“The doctor is treating the disease,” says Marlo Robinson, dean and vice president of Purdue Global School of Nursing, who has more than three decades of experience as a nursing and health care leader. “We’re the ones who are with the patients living with the disease.”
The trust gap isn’t new, but it’s widening. Experts say the reasons for it have to do with how American medicine is structured, taught, and paid for, and because the people patients see most aren't always the ones making the decisions.
Given these differing responsibilities, nurses simply spend more time with patients than doctors do. Doctors work in episodes, Robinson says: They pop in for morning rounds, an afternoon procedure, or a 7-minute consultation. Nurses, on the other hand, often work in 12-hour shifts that allow them to notice changes big or small. “We’re with patients moment to moment,” she says.
Doctors aren’t actually spending less time on their patients than nurses, says Dr. Danielle Ofri, a primary care internist at Bellevue Hospital in New York. They’re spending it differently—often invisibly. They’re adding documentation to the patient’s chart, calling consultants, tracking down a CT result, and arguing with insurance. And, increasingly, they’re checking the patient portal during off-hours, because patients now see their results the moment they post and Ofri doesn’t want anyone sitting alone with a scary result. “When my patient finishes the visit and leaves the room, I'm not done with them,” Ofri says. “I don't know if patients recognize how much work their doctors are putting in behind the scenes.”
Still, nurses’ visible presence isn’t just reassuring; it’s measurable. A growing body of research has linked nurse staffing levels to patient outcomes, with study after study finding that hospitals where nurses care for too many patients at once see higher rates of complications and death. “When you don’t have enough nurses, people die,” Brown says. “That’s not me being dramatic. That’s what the research shows.”
That tracks with what Robinson sees. "We're the early warning system,” she says. “We're noticing these sometimes imperceptible shifts—a slight change in skin tone, fatigue, oxygen levels dropping, a shift in the way they're breathing, a look of quiet panic. We move oftentimes faster than our monitors and machines because we see it and we know what it means."
Patients tell nurses things they won’t tell doctors
The trust gap isn’t only about who’s in the room. It’s also about what patients are willing to say to who’s there.
“It’s almost like this idea of, you don’t want to be whining to the doctor,” Brown says. “It’s sort of like, ‘Don’t bother daddy in his study.’”
Patients often pick up on who feels easiest to talk to. They watch nurses’ faces while doctors talk, and then wait until the doctor leaves the room to ask what the doctor actually meant. “Patients see nurses as more approachable,” Frykenberg says. “We’re the ones who translate.”
Brown thinks the dynamic is partly about jargon, partly about white coats, and partly about an unspoken medical hierarchy patients have absorbed long before they get sick. The result, she says, is that doctors get an edited version of what’s happening with the patient in front of them. Nurses get the unedited one—and they spend a lot of their time relaying it back to doctors. Sometimes that means flagging a symptom the patient downplayed, or asking the doctor a question the patient was too intimidated to voice.
Some patients just assume that nurses are simply nicer people than doctors—that nursing attracts the kind of person who wants to sit at a bedside, while medicine attracts the kind who wants to solve a problem and move on. Yet nurses push back on that idea. Rather than having certain personality traits, their training emphasizes a particular set of skills.
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Medical school, on the other hand, is structured differently. Communication is part of the curriculum, but it isn’t the spine of it. “It’s the add-on, not the primary thing,” Ofri says. The volume of clinical material doctors are expected to learn is enormous, and the time available to teach students how to talk to patients has shrunk accordingly.
Nurses don’t carry the system’s baggage—and patients can feel it
Brown has noticed that her patients increasingly wonder, sometimes out loud, whether the doctor recommending a treatment or procedure has a financial stake in the recommendation. “As money has become more and more integral to our health care system, people's trust in their physicians has taken a big hit,” she says. “They know they need to see a doctor, and yet at the same time they think, ‘Well, is this person just trying to make money off me?’” She doesn’t think most patients believe their doctor is acting in bad faith—but then may carry an unconscious sense that medicine has become a commodity.
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The flip side of all of this is advocacy. Because nurses aren’t paid by the procedure and because their professional code formally orders the patient ahead of the employer, they’re often the ones who push back when an institution’s interests and a patient’s interests diverge, Kennedy says. “We protect the patient from the interests of the system.”
She thinks the deepest version of the trust patients place in nurses shows up at the end of medicine’s reach—in the moments when curative treatment has run out and there’s nothing left for a doctor to do. When that happens, she says, a doctor’s role sometimes narrows, while the nurse’s doesn’t. Nurses help manage a dying patient’s pain, sit with their family, and stay in the room when a cure is no longer an option.
“The most profound trust occurs when medicine can’t do anything else,” Robinson says.
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