Trust is like blood pressure. It’s silent, vital to good health, and if abused it can be deadly.
Frank Sonnenberg, Follow Your Conscience.
By: Annamarie A. Fuchs, Creator. Partners in Health | Conversations
December 18, 2020
Introduction
When we last spoke with our four physicians, they each pointed out some of the elements that that they believe are fundamental to delivering person-centered care. As a reminder, the physicians who contributed to these discussions included:
- A young emergency physician in an urban hospital
- A family physician who practices in a busy rural setting in northern Alberta.
- A general surgeon transitioning out of full-time practice and…
- A recently retired family physician from a large metropolitan Primary Care Network.
Their reflections are blended throughout this article and italics are used wherever their verbatim insights are shared.
In this ‘part 2’ of our series about person-centered care, we explore the concept of trust as both a strategic enabler and, where it is lost, a system defect. Our respondents explained separately but with remarkable conformity that they believe the loss of trust to be the primary obstacle affecting every relationship in the healthcare system, leading to the loss of organizational resilience and ultimately the deterioration of patient care. The following list summarizes examples from the respondents of the effects that the erosion of trust is having on our health system:
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Lack of trust (patient / provider) has become the biggest barrier to the physician’s ability to deliver person-centered care. The system keeps failing patients and patients see physicians as the group who should be able to do something about improving the system.
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We have lost trust in decision makers who are so many levels away from the front lines that they can’t possibly understand the context or the challenges we are dealing with.
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Trust in our representative organizations is deteriorating. These people are supposed to be advocating for physicians and instead have become political power houses.
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We’ve lost trust in each other. There has been a loss of personal and professional accountability as some colleagues game the system leaving others with no incentive to play by the rules.
At the heart of any great relationship is the essential ingredient of trust. As humans we are naturally predisposed to trust others. It’s our default position according to Roderick Kramer of the Harvard Business Review.[1] And when we start from a position of trust, it can take very little to disrupt it and destroy the relationship. The same can be said whether we’re referring to an intimate partner relationship or a complex organizational culture. Where trust between parties is valued and shared, the resulting relationships will strengthen creativity and innovation and prompt us to give our best to the ‘other.’ Consequently, when we find ourselves experiencing a violation of trust, the damage can be catastrophic and perhaps no more so than in the complex and fragile world of healthcare.
One physician remarked that if the actors in the system (providers, leaders, decision makers, and patients) all believed themselves to be trusted ‘colleagues’ who work together to solve common problems by creating mutually respectful relationships, we will be far more likely to acknowledge the principles of person-centered care and action them. However, building positive relationships which requires capturing knowledge, experience, and responsibilities while embracing the roles of all players takes time and another physician suggested that we start with story telling:
Sharing stories could be the driver for translating current knowledge and perspectives into healthy relationships. We need to take the time necessary and we need to start there. That said, my feeling is this concept will only actually become important if the public makes it so. In other words, the emphasis on story telling as a means to create trust will only have merit when our patients who are our customers, believe themselves to be colleagues and partners in redesigning the system.
Context: Trust as an organizational construct
If trust can be acknowledged as both a personal and an organizational value, then the reverse should also be true. It can and should be tackled as a system defect. Tom Cargill of the British Foreign Policy Group explained that “Trust is the bedrock of all strong relationships, whether diplomatic, economic, or personal. It is what allows us to believe in the reliability of others: colleagues, business partners, friends. With trust comes the possibility of co-operation. Without it chaos – or coercion – will dominate.”[2] He goes on to explain that important values such as openness, contribution, and cooperation will enable the creation of a trusting culture which is only earned when all actors both uphold and demonstrate [consistently] those values.
In healthcare, fostering a trusting culture can make the difference between life and death. When trust is lost, people can die, and valued providers can suffer burn out or leave the profession. Ozawa agreed that “trust is important to health systems because it underpins the cooperation throughout the system that is required for health production…and lack of trust among providers…can lead to miscommunication, inefficiency, rising costs, and medical errors where an outcome can mean the difference between life and death for some patients.”[3]
In the Journal of General Internal Medicine (2002) Goold described trust from the standpoint of the relationship between providers and patients. “Trust in the healer is essential to healing itself. Trust, at least to some minimal extent, is undoubtedly a prerequisite to seeking care at all…Trust is of course, essential to both physician and patient.”[4] Finally, in a recent scoping review the authors defended trust as fundamental for the provision of healthcare.[5]
Respondents discuss the power of trust
So, if we agree that our health system should be grounded in the principles of person-centered-care, we must acknowledge that trust in every relationship across the system is essential. With respect to the relationship between providers and patients, as patients become more invested in their own efforts to make informed decisions about their own care, trust in the provider becomes paramount.
Trust building is essential if we expect patients to accept even a degree of paternalism (advice). This is the essence of a social contract. The patient should always define his/her priorities, but the provider is the expert who informs the patient about the best ways to achieve those priorities. That can only happen within a trusted relationship. Trust building is essential to creating an environment of literacy, collaboration, and good judgement. Providers must meet their professional standards to enable patients to safely default their trust to that individual. And, provider actions must be aligned with patient interests with accountability at the center of the interaction. Finding common ground (between patient and provider) is where you consider the patient as a colleague which immediately creates a focus of mutual respect while preserving the best elements of the traditional relationship. The trick will be to shift physician thinking.
