People, when rightly and fully trusted will return that trust.
Abraham Lincoln.
By: Annamarie A. Fuchs, Creator. Partners in Health | Conversations
January 7, 2021
On December 18, 2020 we published part 2 in our series of articles associated with physician opinions surrounding the concept of person-centered care. In that article, the concept of trust was proposed by our respondents as “both a strategic enabler and, where it is lost, a system defect.” Feedback to date has generated considerable interest and a desire on the part of our readers to continue the conversation in much greater depth as we explore how we might work together to rebuild a system that will both enable and expect a culture of trust.
Dr. Scott McLeod, the Registrar of the College of Physicians and Surgeons of Alberta (CPSA) and President of The Federation of Medical Regulatory Authorities of Canada (FMRAC), spoke candidly with me recently about the issue of trust. His belief is that the breakdown of trust is central to many of the challenges we face in health care and specifically to our efforts to deliver person-centered care. Prior to arriving in Alberta in 2017 to take over leadership of the CPSA, Dr. McLeod had been with the Canadian Armed Forces for 27 years where his most recent position was Deputy Surgeon General. In that role, he provided oversight and leadership for all clinical programs in the CAF. What follows are excerpts from our conversation.
- Dr. McLeod, what issues, beliefs, or behaviors do you think are at the heart of the apparent breakdown of relationships between front line physicians and physician leaders?
It’s important that we commend physicians for recognizing that we are both part of the problem and part of the solution. Physician leaders for example are often chastised by the profession for ‘going to the dark side’ and not being connected to real care anymore. As leaders, we are often told that we no longer understand what it’s like to be a doctor. In some cases that may be true but for the most part physicians don’t forget what it was like to provide front line care. What I find fascinating is how this differs from other professions. For example, if you have an engineering company, front-line engineers appreciate the fact that an engineer runs the company, because they ‘get it.’ They ‘think like an engineer’ but they don’t expect that CEO to practice as an engineer. So why in medicine do we complain that the system is run by out of touch managers and accountants, yet we disrespect [and often mistrust] those physicians who give up patient care which they love in order to tackle the vital and strategic challenges inherent in leadership? On the other hand, front line doctors are often too far removed from the system-level problems to understand all the sensitivities and complexities that decision makers must take into consideration. Physician leaders have not forgotten what it means to be a doctor. The vast majority still respect the work being done on the front lines, but I realize that there needs to also be reciprocal respect for trust to flourish if we aspire for it to become an organizational and cultural norm.
- We also hear that health care leaders whether they are physician leaders or other administrators, also struggle with efforts to collaborate with or trust elected officials.
We heard in your first article that some physicians and physician leaders believe that elected officials focus too much on the dollars and nothing else. About 6 months ago when I was trying to convince a senior government official that we need to shift our focus from money to quality and that sizeable cost savings could be enjoyed with that approach, I was struck by that person’s viewpoint. The general comment was, and I’m paraphrasing, ‘Why should we trust doctors? If quality and appropriateness is the solution, why has nothing been done yet? If higher quality care and appropriate care are better and lower cost, why aren’t all doctors doing it?” It’s hard to argue that, because if we know it’s the best, why aren’t we all doing this? If we want government to listen to us and trust us, we need to demonstrate that quality is a part of everything we do. Are we “rewarding” the wrong behaviors at times and not rewarding the best behaviors?
- In our first article, we heard that physicians are frustrated with the idea that trust and accountability appear to have been lost across the healthcare system. You and I have both observed in the past that transparent and reciprocal accountability is necessary if we hope to establish a trusting healthcare culture. And that willingness to hold ourselves and each other accountable must exist at all levels of the system and between all players. How do you see this expectation becoming part of our way of doing business in healthcare?
Well, the bottom line is that the design and delivery of healthcare services is, by a wide margin, our biggest expenditure not only in Alberta but across the country and much of the world. But how do we have trust in a system when there is no accountability for quality outcomes? We need outcome expectations set, measured, reported and acted on. I believe we need that both at the system level and the physician level. In Alberta, taxpayers spend billions of dollars per year on the health care system, yet we don’t do a very good job of determining whether Albertans are getting the quality they are paying for. There needs to be governance and oversight processes implemented that create accountability for physicians to deliver according to quality of care expectations. Alberta Health also needs to be accountable to put mechanisms into place to ensure physicians can indeed deliver on those expectations while barriers that minimize efforts to deliver against expected outcomes are mitigated or extinguished altogether. Right now, providers merely offer evidence that a service was provided, not whether it delivered any value or met any expected outcomes. That’s dual responsibility. The fact that direct accountability isn’t built into the entire system at all levels continues to amaze me.
- What about the problematic behaviors within the profession that the respondents in our first article referred to as resulting in the widespread deterioration of trust?
I need to start off by saying the vast majority of doctors are incredibly professional and go above and beyond the call of duty to look after patients. The examples from article #1 were offered in context to billings, but I believe it goes well beyond that. Every time we see a physician behave in a way that does not hold the profession in the highest regard, it erodes trust. While there are thousands of dedicated and hard-working health professionals who care deeply for their patients and work tirelessly to improve the system, as the CPSA registrar I continue to see inappropriate behavior regularly. What’s worse is I see their colleagues letting it happen. The CPSA is representative of all 11,000 physicians in Alberta. Self-regulation means we all need to stop inappropriate behavior when we see it. As physicians, we have a social contract. For Alberta Physicians that contract is known as the Canadian Medical Association (CMA) Code of Ethics and Professionalism[1]. If all physicians, regardless of their roles, lived up to that code then we wouldn’t need a CPSA, but more importantly there would inevitably be greater trust because we would value each other and the profession by holding each other to account to live up to the expectations of the code.
- So where do we go from here? How can we re-establish trust so that the physician community has a much higher degree of satisfaction and ‘joy in work[2]’ while synchronously creating capacity to actually deliver person-centered care rather than merely paying lip service?
We need to start by hearing from those physicians who are committed to delivering person-centered care in clinical settings, academic settings, and frankly in all roles where they are already conducting themselves respectfully and trustfully. Unfortunately, I’m not sure those people currently have an influential voice. They merely go about their day to day work not wanting to make waves. I would love to start by generating opportunities to share experiences of compassion and kindness as part of everyday life across our healthcare system. I believe that if we could just smile more and thank people for what they do; if we could treat each other with respect no matter what roles we play in the system, recognizing that everyone has their challenges. By working together instead of blaming each other, we could have the best health care system in the country.
Concluding thoughts
Dr. McLeod went on to suggest three key strategies that he believes will enable us to achieve progress in establishing trust as a means to both embrace and deliver person-centered care. In the coming weeks, we will offer more conversations and three articles where we focus in greater depth on the core enablers found in mission command, clinical governance, and patient safety. Stay tuned.
References
[1] Canadian Medical Association. CMA Code of Ethics and Professionalism, 2018. https://policybase.cma.ca/documents/policypdf/PD19-03.pdf#_ga=2.64512879.1963899626.1609787412-1768634259.1609787412
[2] Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2017. (Available at ihi.org) http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx
