In the crucible of mistrust and health care

Trust has always been the foundation of any relationship between a patient and those of us in health care. Clinicians enter patient encounters with the presumption they will be trusted, based on their knowledge and good intentions. But medicine is changing, and today patient-doctor relationships are buffeted by a complex labyrinth of a rapidly evolving health care landscape and an exploding information environment.

As physicians, we must adapt to this changing reality or risk losing our agency in achieving positive health care outcomes. Though we may want to believe that trust-building is either unnecessary or purely a result of our own behavior, it’s important to recognize that trust in health care is very much up for grabs in the current environment. Traditional assumptions about how trust is created and maintained have to be reconsidered within evolving roles of facts, expertise, and authority in our society.

Scholars have noted that the legitimacy of the medical community rests on the credibility of medical science and the scientific method on which modern medicine depends. As physicians, we rely on that foundation in every patient interaction, knowing that our advice is scientifically grounded and should be heeded by rational people.

On the other hand, the intimate and personal nature of each individual doctor-patient relationship creates a sense of trust that many of us believe should transcend any doubts patients may have. Medical legitimacy arises from both collective expertise and individual trust, as well as from the connection between the two.

Gallup polling has revealed that confidence in many institutions has deteriorated greatly over the past four decades, but the most dramatic decline has occurred in “confidence in the medical system,” which fell from 80 percent in 1975 to 37 percent in 2015. Data from the General Social Survey show that confidence in the people running medical institutions has steadily dropped from over 60 percent in 1974 to just 36 percent in 2016.

The American Board of Internal Medicine experienced this erosion firsthand, and in many ways, it was self-inflicted. Yet I believe today we are a better organization because of it, with a continuous process for reflection and improvement. Authentic engagement with Board Certified physicians has helped us rethink how we design our programs so that they are more supportive and representative of the community we serve. And that isn’t the end of our work. Restoring trust is a journey, not a destination.

As trust has declined, alternative sources of “authority” have emerged. Increasingly, patients are obtaining medical information on a variety of electronic platforms that do not effectively distinguish among sources. On social media, friends, relatives, and like-minded people share health-related information from many sources. Medical information that may have originated anywhere on the internet is passed along and implicitly “authorized” by the fact that it came from a friend.

Given the decline in trust in the institution of medicine, simply asserting medical authority or citing evidence is unlikely to win adherents. Indeed, skepticism regarding facts and expertise is widespread.

Still, all is not lost. It’s possible to find a way forward, but only if health care institutions and practitioners take seriously the threat to our science-based professional authority and learn to systematically deploy other approaches to building trust. For instance, individuals and groups that speak against their own apparent interest — not experts — are the most effective messengers of facts and accumulated expertise.

When the ABIM Foundation developed the Choosing Wisely campaign in 2012, physicians and their professional societies were the ones who conveyed the message that more medical intervention is not always better; the very fact that physicians were making recommendations to do less, not more, accounted for much of the campaign’s traction.

In a world where large, successful commercial organizations like Google, Facebook, and Amazon have harnessed technology to “get to know their customers” and use that “knowledge” to convey understanding and connection, health care lags far behind. Our patients often have the trust-destroying experience of being strangers in the health care system — unrecognized as individuals and needing to repeatedly state key parts of their stories.

Knowing and recognizing patients’ unique contexts and circumstances seem to be powerful ways to build trust; feeling recognized is a precondition for trust. Intentional use of information systems and registration protocols to capture meaningful personal information that can be accessed by the many staff members whom patients will encounter may be one strategy for clinicians and institutions to earn the trust of patients.

Explicitly acknowledging the role — and competence — of other members of the health care team may be another way. Executives at Intermountain Healthcare system noted that one of their several emergency departments (EDs) received higher scores on patient satisfaction than the others. Further investigation of that ED revealed that routinely, when staff members were leaving a patient’s room, they would speak positively about the staff that was going to follow them. This practice had apparently increased patients’ trust and satisfaction.  The independent, objective validation of expertise conferred by Board certification can itself be one criterion for helping doctors establish legitimacy and trust with their patients, especially in such a cacophonous medical information environment.

It has been sobering to observe how poorly “facts” and “truth” are faring in the current national discourse, and it would be naive to believe that this state of affairs will not affect health care. Perhaps the problem with facts is that they stand alone, with no context beyond the scientific method used to generate them. Their “objective” nature is precisely what disconnects them from patients’ individual predicaments, and such a connection is the only path that facts ever have to meaning.

If we as physicians are to become more effective in marshaling facts, we will need to become better at connecting them to individual patients’ predicaments. When relationships are paramount, we will also need to do a better job creating trust with patients, and find ways to build relationships consistently and reliably.

This piece was adapted from a New England Journal of Medicine article, “Mistrust in Science – A Threat to the Patient-Physician Relationship.” 

Richard J. Baron is president and chief executive officer, American Board of Internal Medicine.

Image credit: Shutterstock.com

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