything quickly. Others need additional time and effort, and that is what equity is about. Cultural disconnect erodes trust. Each person has their own culture. Beliefs about illness and wellness matter. If you do not explore their background and cultural beliefs, you may give a plan they will never adhere to because it does not match their beliefs. Shared decision making requires understanding their background. Past experiences matter. If someone has had a bad experience or trauma, whether medical gaslighting or systemic discrimination, it can lead to defensiveness and disengagement. It might not have been you, but you still have to build trust going forward. Even if the system broke trust, when they see you as a doctor, they may see you as the system. You have to acknowledge that and say, "I am here to listen. I am here to validate." This connects to cultural competence. Every person has a culture. Culture is not limited to ethnic minority groups. I see many patients from an Irish Celtic background, and stoicism and carrying on can be part of that culture. In menopause, they do not want to make a fuss. They say, "It is all fine," but it is not fine. Not every Irish woman is like that, but I have noticed patterns over time. Cultural competence is care that reflects reality: respecting and understanding the background people come from, what they bring into the consultation, and the loads they carry. It improves communication, trust, and understanding. Intersectionality matters because compounded discrimination based on race, gender, class, sexual orientation, and socioeconomic status can interact. You are the expert in medicine, but the patient is the expert in their own body, and we should treat it as a meeting of two experts. This is a busy slide, but follow me. These are learning strategies for building trust. The mindset is: be curious. Ask about the patient's life and circumstances, not just symptoms. Show humility and recognize the patient is the expert in their own body. Think about trauma and culture and how they shape the consultation. Create safety by listening and believing the patient, educating clearly, using simple, respectful, culturally aware language, and reinforcing it as needed to ensure clear communication. Use language that builds safety. Avoid medical jargon. Use people's preferred names and pronouns. Think aloud and explain your thinking process. I often show patients the guidelines I have based treatment on. In the UK we have Clinical Knowledge Summaries, and I show them the treatment options and where the advice comes from. That reduces fear because they can see it is evidence-based. Check for safety: "What worries you about this?" If you can see they are still uncomfortable or unresolved, ask, "I can still see you have concerns. Can you tell me what you are worried about?" Check understanding: "Can you tell me what you have understood from our conversation? I want to be clear we are on the same page." Ask what will make the plan hard to follow. For the diabetic patient, telling her to do 150 minutes of exercise and follow a Mediterranean diet may not fit her circumstances. Tailor it: maybe dancing with the grandchildren is a way to get physical activity. Make suggestions that are doable, not onerous, and not judgmental. Acknowledge past harm and systemic bias. This can be difficult, especially if you feel it had nothing to do with you. You are not taking on blame; you are validating lived experience and not being defensive. You can acknowledge: "I know the system has not always treated people fairly." We know certain communities have been experimented on and excluded from research. Women were not involved in much medical research until the 1990s, and that is before we even consider ethnic groups, socioeconomic classes, sexual identities, backgrounds, and genders. We want to repair trust when it is broken. Mistakes happen. It is not necessarily the mistake that destroys trust; it is how it is handled and whether you repair the breach. Apologize. Own the impact, not just the intent. Be transparent about what happened. Explain risks, uncertainties, and waiting times. For example, in the UK, the waiting list for a child autism assessment can take up to two years or longer. I had a mother with a four-year-old with really difficult behavior, likely autism but not diagnosed. The child had been on the waiting list for two and a half years. I wrote to the children development service, but I still had to explain to the mother that, despite the letter, it might take more time. Be transparent. Do not promise what you cannot deliver. Invite feedback: "How can we make this better for you?" Share decisions. We are coming to the end of the talk. Practical strategies: practice active listening. It can be difficult because you have to give the patient time. In the UK we call it the golden minute: let them talk and do not interrupt. Use open questions at the beginning of the consultation to give space, especially for patients who may not offer as much. Show empathy, maintain eye contact, clarify, summarize, and reflect back to ensure mutual understanding. Suggest diverse resources. Do not share information that does not fit their context. For example, what does a Mediterranean diet mean to someone from a South Asian background? They may need guidance on how their own foods fit a diabetic diet. It is not a one-size-fits-all approach. With menopause, the average age of menopause in Black women is around 48 to 49, and in South Asian women (Indian or Pakistani background) around 46. If we say the average age is 51, that is for a Caucasian woman. Provide resources that match their experience. Patients should see people who look like them in the resources. Respect privacy. Build follow-up. Follow-up builds relationship, improves outcomes, and builds trust. Make trust a daily practice. Think of one thing you can do each day to build trust with your patients. Inequities exist. Trust drives engagement and adherence. What is your actionable strategy from today? Learn to listen, validate concerns, and check for understanding, because cultural competence, trauma-informed care, and equitable care save lives. I am going to end it there. Please remember that for attending this webinar, you can get 15 percent off