Dr. Mehta

Trust is fundamental to the practice of medicine. As the foundation of a therapeutic relationship, it’s essential for effective care delivery. Trust is a fragile bond, an agreement that, in a state of vulnerability, a patient can rely on the clinician to act in their best interest with integrity and fairness. Traditionally, trust-based relationships existed solely on a patient-clinician level but in modern health care, the concept of trust operates in a complex ecosystem of health care networks, organizations, and multidisciplinary teams.¹ It’s the shared responsibility of all participants in the chain of care to foster trust. As hospitalists, we face an even greater challenge of building trust with patients who are facing difficult choices in states of acute vulnerability—often as virtual strangers—walking in spaces fraught with emotions. We present three elements that bolster trust: compassion, competence, and credibility. These exist on both interpersonal and organizational levels.

Trust in health care has gradually eroded in the U.S. over the last four decades. While 80% of Americans showed confidence in the medical system in 1975, only 37% expressed confidence in 2015, a dramatic fall of more than 50%.² And, the U.S. ranked 24 out of 29 in patients agreeing with the statement “all things considered, doctors in the U.S. can be trusted.”³ These pre-pandemic reports on public trust were an augury of signs to come. 

Dr. Mathews

The cause for this steep decline in trust is multifactorial. Health care in the U.S. evolved in the last few decades into a complex, byzantine system. Emerging business models have turned health care into an industry and patients into customers. And, multiple factors contribute to the fracturing of trust, including an insidious decline of trust in scientific experts, the breakdown of communities and social bonds, structural racism, existing health inequities, and an increasingly polarized media landscape. In this pandemic, the issue of public mistrust has led to our untethering, leaving us in free fall.

Trust in health care lies in relationships. Patients’ trust in clinicians is dependent and intertwined with factors of the organization at large.⁴ Therefore, elements of trust require deeper scrutiny on both interpersonal and organizational fronts. An analysis of factors that affect patients’ perception of trust showed that individual/interpersonal factors (like empathy) had a relatively lower effect compared to the quality metrics of the facility (i.e., reliability, promptness, efficiency, and affordability).⁵ In this regard, health systems bear a larger share of responsibility and ownership in steering public trust. 

Individual trust

Motivated clinicians committed to providing conscientious care to their patients are crucial in building trust. Time limitations, poor communication, unconscious biases, virtual visits, and clinician burnout can lead to the fragmentation of interpersonal relationships and contribute to the erosion of trust between patients and clinicians. 

The essential elements for trust-building are compassion, competence, and credibility.^5,6 Compassion entails empathy—seeking to understand and having a genuine heart for listening. Empathetic communication is also a vital starting point to bridge inequities. Competence involves knowledge and thoroughness, with the ability to elicit and respond to needs efficiently. Competent clinicians exhibit humility and know when to seek help to serve patients’ needs. Credibility is being true to one’s word. It necessitates ethical actions conducted with transparency. Hospitalists should embody and model these trust-building behaviors in their practices.

Organizational trust

To restore patients’ trust in health care and hospital settings, person-to-person trust, while essential, cannot suffice. Simply put, organizational trust is not the sum total of interpersonal trust. Organizations must be mindful and commit to the mission of rebuilding trust. The key interpersonal factors of trust—compassion, competence, and credibility—can be extrapolated to organizations as well.

Compassion: Inequities and community partnerships—For under-resourced groups, trust has been eroded by a lack of equitable access to quality care on top of a history of biased and unethical treatment. There’s an increasing awareness and acknowledgment of the inequities in communities that drive health care disparities. While health care systems strive to provide equitable care for patients within hospitals/systems, it’s imperative for health care systems to actively engage with communities to address and mitigate these disparities. 

Historically, under-resourced communities have faced overt discrimination and racism from the medical community. Black and Hispanic communities still face barriers to care access.⁷ The COVID-19 pandemic brought these inequities into sharp focus with inadequate testing, high rates of cases and deaths, and poor access to vaccines, causing attrition of trust even further.⁸ 

Health care systems and hospitals are often vested in the community as large employers and are vital to its economy. It’s incumbent upon health care systems to strengthen their bonds with the communities they serve. Sincere intent and genuine effort to collaborate with populations are essential to trust-building—listening, seeking to understand, and proactively assessing community needs are important for this endeavor. In acute-care settings, the goal should be to provide the highest quality of care, focusing on the dignity of, and respect for, all patients. Additionally, developing and committing to strategies promoting health maintenance, coverage, and access for populations is paramount. Importantly, health care systems should also commit to creating equity and diversity within their own organizations. Also, advocating for broader representation of people of color and low-income groups in research and clinical trials is overdue to bridge these gaps.

Competence: Communication, quality, safety—Health care systems’ commitment to providing high-quality, safe, and effective care delivered efficiently is a requisite for trust. Currently, one of the greatest challenges is to counter misinformation and relay factual information to the public cogently. According to a Pew Research Center report, Americans are divided along party lines in terms of how they view the value and objectivity of scientists and their ability to act in the public interest.⁹ Of note, the trust report also found that Americans tend to trust the recommendations of science practitioners involved in their direct care, more than those of researchers.⁹ In the era when science, scientific communities, and experts are widely mistrusted while facts are politicized and come into doubt, health care systems need to make concerted efforts to actively build and maintain trust within the communities they serve. In times of uncertainty, empathetic and honest communication, both at individual and organizational levels, is crucial. 