More and more we are experiencing a rise in expectations on the part of patients and families. Many of those expectations cannot be met. For example, it’s common for patients/family members to come with multiple questions and to expect multiple investigations. Our ability to respond to these expectations has ties with the other themes (time, policy, etc.) It’s not enough to ignore someone’s questions or assumptions about appropriate investigations but it takes time to deal with these effectively.
Likewise, strengthening trust and collaboration between providers and decision makers offers incredible strategic value for the system. One respondent provided an example of the downstream effects of organizational redesign without consultation with providers:
Politics instead of patient-centered values are the drivers of decision making around healthcare spending and these decisions pose a huge barrier to achieving person-centered care. It’s important that we try to maintain the services that are available in Alberta. In [another province], one of the reasons why there were multiple delays in providing access for patients to services was because there were no consistent (if any) appropriate referral opportunities. For example, a new diabetic would end up either being discharged from the emergency department without any education or the physician / nurse would try to do some diabetic teaching in the emergency department. In Alberta, there are multiple avenues for accessing available / appropriate resources. Resources such as home care referrals, placement options, diabetic education referrals etc. are commonplace here [and incredibly important]. This approach needs to be preserved (and physicians are in the best position to consult on the most effective ways to create processes that are aligned with person-centeredness).
In [another province] over the course of 2 years, we went through significant organizational changes which included the closure of an urgent care center, and the transition of 3 of the 6 emergency departments in one city into urgent care centers. There was little consultation with physicians or other front-line workers which resulted in a huge reduction in available inpatient and ICU beds. As a result, significant bed blockages and shortages in the emergency department led to very unsafe situations. For example, there were frequent scenarios where CTAS 2’s[6] spent hours waiting in the waiting room, including a situation with someone who presented with acute coronary syndrome. Subsequently, the tremendous increase in physician and nurse burnout alongside the anger and distrust against decision makers became significant. I was one of the many physicians who left the province as a result of these poorly considered decisions.
Relationships matter and the political priorities that influence health care could indeed focus on that as a priority instead of simply focusing on the bottom line. The trouble with our health system is that our elected officials are tasked with the responsibility of managing the money. There should be other levers of evaluating system change beyond the constant focus on money.
Unfair remuneration practices by geographic zones was reported as one example driving the erosion of trust between providers and decision makers. For example, in metro centers, physicians receive a stipend for covering lost billing when they shut down their practices to provide 24/7 call in facilities while physicians in non metro referral centers who provide exactly the same services are denied any stipend. Erratic fee codes also contribute to mounting tension and frustration. Regardless of the remuneration policies and processes, consistency and fairness are essential if decision makers expect trust to be a two-way street.
The reliability of fee codes to ensure effectiveness and fair practice is largely inconsistent. For example, there is a ‘family conference billing code’ that allows a physician to take the time to have a fulsome ‘goals of care’ discussion which is an example of an important, complex, and time-consuming discussion. But we can’t apply that same code to pediatric patient family conferences. In my experience, I spent far more time trying to effectively consult with and support/advise families with a pediatric patient.
All four respondents also revealed that problematic behaviors within the profession have also resulted in the deterioration of trust between members of the profession. Inconsistent billing practices over time create both a sense of entitlement and increasing suspicion. What is more, poorly articulated policies or rules alongside a chronic gap in accountability leaves some physicians disinterested in playing by the rules. For those individuals who bill ethically and appropriately, there is little to no recognition for fair practices and consequently trust continues to decline and subsequent behaviors associated with entitlement continue to increase.
Inconsistent application of fee codes and complex modifiers only strengthens the issues of mistrust between providers and the system. Applying a complex modifier for ‘after hours’ care can be an incentive for a specialist to bill more by putting off the consult until later. As a result, patients wait, and the emergency department bed might be blocked for the entire day which prevents access for other patients who may be waiting for inappropriately long periods of time in the waiting room. A specialist may be ‘in the building’ but won’t come to see the patient. Instead he/she will offer vague advice over the phone and apply the fee code for telephone consults. In my opinion, physicians should not be able to apply the fee code for telephone consults if they’re physically in the building.
Another individual went on to admit that:
Physicians are often the biggest obstacle to change. If we want transformative change, then we as physicians must move our focus away from the money. Our defenses need to come down. We can indeed decide how fast we work and how much we work. Instead of providing person-centered care when it’s convenient, we should be driven by delivering PCC as a value. But this requires a fundamental shift in the balance of power. Perhaps person-centered care needs to be the predominant VALUE in the system for it to spawn the transformation we all seek. Perhaps it should form the fundamental basis of the mission and vision statements for the entire health system.
Solutions
While the focus on politics, ineffective policies, and inconsistent billing practices are merely examples of some of the influencers of declining trust, we can work together to rebuild relationships as a strategic priority for achieving person-centered care. And, we can choose to highlight trust as a core strategic “value” which may be the lever that heralds the return of satisfaction or “joy in work”[7]. It won’t be easy. It will require a fundamental shift in the balance of power. Perhaps trust should become the overarching VALUE in our system if we want transformation to a system the delivers person-centered care.
