A conversation with Spring Street’s President Nancy Wise and Peter Weiss, M.D.
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NW: Peter, before we dig into why there could be an erosion of trust in healthcare, let’s look at what trust is at its core. What do you mean when you are talking about trust in healthcare?
PW: I’ve been thinking a lot about what trust is. When you trust something, it means that you are willing to risk harm by interacting with that thing. You’re willing to be vulnerable. So, when you say you trust someone or something, that means you’re willing to risk something with them. In healthcare, patients may be risking their life, health, time, and money in their interactions with us.
Trust must be freely given; it is not something that can be truly earned or compelled. There’s no obligation for me to trust you, even if you’re very trustworthy. Trust depends upon two parties: It depends on one party being trustworthy and another party agreeing to trust. If I’ve been burned many times by the healthcare system, or even if I’m just a worrier overall, perhaps it doesn’t matter how trustworthy you are. I may not ever trust you, through no fault of your own.
Summarizing, the truster must grant trust to the trustee. And for the purposes of our conversation, I would say that the truster refers to our patients, consumers, or the public, and the trustee represents our physicians, hospital systems, payers, and administrators.
NW: What an interesting perspective…I never thought about trust in that way. I’m so glad we’re talking about this! How would you translate this definition of trust into your work in healthcare?
PW: First, I’m thinking about the role of trust as a physician. If I’m your doctor and you’re my patient, it’s my job to be trustworthy. It’s your decision whether or not to trust me, but it’s my job to be trustworthy. And I think, from a healthcare standpoint, trustworthiness has two components. One is ethical behavior. The other is competence.
If I’m ethical, this means that I have integrity. I recognize the interests of the patient take precedence over my own personal interests. In other words, I wouldn’t do something to you that would benefit me but would cause harm to you.
Now it is possible that I could have very high ethical standards, but still be a terrible doctor. The second component is competence–I need to have appropriate knowledge, experience, and judgment. For any patient with an illness, I should be competent to recommend a treatment plan taking all factors into account. I need to be able to develop the treatment plan, execute that plan, and achieve the intended outcome.
However, my ability to accomplish all those things as a physician is not solely dependent upon my performance because in medicine, so much now takes place at a system level.
NW: I love how you are breaking down these concepts into smaller parts so that we can discuss and examine them. Tell us more about system-level competence.
PW: This is the idea that it’s not just the providers but also the system that has to work correctly for a successful healthcare encounter. The system must be both ethical and competent in order to work for the patient and to be trustworthy as I’ve defined it. We all complain about system failures and inefficiencies, but we don’t always address them. In my experience, almost every patient has a story to tell of healthcare gone wrong. Even systems led by seasoned and well-intentioned leaders often fail to provide reliable service and outcomes.
In the old days, at the doctor’s office, the physician controlled or had accountability for everything. Even in the hospital, the surgeon had a lot of control over the operating room, what supplies were there, and what was going to happen. And so, in this environment, it was the doctor in whom you were placing your trust. Now it’s not like that. Now physicians must be part of the system. And I think this whole idea of trusting the system for proper execution is a big problem.
In this framework, what would make the patient or consumer want to trust the system? Reputation and marketing notwithstanding, I believe their real history or experience with the healthcare system is the key element. If, in their experience everything has always worked fine and they’ve been accommodated very well, then they might be more predisposed to trust. Whereas, if they have experience with the healthcare system where many things have gone wrong, where they have not felt respected, and where they’ve had to take extraordinary action to manage themselves, they might not have a readiness to trust.
The patient’s experience involves a great many things a physician can’t control. For instance, if patients have called and left messages, but those messages are lost or go unreturned, then the patient may lose trust in a physician. Of course, the physician could have no knowledge of this. Even if they know, they may not be able to fix it. As a physician, I have had these experiences. I often tell my patients that the only thing in the system I control is my personal work. I can’t stand behind anything else.
