About 4.5 billion years after the Big Bang, the world’s first rheumatologist emerged.
At first, there was an incomprehensibly loud explosion. And out of that explosion, about 4.5 billion years afterward, emerged the world’s first rheumatologist. Only a few notable things have happened between these two events, but the most important dynamic has been the continuous expansion of our universe. If the speculations of many cosmologists are correct, this expansion will continue, possibly indefinitely, until we end up in a place where galaxies, stars, and even individual atoms distance themselves and isolate themselves into a cold nothingness.
Certainly, this cosmic distancing is happening at such a slow pace that none of us can feel it occurring. Yet we do feel another shift that is occurring in front of our very eyes. Our society and our healthcare systems are ripping apart at the seams, with entire communities dominated by loneliness and mistrust. However, unlike the expansion of the universe, there is something that we rheumatologists can do. So what is our role in stitching together our world? Let’s rheuminate!
For our patients with rheumatic diseases, the stakes appear even higher. Chronic pain, fatigue and physical limitations can isolate individuals, cutting them off from social networks and leaving them to grapple with their conditions in solitude.2 Further, this loneliness can be even more debilitating in the context of already heightened risks of cardiovascular disease and depression in folks with autoimmune disease.
As rheumatologists, we are uniquely positioned to recognize and address the role loneliness plays in our patients’ health. We are privileged that our field involves long-term relationships with patients. We see them repeatedly over years and decades, monitoring their disease activity and empowering them with tools to regain function. This continuity of care allows us to observe patterns that might otherwise go unnoticed—withdrawal from activities, a shift in mood, or comments about feeling disconnected. Identifying (and documenting) these signs is the first step in addressing loneliness.
But what can we do beyond recognizing the problem? One approach is to have a larger interprofessional care team to help address these issues. Physical therapy and occupational therapy can be essential in helping remove social barriers associated with physical limitations. Psychologists and other mental health specialists may similarly provide tools to address mental health issues that contribute to loneliness.
Additionally, clear communication with primary care clinicians may plug people into larger networks that can address loneliness. Indeed, our geriatric colleagues have long grappled with managing patients who feel socially disconnected, and we can learn much from the interprofessional networks they have created.
Another approach is to foster community within and between our clinics. Support groups, either in person or virtual, can provide a space for patients to connect with others facing similar challenges. These groups do more than share information; they offer solidarity, validation and a sense of belonging.3 Similarly, we can encourage patients to engage in gentle physical activities as tolerated, such as yoga or water aerobics, that reinforce the link between physical health and social interaction.
On larger scales, combating loneliness requires us to look beyond the confines of our clinics. It challenges us to advocate for systemic changes that prioritize social well-being—policies that promote community building, equitable access to mental health services and the meaningful integration of social determinants of health into clinical care. In addressing loneliness, we not only improve individual outcomes, but also begin to mend the broader social fabric.
Building Trust with Patients
If loneliness is one side of the societal fragmentation coin, mistrust is the other. Nowhere is this mistrust more pronounced than in our healthcare system, where patients are often alienated by opaque systems, rushed interactions and a sense of being reduced to a collection of symptoms. For patients with rheumatic diseases, who frequently navigate complex treatment regimens and the frustrations of delayed diagnoses and treatment, building trust with their healthcare providers is simultaneously critical and challenging.
As any patient or clinician can tell you, trust begins with listening. As rheumatologists, we pride ourselves on our diagnostic acumen: It is our ability to listen deeply—to hear what is said and unsaid—that lays the foundation for our field. Not coincidentally, these foundations are also the same for the building of trust. When patients feel heard, because they are heard, they are more likely to share openly, adhere to treatment plans and collaborate in their care. This requires more than just asking questions; it demands a commitment to being fully present in the encounter, free from the unneeded distractions of ubiquitous electronic health record systems, ticking clocks, or social media.
Transparency is another cornerstone of trust. We have an obligation to go beyond and educate patients on why we recommend the treatments that we do. Explaining the rationale behind a treatment plan, acknowledging uncertainties, and discussing potential side effects in a way that is understandable to both the patient and clinician openly fosters an equitable sense of partnership.
Just as importantly, trust is built over time. In outpatient rheumatology, we have the capacity to show our dedication, time after time and visit after visit. Patients are watching for consistency of our efforts. Therefore, each follow-up visit is an opportunity to strengthen the relationship, to celebrate progress, and to navigate setbacks together. This continuity not only builds trust, but also reinforces the therapeutic alliance that is essential for managing chronic disease.
Sustaining Trust Within Communities
Clearly, individual patient-physician relationships are the building blocks of a culture of trust, but bonds must also be strengthened at the community level. Communities that trust their healthcare providers are more likely to engage in preventive care, participate in research, and adhere to public health initiatives.4 Conversely, communities where mistrust prevails are at greater risk of health disparities, vaccine hesitancy, and poor outcomes.5
As rheumatologists, we can play a role in fostering community trust by extending ourselves beyond our clinical practices. Engaging with local organizations, speaking at community events, and participating in health fairs are tangible ways to demonstrate our commitment to the well-being of the broader population. These actions humanize us as physicians, breaking down the barriers of hierarchy and formality that often distance clinicians from the communities they serve. However, for these approaches to be sustainable, there needs to be a means of reimbursing outstanding rheumatologists for their community outreach.
Representation matters, too. There remains much work to be done to ensure the rheumatology workforce is as diverse and representative as the groups we care for.6 Support for ongoing intentional efforts to recruit and mentor a diverse pipeline of rheumatologists, as well as designing studies that prioritize inclusivity, are necessary. When communities see themselves reflected in the healthcare system, there is a potential for the creation of trust.
