Patient trust in the surgeon-patient relationship can be enhanced through individual and institutional factors.15 Individual surgeons increase trustworthiness through education, clinical skills, and peer review. The emphasis on normative behavior standards including honesty, integrity, and putting the patient's interest first characterize the surgical residency training.16 Comprehensive sociological investigation has documented what many graduates of such programs appreciate, that the residency system forgives technical errors but not moral failings.12 Moral failings, such as the failure to see and evaluate a patient promptly, are addressed more seriously by attending staff than deficiencies of technique in the operating room. In morbidity and mortality conferences required in surgical departments around the country, residents and staff review errors to, hopefully, minimize recurrence and correct failures in judgment. In practice, the surgeon's fiduciary obligation includes the ability to perform careful, competent surgical procedures. Patients' expectations of competence and skill, while present for all physicians, may be more important for surgeons because of the higher potential for long-lasting even irreversible damage (or its perception) and the immediacy of the need for therapy. Contrast this with the situation in primary care, where expectations of excellence in every category are unrealistic, and where multiple positive experiences of competence can be taken into account when a patient encounters a single bad experience. Although patient outcomes may vary, competent practice that nevertheless results in a bad outcome can morally justify trust even if the outcome itself weakens it. Finally, completion of national board certification, membership in professional societies, and attendance at continuing medical education meetings may enhance the trustworthiness of individual surgeons. The American College of Surgeons, for example, has at its core a commitment to provide high-quality ethical care to surgical patients.