Understanding and Improving Trust Across the Health Care Ecosystem

Introduction

Capable. Reliable. Honest. These words are often used to describe people we trust. Trust is complex—a state between two or more parties involving confidence that the other can do the right thing, will do the right thing, and will act with your best interest in mind. Trust cannot survive in the absence of any one of these elements.¹ In the New York Times essay, “Do You Trust the Medical Profession?”, trust is assessed with these three questions: “Do you know what you’re doing? Will you tell me what you’re doing? Are you doing it to help me or help yourself?”.² These are questions of ability, reliability, and goodwill.

While many think of trust as a sociological phenomenon, both genetics and life experiences influence trust in others, and research shows that several hormones, including oxy­tocin, cortisol, serotonin, and dopamine, affect trust.³ Of note, these hormones also mediate stress, and as stress changes the balance of these hormones, trust decreases.³ Loss of trust may result in poor quality of care and, if stan­dard of care is maintained, loss of trust still may result in anxiety, resentment, anger, and departures from health care relationships.⁴

Data on trust in health care is mixed, incomplete, and often focused on patient trust in physicians. However, there is increasing interest in the role of trust across the health care ecosystem. Recent studies show that there has been a decisive decrease in trust in the health care system in the last 60 years.^5–7 Trust in medical leaders by US residents decreased from 73% in 1966 to 34% in 2012.⁸ In 2021, 30% of physicians stated that their trust in the health care system declined due to the COVID-19 pandemic.⁹ Trust is likely decreasing because the foundations of trust—abil­ity, reliability, and goodwill—have eroded. In addition, two primary mediating factors of trust—communication and stress—have had additive negative effects. These issues accelerated over the course of the pandemic.¹⁰

To understand the issues and potential solutions, the var­ious trust relationships need to be considered.

Trust Between Clinicians

Robust relationships with and between members of the health care team have waned as clinicians in outpatient prac­tice stopped seeing patients in the hospital, and encounters between the inpatient and outpatient teams diminished or occurred only through the medical record. Communication through the electronic health record (EHR) is often unsat­isfactory, with notes meant for optimizing billing and full of unnecessary information for communicating medical issues. Medical society gatherings and face-to-face hospital staff meetings, where physicians could get to know others prac­ticing in their community, have withered. Clinical teams that used to be stable over time have been replaced with teams that quickly gather and dissolve, sometimes before the entire team can develop a trusting relationship.

To improve trust among members of the health care team, we need to increase the opportunities for clinicians to be with each other outside of stressful clinical encoun­ters. Building personal relationships would increase under­standing of each other’s values and increase the likelihood of direct conversations when needed in difficult clinical situations. The use of communication tools needs to be optimized so that key information is easily accessible and clear. Excessive documentation should be eliminated, and training should include concise communication skills. We can improve trust among the clinical team by ensuring that team members are prepared for their work both as individu­als and as teammates. The team needs to be skilled in inter­professional practice, with each person knowing who their teammates are, and understanding each member’s roles and skills. Everyone needs to be supported to work at the appro­priate level for their role. Team formation can be enhanced, even for short-lived teams, and leaders need greater skill in forming strong teams quickly.¹¹

Trust Between Clinicians and Administration

Health care administration takes place in the clinical set­ting as well as at the system, state, and federal levels. There are numerous reasons that trust has diminished between clinicians and administration. Clinicians and administrators often don’t understand one another’s day-to-day world, and administrative directives may arise with little opportunity for the clinical team to interact with the decision-makers. Mergers and acquisitions of hospitals and health systems have resulted in changing practice patterns, scheduling rubrics, and productivity requirements. If the clinical team does not understand organizational goals, those goals may appear to be for the benefit of the organization rather than clinical care.¹²

To improve trust, health systems need to make their goals, strategies, and tactics more transparent to clinicians. In addition, trust would be improved by administration ensuring there are resources to support the implementation of clinical guidelines and quality measures. Clinicians need to express their needs directly and clearly. Improved under­standing between clinicians and administrators will help improve the belief in the positive intent of the other party, reducing stress and increasing trust. Administrators and cli­nicians can spend time with one another so that all parties have a better understanding of the work of the other. Work should be done to align the values of administration and clinical care. Increased emphasis on quality and outcomes over financial and volume-productivity targets will improve collaboration and trust. Administrators and clinicians should feel that they are doing the right thing for the right reason, and the move from pay-for-volume to pay-for-value should be supported and hastened. Collaboration on—and clarifica­tion of—new directives will help build trust between admin­istrators and clinicians.

