Below is a transcript of the following Academic Medicine Podcast episode:
Growing Trust in Patient-Physician Relationships
November 1, 2021
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Hi everyone, I’m Toni Gallo. I’m a staff editor with the journal. And my cohost for today’s episode is Dr. Colin West, one of Academic Medicine’s deputy editors. And we’ll be talking to Dr. Richard Baron about his article entitled, “A Trust Initiative in Health Care: Why and Why Now.” That article was published in the April 2019 issue of the journal, and it’s available to read for free on academicmedicine.org. I’ll put the link to that article in the notes for this episode.
Our discussion today is really going to focus on the importance of trust in patient-physician relationships and how to build or rebuild that trust if it’s been lost. I want to start our conversation with some introductions. Colin, would you like to go first?
Certainly. Thank you, Toni. As Toni mentioned, I’m a deputy editor at Academic Medicine and in my non-journal roles, I’m a professor of medicine, medical education, and biostatistics in the Division of General Internal Medicine at Mayo Clinic in Rochester, Minnesota.
Thanks Colin. Rich?
I’m Richard Baron, I’m president and CEO of the American Board of Internal Medicine and the ABIM Foundation. Before that, I spent 30 years of my career in the community practice of internal medicine and geriatrics in the community in which I lived. And then an interlude of a couple of years at the Innovation Center at CMS, leading primary care models and ACO models, but I’ve been at ABIM and the ABIM Foundation for almost 9 years now.
So trust in health care had been identified by the ABIM and others as an issue even before the COVID-19 pandemic, but the current crisis has certainly emphasized how important trust in medicine is to so many aspects of public health. Dr. Baron, could you say a bit more about the importance of trust in medicine, specifically as it applies to the patient-physician relationships that Toni mentioned?
We realized that lots of people in academic medicine, around the country, believe that their position with their patients and their communities is secure and everyone will trust them because they’ve got the latest technology and they’re practicing the best science. And we realized that people need to take a step back and realize that, as a profession, we no longer enjoy that automatic trust just because we’re scientists.
And I just want to add because you mentioned, Colin, the issue of the pandemic. I think the pandemic has so demonstrated the way that many people in the country don’t trust the health care delivery system, don’t trust us as physicians to operate in their best interests.
And when you look at some of the health equity issues that the pandemic has laid bare, you realize that there are entire communities who have earned mistrust with respect to the institutions that are supposed to be serving them. So we think trust is foundational, that we’ve taken it for granted in health care, and in fact that’s a mistake, given the state of play in the country right now.
So I want to emphasize one piece that I take away from this, from your comments, Rich. I think, really importantly, what you’re conveying is in not taking this for granted. When we’re in positions where we like to feel like we’ve earned a certain level of trust, we can’t rest on our laurels. That trust needs to continue to be actively maintained and earned, and I think that’s something in medicine, as you mentioned, we sometimes just take for granted. We’ve, you know, achieved a certain level of expertise and therefore trust should simply continue to be given to us.
And it’s humbling across the profession frankly to step back and recognize no, you need to re-earn that. Every patient encounter, every interaction that we have, is another opportunity to, in some cases, restore but certainly maintain or build upon the trust that we have.
I think that’s absolutely true, and I can remember very early in my career when I opened my community practice, I was taking care of … I saw as a new patient a 55-year-old Black sign painter, really nice guy. And I was at that phase of career where, you know, I just finished training so everything I did was comprehensive, you know, I did the full physical. I did the full review, I did everything.
And I would, you know, sit down with patients after they got dressed and talk to them about what was going on. And after I did this, this man says as he’s getting dressed, “Doctor I have to ask you a question. If I were a United States Senator, would you have done the same thing that you just did for me?”
And I was kind of shocked and my feelings were hurt. I was like, what do you mean? I just did like the Yale Medical School, NYU Bellevue comprehensive exam and you’re asking me if I would have done the same if you were a Senator.
And at first my feelings were hurt, but since then I have learned he came into that exam room with a life history very different from mine. That he did not just assume that I had wonderful intentions toward him. And he probably had lots of very real personal experiences to make him suspicious of whether I was taking care of him the way I would take care of a US Senator.
Yeah, another really fascinating point there that we discount sometimes is that mistrust sometimes has also been earned. And we have to overcome that as a profession and really make sure that the highest standards are consistently expected and modeled.
