Q&A: Rebuilding trust between physicians, patients, health care leaders

In a new ABIM Foundation survey, 30% of physicians said their trust in the United States health care system and health care organization leadership has decreased over the past year.

Richard J. Baron, MD, president and CEO of the American Board of Internal Medicine and ABIM Foundation noted that the COVID-19 pandemic has exacerbated an already fragile relationship.

“It is not news that physicians are a little distrustful of health system leadership,” he said in an interview with Healio Primary Care. “But the gap between how much physicians trusted their colleagues who also faced stress during the pandemic and how much they trusted administration and leadership, that is meaningful.”

Of the 600 physicians who were surveyed, data showed that 94% trusted other doctors within their practice, 85% trusted doctors outside of their practice and 89% trusted nurses. However, only 66% said they trust health care organization leaders and executives. In addition, 43% of physicians said their trust in government health care agencies has declined amid the pandemic.

A second, simultaneously released ABIM Foundation survey revealed distrust among patients, as well. Overall, of 2,069 American adults who were surveyed, 84% said they trusted doctors, 85% trusted nurses and 64% said they trusted the health care system “as a whole.” But 32% said their trust in the health care system has dropped during the pandemic. Among those who lack confidence in their doctors, 25% said their physician “spends too little time with them” and 14% said their physician “does not know or listen to them.”

Baron said a new ABIM Foundation initiative called Building Trust aims to improve relationships between patients, clinicians and health care leaders. We asked Baron to discuss why trust in the U.S. health care system is declining, how the new initiative may help reverse this trend and more.

Healio Primary Care: Why do you think trust in health care leadership is declining among physicians?

Baron: In many ways, the pandemic was a stress test for health systems and everybody in them. There were some more obvious public failures such as mortality rates being so dramatically different in communities of color. Every health care institution faced the real challenge of declining revenues in the second quarter of 2020 and asked questions like ‘Do we lay people off’? ‘Do we reduce salaries?’ ‘Do you end bonuses?’ A lot of these institutions also failed in areas such as providing sufficient personal protective equipment, adequate staffing and having policies that made sense.

Everybody faced a bunch of difficult choices. Some health care systems did really well. Other organizations did not. Lots of organizations, whether they meant to or not, implied they had their mind on other things besides maintaining the core relationships among staff.

Healio Primary Care: About one in three consumers said their trust in the health care system has decreased amid the pandemic. Why do you think that is?

Baron: We know that we have significant swathes of the population, such as people of color, who receive worse care from the health system than others. That is a big reason there is a lack of trust.

There are also a lot of downstream financial ramifications from COVID-19. Many consumers somehow believe that certain things tied to COVID-19 such as lung scans were not supposed to have any kind of copay. And now, of course, there are all sorts of arguments out there about whether it should be covered or not.

Healio Primary Care: What is the Building Trust initiative? How is it being implemented?

Baron: Many leaders in health care think that their legitimacy and authority come from the science that they are offering to patients.

We think that all the assaults on expertise and all the assaults on facts have exposed that science by itself is not enough nor is it enough for the delivery system to focus on facts. It really needs to focus on trust and trust building. If you do not have trust, patients are not going rely on the advice that you offer. We think it is really important to focus on trust building as a core strategy for being effective as a health care organization.

There are four components of the Building Trust campaign. One of them is what we call thought leadership. I’m writing blogs, doing interviews and conducting podcasts to create a whole network of people inviting others to think differently about trust rather than just presume it is there. The second thing we are doing — and this is sort of a page from our Choosing Wisely campaign — is trying to invite people from different institutions to have conversations about trust. The third component is research. We just had a big meeting with Academy Health, the health services research organization, to map out an agenda to find out what we need to know. The fourth is exemplars, which consists of looking for people and institutions who have stepped up to make trust a central organizational priority and helping them tell and amplify their stories.

Healio Primary Care: How will the initiative help restore physicians’ trust in health care leadership?

Baron: It is not the initiative that will restore trust, it is activities of the people who are inspired by or engaged in the initiative that will.

If you thought it was your job in the second quarter of 2020 to preserve the annual picture of your finances, you might have made a bunch of decisions that you would not have made if you were prioritizing being trustworthy. And you might have made those decisions in different ways than you made them because one thing that we know about trust building is the importance of inclusion, inclusivity and transparency — it is critical to give people structural ways to have some confidence their voices are being heard. This is one of the themes that we are discovering and thinking about in the trust-building research and is true for health care institutions serving communities. Is the community voice authentically at the table? What does it mean? Does the health system care about the community in any way other than as potential business? What investments is the health system making in the things that the community cares about?

By putting these things on the radar screens of leaders, you can see all sorts of things start to happen. You can see organizational metrics develop, you can see it written into board-level expectations for managerial performance and you can see it in people having serious conversations about redesigning our structures.

Healio Primary Care: How will the initiative help restore trust between physicians and patients?

Baron: Let me give you an example using electronic health records. One way people could be intentionally using the electronic health record is to record and display important personal information about a patient, how they want their name pronounced, what their gender identity is and the names of their kids, those types of things.

Every interaction with a patient is an opportunity to build or destroy trust, whether it’s training of staff, whether it’s use of technology or whether it’s the creation of systems. Lots of other industries send people birthday cards. Health care does not do this as much. It’s an example of thinking about what you can do to build stronger relationships. Health care has a long way to go with many potential options that we could be doing to build stronger relationships.

Healio Primary Care: What is your message to physicians who lack confidence in their health care system?

Baron: Step up. Get involved. Health care systems cannot run without physicians’ committed engagement. It is not the only thing that health systems need. They need nurses, they need customer service people, they need vendors. But physicians have an important role.

Any conversation with an administrator should begin with ‘I think we can do better here, and I have some ideas.’ If the first person you say that to is not interested in having this type of conversation, find someone else to have the conversation with. The idea that somehow, we can assume we should be able to show up and everything should just work is self-destructive. For it to work, we have to step up, we have to pitch in, we have to get involved in trying to make it better.

I started a community practice, and I ran my own practice. One of the things I had to get was a telephone system, and I had to spend a lot of time talking to vendors about telephones. As a general internist and geriatrician, why did I want to spend time learning about telephone systems? The answer was because if I was going to serve patients effectively and operate this enterprise, I needed to pay some attention to it. It goes with the territory in any job that you have an opportunity to make your organization better.

References:

ABIM Foundation. Poll: Physicians' trust In health system leadership declines during COVID-19 pandemic. Available at: https://www.prnewswire.com/news-releases/poll-physicians-trust-in-health-system-leadership-declines-during-covid-19-pandemic-301296576.html. Accessed May 24, 2021.

Building Trust. Public & physician trust in the U.S. health care system. Available at: https://buildingtrust.org/public-physician-trust-in-the-u-s-health-care-system/. Accessed May 24, 2021.