Where can we begin in our collective effort to heal our relationships across health care in Alberta and restore trust? Providing education and transparency in building healthier relationships with patients might be a good place to start.
We miss the point of person-centered care entirely when we (providers and decision makers) try to fit it into our own constructs, controls, or requirements when the reverse should be the case. We must spend time educating the public that it’s essential that the system focuses on efforts to meet their needs and not their expectations. There is a c-change between these two. ‘Expectations’ are the actual commodity that patients require and ‘needs’ vary with perspective. We (the system) view “need’ from the lens of the ‘best possible medical outcome within available options/costs/time.” Patients, however, view this somewhat differently. Excellent outcomes are expected by patients regardless of any other factors that may be at play.
For example, a patient with multiple co-morbid conditions who is also a heavy smoker requires surgery for an acute injury. That individual’s ‘best possible medical outcome’ may end up being vastly different from another similar patient with the same injury but who is otherwise healthy and doesn’t smoke. Reciprocal accountability needs to be built into the relationships where the hard questions are asked and answered with absolute honesty and fairness.
We also discussed whether it is possible to demonstrate our commitment to the patient as ‘colleague’ by asking physicians to write or dictate their consults directly “to” the patient as the primary recipient of information and advice. For example, what if a consult looked like this: Dear patient; Thank you for allowing me the opportunity to participate in your care. When we last met, we discussed…”
There is little doubt that the democratization of information would indeed contribute to building trust and mutual respect (patients with providers and vice versa) but there are shared responsibilities and accountabilities for this to be effective. In the example you provided, the individual becomes the direct recipient of not simply the “care” but all the information within and surrounding the care. Suddenly, the entire experience becomes “theirs” not only to own but to reflect on, consider, enquire further about, and so on. With a change in practice like this, there is potential to create more meaningful interactions and subsequently, increased trust. But with this also comes the responsibility on the patient to receive it and to work diligently to understand and to be responsible to follow up with the provider. It also lays a heavy burden on the provider who must be willing and able to not only do the job of being the physician but to translate information into meaningful, understandable, and non-judgmental language. Finally, in situations where specialists consult about a patient at the request of a family physician, emergency physician, or other, there is an educational aspect to the consult note that cannot be lost. The consultant very often teaches me about the problem in the letter, providing me with the knowledge about how to better manage the patient. It may require two letters – one to the patient and one to me as the family physician. But this is a problem that can be overcome with good discussion. At the end of the day, if the patient truly owned the information, that would indeed be truly transformative!
Finally, as we talked about in the introduction, one respondent suggested that story telling may be a driver for translating current knowledge and perspectives into healthy relationships. As a species, we have been sharing stories from the beginning of time. Stories help us to make sense of the world and to share our unique experiences with others. Story telling creates transparency and vulnerability and they can provide us with “an opportunity to learn from another person’s experience to shape, strengthen, or challenge our opinions and values. When a story catches our attention and engages us, we are more likely to absorb the message and the meaning within it than if the same message was presented simply with facts and figures.[8] The Health Foundation uses story telling to encourage people to dig deeper into the evidence about what works and what doesn’t work to improve health and healthcare. Perhaps we can start there. When we choose to expose ourselves through story telling, we may ultimately create an environment where we are able to truly understand the other’s experience, and over time, rebuild trust.
In our next article, we will collaborate with a citizen-based Alberta group to discuss person-centered care from the vantage point of the most important members of the health system, patients and family members.
References
[1] Kramer, R.M. Rethinking Trust. Harvard Business Review, June 2009. https://hbr.org/2009/06/rethinking-trust
[2] British Council. The Value of Trust: How trust is earned and why it matters. https://www.britishcouncil.org/sites/default/files/the_value_of_trust.pdf
[3] Ozawa, S. The role of trust in healthcare settings: Does trust matter? 2008, Oxford Policy Institute. https://www.britishcouncil.org/sites/default/files/the_value_of_trust.pdf
[4] Goold, S.D. Trust, Distrust, and Trustworthiness: Lessons from the Field. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495000/
[5] Rasiah, S., Jaafar, S., Uusof, S., Ponnudurai, G., Yin Chung, K.P., & Amirthalingam, S.D. A study of the nature and level of trust between patients and healthcare providers, its dimensions and determinants: A scoping review protocol. British Medical Journal Open 2020; 10e028061. Doi: 10.1136/bmjopen-2018-028061.
[6] CTAS is the “Canadian Triage and Assessment Score.” https://hopitalmontfort.com/en/canadian-triage-and-acuity-scale A CTAS 2 refers to a patient whose needs are emergent and whose conditions are a potential threat to life, limb, or function.
[7] Institute for Healthcare Improvement. Joy in Work. http://www.ihi.org/Topics/Joy-In-Work/Pages/default.aspx
[8] The Health Foundation. The power of storytelling. 12 December 2016. https://www.health.org.uk/newsletter-feature/power-of-storytelling