Right and we often talk about earned mistrust in historical terms. But again, with the pandemic, if you’re a Black person in America, you’re entitled to look at the statistics and say, well, whatever they’re doing, they’re not taking care of me the same as they’re taking care of everybody else. And so earned mistrust continues, structural racism continues. And institutions need to take seriously the populations that we’re serving for very good reason, not just for historical reasons, can be skeptical of whether we’re in it for them or in it for ourselves.
We may touch on this a bit later, and I’m going to let Toni jump in with the next question, but that also raises the question of, you know, restoring / maintaining trust, this is not just a nice to have, this is actually an obligation, and we owe it to communities to get things to a better place, to do right by all of our populations. Toni, I’ll hand it over to you.
So I wonder if we can continue the conversation about opportunities where trust is lost or where that we’ve seen decline in trust. And Rich you talk a little bit about some of these in your article, but I wonder if there are other examples you want to share.
As Colin mentioned, we will go back to some COVID examples later in our conversation, but to kind of better understand what are some of the reasons why we’ve seen this decline in trust or this growth in mistrust? Specifically thinking about patient-physician relationships.
Right, so certainly there’s a global environment of decline in trust of the health care delivery system, of institutions, of science, of facts. And maybe we can talk about that later, but you’re asking some about specific things in the doctor-patient relationship, and I’ll give one of my favorite examples.
I have a colleague … He tells the story, he met a patient, who the first time he met him, he was a 70-year-old engineer. The guy puts out his hand, he says, “My name rhymes with needle.” What’s he telling me? He’s telling me, I have a hard to pronounce name and I’m going to tell you how to pronounce it right, but you know what, if the next time I see you, you don’t pronounce it right, I’m going to wonder if you’re actually paying any attention to me. Think about the number of times that we mispronounce people’s names. And that is … I don’t know who you are. I am not paying attention.
Another one of my favorites going back to the earliest part of my medical training … When I was trained, I learned that the chief complaint was in the patient’s own words what they said was the thing of most concern to them. How many times have I witnessed a medical student or a resident doing an interview of a patient being admitted for chest pain and the patient says, “I have this chest pressure” and the doctor says, “Well how long have you had the pain?”
“Well, it’s not pain, its pressure.” “Okay, does the pain get worse when you climb the stairs?” “No, it’s pressure.” “How often do you get the pain?” And at that point, the patient gives up. It’s like, if you’re not gonna listen to me enough to use my language, I’m just not going to assume that you’re paying any attention to who I am.
So I think we have all sorts of things that happen in the interaction that take us away from … How do we use electronic health records? Do we use them as screens to keep us from interacting with patients? Or do we use them as tools to bring patients into a conversation?
I think there are a whole variety of opportunities like that which are explicitly about relationship building and trust building. But you don’t think you need to do them if you go to work every day presuming that good intentions and competence are all you need. If you realize, the moment you realize, you need more than that you are confronted with endless opportunities to do better in that space.
I think some really interesting concepts there. I’m fascinated by the role of language in building trust, demonstrating respect, and really honoring people’s identities and, as you’ve alluded to, what our patients are bringing to the relationships with their health care professionals.
I think historically that has not always been front and center, you know. We have an entire language in medicine that’s around the patients, you know, coming to us as if we’re an oracle of all medical decision making, as opposed to relational partners.
And, you know, “Are patients compliant with our recommendations?” Language that makes me shake my head. Because, you know, I was brought up with this as a medical student. But like well, this is how we talked about things. “The patient complains of …” Well really? That makes it sound like they’re bothering us with a concern.
And we didn’t used to think about those kinds of things. But are those really the most respectful ways of communicating with our patients and honoring their identities? Something I teach my own medical students and residents at Mayo is how important just what you mentioned, Rich, names and pronunciations.
And I can’t tell you how many times I’ve had patients with names that we think are complicated to pronounce. I’m thinking of one in particular many years ago. And when I walked into that room, having done my homework. I had my desk staff who were rooming the patient actually inquire. They coached me on it, and I walked in and said it mostly correctly.
The first response out of that patient’s mouth was “Doctor, are you from …?” And he asked me was I from the part of the world that he was from. Or had I spent time there. And I fessed up, no I actually had my … remember my desk staff were asking you how you said your name? They were taking that information back to me.