Osmosis. That is a QR code you can scan to get the discount code if you want to take advantage of it. I am at the end of my talk, so now it is time to answer questions. We have a few in the chat. In what ways has diversity among your staff or leadership influenced trust with patients from different communities? Representation matters. It matters hugely because when you can see someone who looks like you among clinicians or in leadership, you can feel represented and more confident about the care being delivered. We treat a diverse community of patients, so we want a diverse community of healthcare professionals because it improves trust and outcomes. There is evidence from the US showing that when Black newborns are looked after by Black midwives and Black nurses, they are more likely to survive. Any clinician should be able to look after anyone, and I am not saying you should only be looked after by someone from your background. We are a team. But when we have diverse thoughts, it builds all of us up. We learn from each other, and we better serve the community. How do you approach shared decision making when cultural beliefs or family dynamics influence treatment choices? I see this a lot. For example, with HRT in women from Black or South Asian backgrounds, in some South Asian communities the word menopause does not even exist. It can be taboo. There is fear around HRT, and I have had patients say they thought HRT was just for White women. There is fear about breast cancer. People receive WhatsApp messages saying Western doctors are trying to give you HRT and it will cause breast cancer. The first step is to understand. The second is to listen and believe, and not make them feel stupid or judged. Say, "I can see where you are coming from." Explain the context and the nuance of current evidence. I often explain that the added risk is small and focus on quality-of-life benefits. I do not always win in the first consultation, and I do not push too hard. Sometimes it is a knock on the door: I tell them to go and think, and I send culturally appropriate resources so they can hear other voices from their community and then come back for a second conversation. Pushing too hard can feel like an oversell and break trust. Space can help. Similarly, with hypertension treatment, some communities prefer traditional medicines. Rather than judging, align on the shared goal: you want their blood pressure better, and so do I. Ask what is in the traditional medication. Sometimes we do not know what is in it, and some products may contain harmful ingredients. With regulated medicines, what is on the box is what is in the box, and it has been tested. Sometimes I share my own experience: I have been on blood pressure medication since I was 27, and it has helped me stay well without complications. How do you maintain trust in telehealth or digital tools with patients who may be new to technology or have privacy concerns? Check they are in a room by themselves. If they cannot be, suggest headphones or finding a more private space. It is important they have space to talk. Telehealth can be trickier; it can take longer to build rapport without face-to-face interaction. But you can still communicate care, compassion, empathy, and listening. Reassure them that you are also in a private space and maintaining privacy. How do you measure trust over time and what metrics have been most actionable for you? You can track outcomes over time, for example improved HbA1c if you are working on diabetes management. You can do audits based on interventions. Clinically, you can see whether patients are coming back, improving, and engaging. In mental health, continuity of care matters. Over years, you can see patients move from a very difficult place to better functioning, even with occasional blips. That relationship and improvement reflect trust building over time. Where do you turn for diverse resources? There are many places. For example, in the UK, Diabetes UK has resources, and there is Diabetes Africa for the African community. There are also resources for the South Asian community. In the US there are similar organizations. It takes some searching to find well evidence-based resources. Charities, colleges, and professional societies should have diverse resources. If you cannot find what you need and you are passionate, make it. I could not find a menopause resource for Black women, so I wrote one called "Your Personal Guide to Menopause for Black Women," and it has been shared widely and has helped women in the UK and internationally. Can you share a time when you realized a miscommunication impacted trust and how you repaired it? I had a patient who kept coming to see me about hormone tests that clearly showed she was menopausal. She was from an African country but lived in the UK. I explained menopause and treatment options, but she kept saying, "Why are you telling me I have menopause? I do not have menopause. I am still young." She was in her early 40s, but her tests clearly indicated menopause. She seemed really upset. Eventually, I understood the context: she and her husband had been trying for a baby for a long time unsuccessfully. The menopause diagnosis felt like a finality that she would never have that baby. Her husband had gone back to the African country, married another wife, and was trying to bring her to the UK. The patient felt that accepting the menopause diagnosis would be "nailing the coffin" to her marriage. She knew I was giving the right information, but she was not ready to accept it. We were able to talk, unpack it, and I listened and validated her fears. We discussed options like adoption and other ways she might support a child. She left feeling better. It could have gone badly if I had persisted in a purely black-and-white way without understanding the context. At first, I did not understand the context and went straight to the diagnosis, which I later realized landed like a slap in the face. We are coming to the end of the questions. I hope you found this useful and that you can take something forward in your career. It has been a pleasure and a joy speaking to you all. Have a wonderful evening. Very nice to have seen you all. Helping current and future clinicians focus, learn, retain, and thrive. Learn more.