NW: So how are providers managing in the trenches?
PW: Most older physicians I know are saddened by the loss of professionalism and of the public’s trust that has occurred over their careers. The younger providers are not as aware of what it used to be like. A short definition for professionalism in medicine is just being trustworthy as we’ve defined it. A professional claims to hold him- or herself to a high standard of ethical behavior and competence, that is, he or she behaves in a manner worthy of trust.
Medicine has changed from a cottage industry of (and led by) professionals to a real industry led by major commercial enterprises. The historic non-profits are often indistinguishable in practice from their for-profit competitors. Professionals (in the historic sense of the word I have been using) are no longer in charge. There is often a huge gap between the values healthcare executives profess and the experiences that patients have within the system. To many patients and professionals (myself included), healthcare seems to be evolving into just another big business. In your experience, are most big businesses trustworthy?
At the same time, we’re also moving from a high trust society, where people were willing to extend trust to professionals or officials based on their position alone, to now, a low trust society where people are no longer willing to do that. I believe that most physicians, young and old, are just trying to do the best they can for the patient in front of them.
NW: How do you think this transition has affected consumers?
PW: I’m old enough to have accumulated a few serious medical conditions. Speaking as a consumer or a patient myself, I wish I could trust the system. Life would be easier then. Even as a physician, I’m not able to figure out the best treatment for my own illnesses and control all the moving parts that impact my care.
Perhaps I am a worrier and know too much, but consumers use different experiences as proxies of trust, and in many healthcare system encounters, the experience may be one of disrespect or suboptimal outcome. For example, if the system cannot even return phone messages well, why should I think they can do heart surgery well?
NW: So, what can a healthcare organization do?
PW: To address trust at the organizational level, I would suggest beginning with patient complaints and known quality and service issues. Why are these occurring and why haven’t they been fixed yet? How are these issues affecting patient trust in the organization? Likely negatively.
Every time expectations are met or exceeded, trust grows. Every time patients experience negative service or clinical outcomes, trust is harmed. How are the thousands or tens of thousands of small and large encounters each day growing or shrinking the organization’s reputation for trustworthiness and the trust its patients have in it?
To create a focus on this issue, perhaps organizations could develop an overall trustworthiness score built from key service and clinical outcome measurements. The exact scale and elements involved would not matter so much as a commitment to measuring and improving it on an ongoing basis. If the score is 65 this year, what can be done to get to 70 next year?
Organizations could also add questions regarding trust to their routine patient surveys. Do you trust your doctor to recommend the best treatment? Do you trust that things will go well when you are having treatment in our hospital? Are you afraid of mistakes in your care? Etc.
Lastly, just as organizations have a compliance function to ensure meeting government obligations, they could establish a compliance-like function dedicated to creating and increasing trust. I’m not thinking about major new departments, but more a new role, Chief Trust Officer, who would be responsible for this view of operations. This person might even be the current director of patient experience. I believe most systems have such a leader or chief of patient experience now. The important elements would be viewing all things (large and small) from the perspective of trust and being willing to speak truth to power about the issues affecting it in the organization.
NW: This is an incredible framework, and you have my brain popping in a new way to think about trust. How hopeful are you that the healthcare system can move in this direction?
PW: Not very hopeful. I’m not saying that it’s not possible, because of course it is possible. But I don’t see that we have the will or business model in place to sufficiently address distrust, all while we are living in a world where there is an erosion of trust in systems and leadership of all sorts. If we want to fix this in healthcare, we will need to take big steps.
NW: What do you think Spring Street can do to help organizations who want to embrace improving trust?
PW: I think many firms could use both thought leadership and practical help. Spring Street has successfully developed an assessment/scoring framework for addressing the social drivers of healthcare. In fact, you have become a thought leader in this area. Similar to how you accomplished that, perhaps Spring Street could partner with select organizations interested in becoming high trust systems and work together to develop, pilot, and refine this trust index concept.