And he said, you know, he was probably 70 years old. It was his first medical visit in his life that anyone had ever pronounced his name correctly, even after seeing him repeatedly. And it’s a small thing but those small things add up to build relationship, which is a huge part of that trust dynamic that we’re trying to maintain. So I love the story that you sort of touched on there in the importance of respect for identity.
And I think your story adds to the challenge of all of us working in medical institutions. That stuff isn’t going to happen by magic, you know. We’ve built systems where we don’t see patients who haven’t had their blood pressure and their weight measured before we got there. But we see patients all the time who haven’t had the pronunciation of their name worked out before we got there.
Especially with information technology, we have the ability to do much better in that, but it’s about taking on intentionally the goal of building better systems to build trust, and I think that’s what we’re really focusing on in the article. We’re trying to say we shouldn’t be taking that stuff for granted. We should be asking ourselves what steps could we be taking to build that kind of trust.
And using our systems to help us toward that collective goal of, you know, having phonetic pronunciations in our electronic health records. That’s an easy thing to do and it’s remarkable how challenging such an easy straightforward thing to do can be in many electronic health records.
Other aspects of identity, you know, personal pronouns, things like that. We’ve had in our resident clinic some remarkable successes in engaging patients in more trust-filled relationships and, you know, discussions about sensitive topics, when our trainees, who are in many ways leaders in this because they’re much closer to these societal shifts and advances than many of us are.
But you know they recognize that this is important and they’re coming out of the room saying, hey this patient wishes to be identified this way. How can we make that happen so that when this patient sees other people in our health care system, they don’t consistently have to repeat their story?
We honor that part of their identity without them having to feel like they constantly have to announce it. We have ways to do this in systems and leveraging our teams in a way that we haven’t maybe recognized in the past, but medicine as a team sport can serve to our advantage in building these kind of trust relationships.
Absolutely and it’s on us to orient our systems toward that target.
You know, in recent years, the ABIM Foundation turned its attention to issues of trust in health care. You describe those in your paper. Some of this has been about identifying existing practices that help build or rebuild trust in various aspects of the health care system. We’ve touched on a few of these informally in the last few minutes, but I wonder, in your work and in your leadership roles, have you encountered practices or exemplars that relate to promoting trust in the patient-physician relationship that might help our listeners with you know sort of tangible suggestions for their own practices?
Well we’ve certainly touched on some of them and your pronoun example was actually one identified in a clinic oriented to serve transgendered populations in Iowa. And what they needed to solve a whole variety of problems about how do you record the pronoun in the EHR. How does it show up in the lab order so that the person who is drawing the blood knows what the pronoun is.
So system approaches to some of these things that we’ve been discussing have been a major thing we’ve surfaced in sort of individual doctor-patient interactions. And activating teams to make that work reliable.
We also have seen examples where, and this is a sort of funny way to put it, but one of the people that we’re working with described that patients often asked her how they should choose a doctor for their pediatrician. And she said choose a pediatrician who trusts you and told stories of the way in which, as a mom, she had not been listened to by a pediatrician and her child had gotten into trouble.
So I think the way in which we as clinicians can demonstrate trust in our patients by validating what they say, by taking seriously what they say. I mean it’s interesting, I listened to a CDC webinar about long COVID. And, you know, some expert from CDC is saying we may not have a clear symptomatic definition, but you know what, if a patient tells you that they’re not feeling well, you have to take that seriously.
And I’m thinking, my goodness, we have to have some CDC expert tell us that if a patient says they’re not feeling well, even if we can’t find any laboratory stuff, we have to take that seriously. So I think finding ways to take patients seriously is an important part of trust building strategies.
And then I think validating and being open to the alternative experiences that your patients have had. I think White doctors going in to see Black patients are seeing people who have had a very different personal experience with the health care delivery system. Being open to that in the way that you give space for that to be expressed, you affirm the legitimacy of that, and you make a commitment which you try to keep to do better and do as authentically as you can. But recognizing that people’s personal histories are very powerful, and we don’t know them. We are looking at just the very tip of an iceberg that goes very deep.
I think that’s a good lead in to the second part of this question, which is maybe just a request for any expansion that you might think of in recognizing as we’ve been talking an important part about rebuilding trust in many of our communities is acknowledging and addressing systemic structural racism, historical abuses of minoritized communities. Anything that you would add further in terms of examples of practices that you or the ABIM have identified that specifically aim at this goal or you’ve seen be effective.
