The promise of high-quality, affordable care aligning with the individual needs of patients remains elusive. Increasingly, the missing ingredient seems obvious: trust.
The American Journal of Accountable Care. 2019;7(3):24-25Over the past 30 years, even after major strides to expand access, improve outcomes, and control costs, fulfilling the promise of delivering high-quality, affordable care that aligns with the individual goals and needs of this country’s patients remains elusive. Increasingly, the missing ingredient seems obvious: trust.
Everyone recognizes the value of trust in underpinning meaningful, resilient patient—physician relationships. But it’s more than that. Trust in an increasingly complicated and integrated healthcare system requires an ecosystem in which organizations and the individuals within them proactively model trustworthy behavior and nurture it in others. Unfortunately, data show that our levels of trust are low, while the precipitous rise in cynicism and misinformation spreads throughout society.
Gallup polling reveals that confidence in almost all institutions in the United States, including Congress and the news media, has greatly deteriorated over the past 4 decades. What’s especially sobering is the fact that the most dramatic decline has occurred in “confidence in the medical system,” which fell by more than 50%, from 80% in 1975 to 38% in 2019. Confirming this trend, data from the General Social Survey show that confidence in the people running medical institutions has also steadily dropped, from 61% in 1974 to just 37% in 2018.1
As trust in healthcare has declined, alternative sources of information have arisen to challenge and even supplant rigorous scientific knowledge and experience—sources that are accessible on a variety of platforms that make little effort to validate their medical claims. Such information, be it true or false, can have a powerful and potentially dangerous impact on patients. The stubborn persistence of antivaccination messages in the face of overwhelming evidence of vaccine safety is a case in point.
News coverage of dozens of children contracting measles and communities declaring public health emergencies should be urgent clarion calls for a national conversation on rebuilding trust in medicine and science. Overcoming current trends requires a different, collaborative, 360-degree approach that engages everyone. Each aspect of the healthcare ecosystem must examine itself and proactively choose to build trust if we ever hope to improve our healthcare system.
The Trust-Building Journey
At the American Board of Internal Medicine (ABIM), we know firsthand what it’s like to enjoy, and then lose, trust. That’s one of the things that makes me a wounded but wiser messenger. It is humbling to accept that one’s organization has lost trust, as did ABIM, and yet the situation offers an incredible opportunity for transformation. In 21st-century America, getting to trusting relationships is a journey, not a destination. It’s a continuous process that makes us better. ABIM’s organizational learnings about rebuilding trust have educated us about the risks for other healthcare organizations and the importance of proactively focusing on building trust.
Two points of good news: First, although rebuilding trust may require new technology and procedures, it isn’t rocket science. It requires us to act toward others the same way we would like to be treated. Second, we can build on work that’s already being done to replicate and apply those hard-earned lessons to practices across the country. That’s already happening.
Thinking back to one of my own patients, it was her first visit to my office, and I was 30 minutes late. By the time I saw her, she was understandably furious. Instead of being defensive, I apologized sincerely. She calmed down. We were able to start over and tackle the issue that brought her in. For 20 years, we worked together in sickness and health, as patient and physician. That encounter taught me that people need to be respected and heard in the doctor’s office or the trust needed to care for them will never develop.
Last year, the ABIM Foundation asked leaders in healthcare to examine trust in a variety of contexts, interactions, and relationships—including between physician and patient, physician and physician, physician and health system, health system and payer, and physician and government and within healthcare systems—within the communities that they serve. Since January, we have published a series of Viewpoint articles in JAMA based on those discussions, accompanied by suggestions of practical steps to nurture trust, better support patient care, and help laypeople develop a more discerning eye for credible medical information.
In addition to the JAMA series, the ABIM Foundation launched a Trust Practice Challenge to directly address the “trust gap” in healthcare by identifying and promoting existing practices that promote trustworthiness.2 Through the Trust Practice Challenge, the ABIM Foundation recognized 8 organizations for confronting the friction points where trust can break down in the daily practice of medicine, developing new approaches to address them, and putting procedures in place to systematize those solutions. The challenge celebrates the passionate commitment that providers have to their patients and highlights the special insights that they glean from their interactions.
While some of those innovations focus on patients’ interactions with physicians, others examine the important role that institutions like health systems and payers have in developing and deploying technology to improve care coordination. Perhaps most importantly, each of the innovations has a framework that might be measured over time and perhaps recalibrated, if need be, to judge and improve its effectiveness.
As a primary care physician, I felt particularly inspired by UnityPoint Health’s efforts in Des Moines, Iowa, to connect with its LGBTQ patients. In launching a primary care clinic focused on this community, the health system recognized the community’s particular needs and the importance of creating a safe space for patients to feel comfortable by developing a trusting relationship with their care team. After altering a number of care practices, the organization now has an opportunity to close potential gaps in delivering coordinated, patient-centered care.
Beyond Individuals—Organizations Have a Critical Role
Looking ahead, beyond the innovations of individual physicians and their organizations, we seek to identify opportunities to rebuild trust on a scale substantial enough to deliver the quality, affordable, and attentive care that patients deserve. Achieving that vision will require the engaged participation of large organizations with the broad reach and resources to systematize the most promising trust-building approaches.
With the proactive support of organizations, we can forge a new standard of care throughout our healthcare system that recognizes trust as an essential component in quality healthcare. Under this rubric, each stakeholder would be accountable for its contribution to trust in healthcare and charged with identifying pathways to rebuild and nurture trust going forward. Whether it is a major health system, provider association, insurer, gold-standard accreditor, or nationwide patient group, each has a critical and additive role to play in improving the healthcare system.
With Choosing Wisely, the ABIM Foundation launched a national conversation about overuse in healthcare and galvanized a movement with the support of more than 80 partners. Together, we flagged more than 550 commonly overused procedures with limited clinical value and encouraged conversation about them between patients and physicians. In large part, Choosing Wisely is successful because it focuses on the patient−physician relationship. Over time, it built trust, especially between patients and their physicians and among physicians themselves.
Now we need to do more. Rebuilding trust within our healthcare system and nurturing an ecosystem in which trust is a core operating principle requires a more comprehensive and sustained effort. It can’t just be physicians and patients. We need everyone.
The urgency of the crisis of trust that we face in healthcare has grown more pointed over the past several years. The ABIM Foundation is committed to generating solutions and looks forward to collaborating with other organizations to enhance trust together.
Building trusting relationships is hard work, to be sure, but it is work we can and must do for our profession and for our patients.Author Affiliation: American Board of Internal Medicine and ABIM Foundation, Philadelphia, PA.
Source of Funding: None.
Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.
Send Correspondence to: Richard J. Baron, MD, American Board of Internal Medicine, 510 Walnut St, 17th Floor, Philadelphia, PA 19106. Email: firstname.lastname@example.org.REFERENCES
1. Baron RJ, Berinsky AJ. Mistrust in science—a threat to the patient-physician relationship. N Engl J Med. 2019;381(2):182-185. doi: 10.1056/NEJMms1813043.
2. Eight organizations named winners of Trust Practice Challenge. ABIM Foundation website. abimfoundation.org/what-we-do/rebuilding-trust-in-health-care/trust-practice-challenge. Published May 2019. Accessed July 30, 2019.