An article publised in JAMA (January 24, 2019) treats a medical worldwide issue that need for atention. It afirms, Trust matters in health care. It makes patients feel less vulnerable, clinicians feel more effective, and reduces the imbalances of information by improving the flow of information. Trust is so fundamental to the patient-physician relationship that it is easy to assume it exists. But because of changes in health care and society at large, trust is increasingly understood to be at risk and in need of attention.
Our opinion
From a bioethics point of view, health care organization and the doctor-patient relationship deserves our serious attention and protection during these dangerous times when the emergence of computer science and AI in medicine, the urgent need for organs for transplantation, new advances in genetic diagnoses, increasing cell and gene therapy trials, etc. create new kinds of doctor-patient relationships and behaviours.
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The Problem. Deprioritzing realtionship in medicine
Cultivating the trust of patients in the teams delivering their care would be simpler if those teams were well established, but many teams do not function well. Clinicians caring for a patient may not know or talk to each other, and all too often may just focus on the narrow areas of their expertise. However, there are exceptions such as multidisciplinary integrated practice units that are organized around patient conditions and take responsibility for patients across the continuum of care (eg, heart failure teams) and well-run and efficient ambulatory practices that do function as a team. The regularity of interactions among personnel and between the clinician and the patient provides the opportunity for the building of trust. Integrated practice units are becoming more common at larger medical centers, but still deliver only a small percentage of care.
Most clinicians have not cultivated the ability to form effective teams among personnel who may not have met before. However, examples of effective teams can be found on a daily basis in operating rooms where the use of the surgical checklist helps ensure that everyone introduces himself or herself and has the same understanding of the procedure to be undertaken. Even though many surgeons and other operating personnel were resistant to expectations that they use the surgical checklist when it was introduced, 93.4% (of 257 clinicians surveyed) indicated that if they were having a procedure performed on them, they would want the checklist used.2 That insight helped operating room personnel understand that the checklist had cultural goals beyond the obvious immediate focus on safety issues. The checklist helped build the team’s sense of shared purpose, and when clinicians imagined themselves as patients, they understood that such cohesiveness enhanced trust.
Another source of the problem is that the organizational structures within which these teams exist are changing rapidly. Organizations are merging, creating new structures, and adopting new names in place of those known to patients for decades, leading to the loss of familiar brands with trusted reputations. The merging process can also lead to changes in tangible and intangible aspects of the care experience that leave patients feeling like they have changed clinicians even when they are seeing the same clinicians but in a setting that looks, feels, and acts differently.
These types of changes put patients at risk for feeling untethered in systems that can seem bureaucratic, impersonal, uncaring, and unworthy of trust. These types of changes and their effects are also dispiriting for health care personnel, who tend to expect gratifying relationships with patients and colleagues. The reality is that the United States will not return to a delivery system model based on fewer specialties or more intimate care settings. Therefore, the challenge is infusing trust into the current delivery system care experience.
Possible solutions
There is reason for optimism. Research has identified factors that influence the development of trust, ranging from technical competency and interpersonal attributes to organizational factors. Physician behavior is especially critical; patients’ trust is affected by their perceptions of physician empathy and honesty. Trust correlates most highly with the patient’s assessments of the ways physicians communicate, knowledge of the patient, and the interpersonal relationship. In contrast, trust is not highly correlated with the length of the patient-physician relationship or the patient’s financial access to care. According to 1 study, most patients (>77% of 1578) reported that they completely or mostly trust their physicians “to put their health and well-being above keeping down the health plan’s costs” even in the presence of incentives for efficiency.
Because of insights from such research, it is clear that trust can be measured directly and indirectly and it can improve as well as deteriorate. Health care organizations have business strategies that rely on patients being willing to trust them, and are therefore acquiring experience with data from patients that reflect on trust. Myths and facts about patient experience data are increasingly well defined so that these data on trust can be assured and trust can be reestablished.
To identify and prioritize actions that will increase trust among patients and the organizations and teams that care for them, a work group of 17 health care leaders and patient advocates who were attending the 2018 American Board of Internal Medicine Foundation Forum on [Re]Building Trust (see Additional Contributions) conducted a structured exercise aimed at the identifying and prioritizing interventions. Ultimately, the group focused on 3 questions: What factors are the most important forces decreasing trust between patients and the organizations that care for them? What measures can increase trust between patients and the organizations that care for them? What steps should key stakeholders take to increase trust between patients and the organizations that care for them?
The article also proposes potential approaches for increasing trust:
Leadership (boards and senior management) should acknowledge that trust is foundational and that creating a trusting environment and experience is essential for good processes and outcomes.
Measurement of trust and related issues should become a standard part of the evaluation of patient care experiences and experiences with health plans. For example, data on patients’ “likelihood to recommend” organizations are available along with benchmark information from comparable institutions. Data from physicians, nurses, and other personnel on their engagement (eg, “I am proud to tell people I work for this organization”) provide insight into the extent to which the caregivers trust that their organization shares their values.
Transparency of patient care experiences and outcomes should be part of a system of measurement, monitoring, reporting, and continuous improvement of quality and safety. For example, payers should make such data transparent as a default model for clinicians and health care organizations.
Boards and senior leadership should regularly examine data that reflect on trust by patients and among personnel. Data on trust should be discussed along with financial metrics that the board monitors and uses to reward the leadership team.
Standards, training, and accountability systems should be developed for individual clinicians. Training and education should emphasize communication and relationship skills. Some organizations, such as the Cleveland Clinic and Texas Children’s Hospital, have required that all physicians undergo formal training in communication, and have seen patient experience improve afterward. Health care system leaders should convene patients and frontline clinicians to identify specific barriers to coordination and articulate solutions.
Standards, best practices, and accountability systems should be developed for team functioning to create trusting environments. For example, clinicians should receive feedback on how patients evaluate the coordination of their care. Through payment models that explicitly reward patient trust and care coordination, payers can play an important role in motivating clinician efforts to achieve high performance in these critical areas.
Relationships between patients and health care professionals (including teams) should be structured with the goal that patients can make choices that reflect their preferences. Clinicians should recognize that, just as there is an information imbalance in which they know more medical science than patients, there is a second information imbalance in which patients know more about what matters to them and how they are doing than clinicians, and discussions should occur to correct that information imbalance.
Health systems should ensure that the needs of patients for a navigator or translator are reliably met. Patients must be confident that someone on the care delivery team will help them understand the care that they are receiving, ensure coordination, elicit the preferences of the patients, and advocate for patients when necessary.
Patients should be actively engaged in designing solutions to fix the erosion of trust. Top senior management should attend meetings of patient advisory councils. Many organizations now include patients on operational committees as their default approach. This best practice should be adopted widely.