Credibility: Integrity, transparency, and affordability—With extraordinary progress and expanded capabilities in medicine, modern health care has evolved into an exorbitant and complex web of systems. Health care systems are often viewed as efficient operations, driven by market forces with the central goal of maximizing profits. A cross-national data analysis of 23 countries revealed that commodification or commercialization of health care may play a significant role in the deterioration of public trust in individual physicians. 

Nations that consider health care as a basic human right had higher levels of trust in physicians.³ This underscores the point that interpersonal trust and organizational trust do not operate in silos but are intertwined. Patients and communities feel disconnected from the hazy interplay of insurance plans, pharmaceuticals, organizations’ financial ties, and payment models within health care systems. Increasing commercialization, in which patients assume the role of customers or clients, buying services in exchange for money, makes health care transactional and less trustworthy. 

Patients (and often clinicians) find billing and health care pricing processes opaque. Unexplainable price variability and expensive surprise medical bills further erode the trust of patients. Lack of standardized costs of services and medications is common. Patients’ trust also varies based on health care system configurations (public/private), insurance coverages, hospital experiences, and autonomy/choice, as these contexts drive how patients manage their vulnerabilities.¹⁰ It’s incumbent on organizations to be transparent regarding their business models, financial ties, and billing processes. Therefore, the core tenet of restored trust should be a commitment to transparency and the creation of affordable care by health care systems. 

Steps toward restoring trust

Rebuilding public trust in health care is the need of the hour. Concerted efforts by health care systems toward building trust and a willingness to fundamentally change operations, keeping trust as a focus, is essential. Creating a culture geared toward compassion, competence, and credibility—on interpersonal and organizational levels—can be instrumental in fostering trust. As hospitalists, we’re stakeholders and integrally involved in the operations, decision making, and functioning of hospitals. Hospitalists lead key missions in hospitals, including safety and quality. Health care systems should consider creating space and resources for “trust officers”, “trust trustees”, or teams with the intent to commit to restoring and maintaining trust with the communities they serve. Hospitalists are well-positioned to contribute meaningfully to this cause and to become custodians of trust and ambassadors of their organizations. Trust metrics should be devised and tracked. Trust officers should have a seat at the table in operational decisions, weighing these through the lens of trust. Trust teams can engage in transparency, advocate for equity, and improve access to care. These teams may also act as community liaisons, creating partnerships and strengthening bonds. In cases of breaches of trust, organizations should be transparent and hold parties accountable. 

In this era of uncertainty, tumult, and widening chasms between patients and clinicians, building bridges of trust is a key way out of precarity.  

Dr.  Mehta is a hospitalist with HealthPartners, St. Paul, Minn., and an assistant professor at the University of Minnesota Medical School. Dr. Mathews is the chief of hospital medicine at Regions Hospital, HealthPartners, St. Paul, Minn., and an associate professor at the University of Minnesota Medical School.

Additional reading: For more articles on trust, read The Journal of Hospital Medicine’s Trust Series.

References

1. Lee TH, et al. A framework for increasing trust between patients and the organizations that care for them. JAMA. 2019;321(6):539-540.
2. Aspen Institute. Crisis in democracy: renewing trust in America. Knight Commission report on Trust, Media and Democracy. (http://csreports.aspeninstitute.org/documents/Knight2019.pdf). Published online 2/4/2019. Accessed 4/2/2022.
3. Huang EC, et al. Public trust in physicians-health care commodification as a possible deteriorating factor: cross-sectional analysis of 23 countries. Inquiry. 2018 March 5. doi:10.1177/0046958018759174.
4. Lee TH, et al. A framework for increasing trust between patients and the organizations that care for them. JAMA. 2019;321 (6):523-620.
5. Greene J, Samuel-Jakubos H. Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors. Jt Comm J Qual Patient Saf. 2021;47(12):768-774.
6. Frei FX, Morris A. Begin with trust. Harvard Business Review. May-June 2020.
7. Burwell SM. Setting value-based payment goals: HHS efforts to improve US health care. N Engl J Med. 2015;372(10):897-899. 
8. Wadhera RK, et al. Variation in COVID-19 hospitalizations and deaths across New York City boroughs. JAMA. 2020;323(21),2192–2195.
9. Pew Research Center Science & Society. Trust and mistrust in Americans’ views of scientific experts. Available at: https://www.pewresearch.org/science/2019/08/02/trust-and-mistrust-in-americans-views-of-scientific-experts. Published online 8/2/2019. Accessed 4/2/2022.
10. Ward PR, et al. A qualitative study of patient (dis)trust in public and private hospitals: the importance of choice and pragmatic acceptance for trust considerations in South Australia. BMC Health Serv Res. 2015;15:297.