So great question and I think that a lot of the successful activities fall broadly under the domain of community engagement. But I don’t want to be glib that, because you set up a community engagement department, because you set up a community advisory council, because you set up a patient advisory council, that you’ve now solved the problem and can check the box and move on.
One of the more interesting examples that we’ve run across is many large organizations, on the HR side, are creating what are described as employee resource groups. So they’re basically trying to create micro communities in which people can affiliate within the organization.
And so we have employee resource groups of employees who share an identity and want to get together with other employees within the organization to sort of support each other and potentially engage in dialogue with the organization about how they can be better worked with.
Another example … language issues … If you’re not getting language stuff right, if you’re not … and again the best practice we’ve seen is not English proficiency but preferred language, which are different things. And preferred language, if you identify it …
First of all, you’ve only begun to identify the problem that you have, because now you know you have all these people you’re serving that you don’t have necessarily any reliable way to communicate with. You will not serve those people well.
I think with respect to community engagement around structural racism, it’s about giving communities authentic voices to talk about what their history with the institution has been, to engage in institutional prioritization and planning for what the institution is going to be doing, whether it’s locating new facilities or offering new service lines or thinking differently about how to make services accessible.
That needs to happen in some form of authentic dialogue with the community. Very hard to do. Who’s a community leader? How do you identify a community leader? How do you identify voices to get to that table? But I think organizations that are investing in that and focusing on that are having more success in managing those conversations.
One quick comment that I would just you know add to what you’ve suggested already is … You mentioned resources and, as we think about building bridges with communities, one area that I think is increasingly recognized that we still need to do more at is … You know, we ask a lot of our underrepresented colleagues to carry the load in terms of reaching out to other communities in a way that we have not either recognized or been as effective as we need to be in sort of majority groups, if you will.
And so the importance of supporting and appropriately resourcing our colleagues who have the skill sets to help our collective goals rather than sort of assuming that, by virtue of a demographic or a characteristic that they possess, that that’s automatically a tax, if you will, that they have an obligation to carry out on our behalf. And so just making sure that we’re resourcing what we’re requesting, so that we don’t unwittingly push toward even further inequity, if you will.
And then you know we’re talking about patient-physician trust, but then we start talking about eroding trust within our communities within health care professionals as well. And so just another layer since you opened the door to the resources point that I would just extend a bit to, you know, to make sure that we’re supporting these groups that do offer unique skills that we require to do better with our patients.
Absolutely, I think that’s right. And I think your image of a tax on minority physicians or minority leaders to carry this forward is an accurate statement of the way many people are experiencing this.
I want to take us back to COVID now. We had mentioned it earlier in the conversation, but one of the specific reasons you cite in your paper, which was published again in 2019, so predating COVID. But one of the potential reasons for decline in trust in medicine is as you say “the rapid growth of competing and contradictory sources of information.” So I think we would all agree that that problem has only gotten worse in the last few years, and I wonder if you could talk about some examples specifically related to COVID or vaccine safety and misinformation and how physicians might think about building trust around those conversations.
That’s a great question Toni and one we are struggling with at ABIM right now. I think that we have a lot of things going on at the same time. We have a lot more information than we’ve ever had. And processing it in real time, it is overwhelming and so we’ve got this unprecedented pandemic at a time that the world is so interconnected that data move around at a sort of terrifying velocity.
And one of the challenges is not all of those data are good data and sometimes they get swept up into meta-analyses and then you have a conclusion built on a faulty foundation that gets all over the place before anybody can get ahead of it, so I think that that’s one of our challenges, how much information.
Another challenge is the way in which people have I’ll say an earned mistrust of institutions. We have a challenging record of federal government leadership during the pandemic. We have the FDA being on one side of hydroxychloroquine then being on the other side of hydroxychloroquine then being attacked for being on the other side of hydroxychloroquine. What’s the public to think?
We have most recently a CDC advisory panel making a recommendation, being overruled by the CDC director. I think the first thing I would say is we need to have a fair amount of empathy for the confusion and uncertainty that patients have even in areas where we feel a high degree of certainty. And probably the shining example of that is vaccination, where it’s hard to imagine anybody who isn’t evidence based, science driven not being foursquare behind if what you’re trying to do is not die from COVID or wind up in the hospital from COVID you should get vaccinated.