Patient Trust in Health Care

Patients trust clinicians when the clinician truly hears the patient’s concerns and demonstrates that they are acting in the patient’s best interest. Time pressure in the clinical setting and unskilled use of electronic tools worsens two-way communication. The ways patients can engage with the health care system have also changed significantly in recent years. Health topics that were not usually talked about in public are frequently discussed openly. Prescription medica­tions are advertised directly to the consumer. Patient por­tals, virtual visits, and texting all offer benefits of increased engagement with health care providers but are also in their infancy with regard to best practice. Anyone can access information about a health condition online, so many patients go into a clinical encounter well versed in informa­tion they have gained outside the clinical setting that may be accurate, skewed, or incorrect. These changes especially affect members of marginalized populations. As data have become more available, variation in clinical experience among marginalized populations is more visible and adds to skepticism about the goodwill of clinicians and the health care system.^13,14

Patients feel the changes in the system, especially when they do not understand them. As Lee and colleagues note:

“Organizations are merging, creating new structures, and adopting new names in place of those known to patients for decades, leading to the loss of familiar brands with trusted reputations. The merging process can also lead to changes in tangible and intangible aspects of the care experience that leave patients feeling like they have changed clinicians even when they are seeing the same clinicians but in a setting that looks, feels, and acts differently”.¹⁵

To improve patient trust, clinicians need to take the time to listen and engage with their patients to determine and carry out the appropriate care plan. More needs to be learned about the best ways to utilize the EHR and other vir­tual tools, and both patients and clinicians will need to adopt best practices. The health care system and clinicians need to focus on understanding and meeting the needs of racial minorities and marginalized populations, since trust is most often lacking in these groups of patients.¹⁴ Systems need to ensure that patients understand the structure of new and merged systems and should function in ways that demon­strate the benefit of these new constructs to the patient.

Patients need to be empowered to find the best informa­tion available and develop skills to differentiate good infor­mation from bad. Clinicians should recognize that while they may have a knowledge advantage about a clinical condition, the patient has the knowledge advantage about the patient’s own experience. Patients and clinicians need to improve two-way conversations about concerns and plans.

Addressing Stress

Stress among the workforce in the clinical setting has increased dramatically due to organizational mergers, inad­equate staffing, tight clinical schedules, performance tar­gets, and burdens arising from the EHR. Chaos in a clinical setting—including diminished control and bottlenecks in clinic flow—leads to lower job satisfaction, decreased team­work and professionalism, more stress, and a higher likeli­hood of leaving the practice within two years. Chaotic clinics also have higher rates of medical errors and missed oppor­tunities for preventive care.^16,17

Too much stress has a serious negative impact on trust. Clinicians should have an opportunity to fully understand new administrative constructs and requirements. Clinical sites need to be managed in a way that reduces chaos, clini­cians should have the tools to provide needed care, schedules should be realistic, and supports must be in place to stream­line the workflow. Emphasis on quality, communicating accu­rate information, clinician cohesion, and values alignment between clinicians and administration will improve trust.¹² In addition, clinicians and administrators need to prac­tice self-care and be given the time to do so. “Found” time (efficiencies gained by good use of EHR, for example) should be returned to clinicians for clinical engagement or self-care, instead of pushing more patients through the system.

What can we do to improve trust in health care?

Federal guidelines, changes in reimbursement, produc­tivity requirements, the unknowns of the pandemic, hospi­tal mergers and closings, and the way people receive their health news all affect stress and trust. It is no wonder that trust in the health care ecosystem is low. However, we aren’t going back to the health care system of the past, and we must learn to build trust in this larger, ever-changing health care climate.

Trust allows people to feel safe even when they are vul­nerable. Lacking trust, people reduce their engagement; patients are more likely to accept and follow physician treat­ment recommendations when they trust their physicians, and high trust can mitigate disparities in care.^6,18 Teams are more effective when the team members trust each other, when clinicians trust their health care organizations, and when patients can be moved through systems more effec­tively.¹² Every participant in the health care ecosystem can learn knowledge and skills that will improve trust.

We need to learn more about trust in health care. There is a growing body of literature on the topic, and more research needs to be done. Where are the weak points, how are they changing over time, and what is causing changes in trust? To slow and reverse the decline in trust, we need to focus as much on trust as we do on quality of care. We should sur­vey administration, clinicians, patients, and their families on trust as well as on outcomes and satisfaction. Identifying specific factors that undermine trust can pinpoint areas to target for improvement.

Finally, the pandemic has certainly affected trust across the world and within health care. The opportunity to witness the emergence of a disease as well as the resulting evolution of knowledge, treatment recommendations, and questions of politicization, all can lead to reduced trust in health care.^10,13,19 We need to gain more understanding of the ways that trust has been challenged by the pandemic and work to improve trust so that the health care ecosystem will be more resilient in the future.

Disclosure of interests

No interests were disclosed.