Moreover, sustaining trust within communities requires acknowledging past wrongs conducted by the medical community and working to prevent future harm. Historical injustices, from unethical research practices to systemic discrimination, have left deep scars in many marginalized communities. As rheumatologists, we must join hands with others to advocate for equity in care delivery, transparency in research, and policies that address the root causes of health disparities. Trust is not given; it is earned through consistent, meaningful action.
Countering Misinformation in Science
Compounding the problem of mistrust and loneliness is misinformation. In the age of social media and the 24-hour news cycle, misinformation spreads rapidly, eroding trust in science and medicine faster than we can build it. For patients with rheumatic diseases, who often turn to the internet for answers, the abundance of often conflicting and inaccurate information can be overwhelming and harmful. As rheumatologists, we have both the responsibility and a great opportunity to counter misinformation with evidence-based, compassionate communication.
One of the first steps is recognizing the power dynamics at play. Patients often feel intimidated or dismissed when questioning medical advice, which leads them to seek validation from less reliable sources. By creating a safe space for questions and concerns, we can guide patients toward accurate information without judgment. It’s not enough to say, “Don’t ask Dr. Google.” We must actively provide resources that are accessible, trustworthy and tailored to their needs.
Education is another critical component. Whether it is through patient handouts, clinic websites, or public health campaigns, we can take an active role in shaping the narrative around rheumatologic diseases and treatments, as the ACR currently does. Social media, when used thoughtfully, can be a powerful tool for disseminating accurate information and engaging with patients in real-time. Such platforms as X (Twitter) and Instagram allow us to reach audiences far beyond our clinics, building a digital community grounded in trust.
Finally, countering misinformation requires collaboration. Volunteering with the ACR, as well as partnering with patient advocacy groups, public health agencies and others, amplifies our message and ensures consistency across channels. When patients hear the same accurate, evidence-based information from multiple sources, they are more likely to trust it. In this world increasingly saturated with noise, our collective voice as rheumatologists can serve as a beacon of clarity.
Can We Teach Trust Building in Rheumatology Fellowship?
If trust is so central to our work, then surely it must be a teachable skill. Yet until fairly recently, traditional medical education seemed to focus more on technical competencies than on the interpersonal dynamics that underpin trust. As educators, we have an obligation to ensure that the next generation of rheumatologists is not only clinically adept but also skilled in building and sustaining trust.
Teaching trust building begins with modeling it. Fellows learn not just from what we say, but from what we do—how we listen to patients, how we navigate difficult conversations and how we admit when we don’t have all the answers. Through everyday demonstrations of vulnerability and empathy, we show trainees that trust is not about projecting infallibility but about cultivating authenticity.
Structured opportunities for learning are also essential. Role-playing scenarios like objective structured clinical examinations (OSCEs), reflective writing exercises and longitudinal mentorship programs can help fellows and other trainees develop their communication and relationship-building skills. Encouraging trainees to seek feedback from patients and peers creates a culture of continuous improvement, where trust building is seen as an ongoing process rather than a one-time achievement.
Finally, we must acknowledge the systemic factors that influence trust. By the time of their graduation, fellows need to understand how social determinants of health, healthcare disparities and institutional biases affect their patients’ experiences. By integrating these discussions into curricula throughout the nation and the world, we prepare trainees to navigate the complexities of trust building in diverse, real-world settings.
Conclusion: Stitching Together Our World
As the universe continues its slow, inevitable expansion, we are left to contend with the more immediate fractures in our own world at this very moment. Loneliness, mistrust and misinformation threaten the fabric of our society and our healthcare systems. As rheumatologists, we have the tools—and the responsibility—to stitch together these fraying threads for the benefit of our patients and ourselves.
Through our relationships with patients, our engagement with communities, and our steadfast commitment to truth (regardless of popularity), we can create a tapestry of trust and connection. It is very clearly not an easy task, nor one that will be completed in a single year, or even a single generation. But with each small act of listening, educating, and advocating, we move closer to a world that is not only healthier but also more unified.
Yes, the universe may keep inexorably expanding, but so too is our capacity to care, to connect and to build trust. Let’s not let that opportunity slip away.
Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on X (formerly Twitter) @BharatKumarMD.
References
- Powell SK. The loneliness epidemic. Prof Case Manag. 2024 Mar–Apr;29(2):1–2.
- Vestergaard SB, Esbensen BA, Midtgaard J, et al. Associations between loneliness, disease activity, and disease impact in inflammatory arthritis: A nationwide cross-sectional study among > 12,000 patients. Rheumatology (Oxford). 2024 Sep 11;keae471.
- McCarron A. An exploration of the perceived effects of a support group for individuals with rheumatoid arthritis. J Am Assoc Nurse Pract. 2015 Mar;27(3):160–166.
- Nandyal S, Strawhun D, Stephen H, et al. Building trust in American hospital-community development projects: A scoping review. J Community Hosp Intern Med Perspect. 2021 Jun 21;11(4):439–445.
- Charura D, Hill AP, Etherson ME. COVID-19 vaccine hesitancy, medical mistrust, and mattering in ethnically diverse communities. J Racial Ethn Health Disparities. 2023 Jun;10(3):1518–1525.
- Sawalha AH, Allen KD, Feldman CH, et al. Diversity and inclusivity in rheumatology publications. ACR Open Rheumatol. 2024 Nov; 6(11):732–733.