To us it’s completely blindingly obvious. And certainly our colleagues who are working in overwhelmed ICUs full of unvaccinated patients, you can’t blame them for being frustrated and impatient with people who just won’t accept vaccination.
But taking a step back and realizing how confusing some of the messaging has been, I think trying to meet people where they are and understand that it has been a confusing time and to validate that and to try to help people find what could feel like secure ground in a very confusing and turbulent information universe.
And that can take a lot of time, but it begins with respecting what people think they know, understanding what they think they know, trying to engage with what they think they know.
So finding that kind of firm ground to stand on, but standing on it in a way that is an engagement stance as opposed to a “I’m going to deliver you the truth” stance is, I think, where we need to be.
Yeah, so I would translate that as, again as we talked about at the beginning part of this conversation, these relationship-based interactions as opposed to we are delivering aliquots of knowledge from on high that patients are obligated to simply accept.
And we may disagree with decisions that patients make, but there are motivations behind those decisions. Sometimes we can help fill in knowledge gaps patients may have or correct misunderstandings. And the converse can also be true, they can help educate us about what’s going on in their lives that’s contributing to certain thought processes that they may have.
You know my colleague at Mayo, Victor Montori, talks about careful and kind care, patient-centered care in its truest form. And I think you know, as clinicians, it’s really important that we step back and, as you mentioned earlier Rich, trust our patients and show them the respect, that we are going to have a conversation, a discussion, a relationship-based interaction to help meet our combined, you know, shared goals, hopefully of a better health state.
I want to shift if I might to what is our last substantive question, mindful of our time together and shift gears a bit. So in your paper from a couple of years ago, you and your team described the importance of learning how to measure trust to build an evidence base that connects trusts to clinical and other important outcomes. So I’m curious, you know, with the interruption of the pandemic, of course, where are you on that journey and where would you like to see that journey continue to go.
That’s a terrific question. We are collaborating with Academy Health, because they are a community of health services researchers, really the leading community of health services researchers, to help us work this through. And we’ve identified some priority research questions and you’ve named some of them.
Certainly, having an operational measure of trust is probably one of the most important things we could have. There was some work done on this in creating the original CAHPS survey. And it wound up being left behind as the survey moved forward. But some of the folks that Academy Health are talking about going back to some of that early work to bring forward some of the early thinking about how do you have a measure of trust.
And then of course the sort of the research question is correlating some version of performance on that measure with health outcomes that you care about. And those health outcomes are you know legion. You can be talking about everything from clinical outcomes, whether it’s you know classic hedis type measures of diabetes care or blood pressure control, inheritance engagement to therapy, that’s one kind of outcome.
You could also be looking at total cost of care outcomes because people who don’t trust are going to go all over the place to get second and third and fourth opinions and are going to do endless testing to try to put their anxiety and apprehension to bed.
I think we’re at the early stages of having a trust research agenda and … but I think that the critical issues are having a way to measure it that you feel has construct validity and feasibility for deploying and then being able to correlate that measure with outcomes you care about.
Any additional comments or final thoughts for us before I hand it back to Toni for our closing?
Well, I think … I really am grateful for the opportunity to connect with your listeners. When I was in training, the way that you knew what an excellent physician looked like, it involved people who could cite the literature and people who knew the most recent New England Journal story.
When I went into practice in rural Tennessee, after leaving training, going from New York City to rural Tennessee, I saw something I’d never seen before. The patients as members of my community. I would be standing next to them on the grocery store line, they would be fixing my car. I would be eating in their restaurant. There were all sorts of connections that were different.
And I think that it’s in the nature of training and research communities that they can get pretty insular from the people that they serve, who become subjects or who become teaching material. How to recreate those folks as humans, recreate those communities as real communities, I think it’s a genuine challenge for academic institutions that are competing on volume of NIH grants and you know placements in residences and so on and so on and so on.
And I think for us collectively to develop metrics that are truer to the service mission that underlies what medicine really is, that’s a quest I hope we can all go on together.
I want to thank you both for joining the conversation today. And I want to remind our listeners to look for Rich’s paper which was published in the April 2019 issue, and you can check the notes for this episode to find the link for that.
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