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Viewpoint
Trust in Health Care
January 24, 2019

A Framework for Increasing Trust Between Patients and the Organizations That Care for Them

Author Affiliations
  • 1Press Ganey, Boston, Massachusetts
  • 2Kaiser Permanente, Pasadena, California
  • 3The Health Institute, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts
JAMA. 2019;321(6):539-540. doi:10.1001/jama.2018.19186

Trust matters in health care. It makes patients feel less vulnerable, clinicians feel more effective, and reduces the imbalances of information by improving the flow of information. Trust is so fundamental to the patient-physician relationship that it is easy to assume it exists. But because of changes in health care and society at large, trust is increasingly understood to be at risk and in need of attention.1

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    4 Comments for this article
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    Trust Must Be Earned By Hospital Leadership
    Francis Holt, PhD, RN, PhD, RN, MSEd, BSN |
    "Boards and senior leadership should regularly examine data that reflect on trust by patients and among personnel." Nice thought, but I doubt that personnel would take the risk of honest criticism were it deserved; especially in rural areas where other healthcare jobs are scarce. Yesterday, I read results of Medscape's Nurse Career Satisfaction Report 2018 (1). The "Least satisfying aspect of job" for RN's, LPN's and APRN's was "Administration/Workplace politics." I have been an RN for 40 years and have to say that trust of administration, boards, senior leadership has been a diminishing commodity over that time. Often, in nursing, I have seen trust lost by administrators making decisions about nursing without understanding very much about nursing and a nurse's responsibility and scope of practice. Unless boards make a real and concerted effort to solicit feedback without reprisal, I suspect that downward trend will continue.

    References

    1. https://www.medscape.com/slideshow/2018-nurse-career-satisfaction-report-6011115
    CONFLICT OF INTEREST: None Reported
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    Health Education and Communication
    Shivakumar Narayanan |
    There is little said about improving health education and literacy. Mistrust also stems from large differences in patients' background knowledge about their health status, and non-parallel goals of treatment of the physician team vs patients and their families. Everyone will agree that an informed patient is a better satisfied patient.
    CONFLICT OF INTEREST: None Reported
    Increasing the Trust that Patients Have Towards Physicians & Organizations
    Stephen Strum, MD | Hematologist/Oncologist in the Community Practice of Medicine
    I read the Viewpoint by Lee et al and although I agree with some of the recommendations to enhance the trust that patients have towards physicians and organizations, the harsh reality of the devolvement of patient trust over the course of my 50 years in medicine leads me to conclude that the authors' recommendations are unlikely to translate into reality. There are 9 bulleted recommendations made in the viewpoint, of which 3 are in need of major repair, while the other 6 I would put into the category of "not going to happen in the next ten years". Addressing, in my opinion, the 3 substantive recommendations, it is clear that these items are in need of major repair. I address these in the numerical order of the bulleted list in the editorial:

    3. Transparency of "patient care experiences" where the authors talk about making data "transparent". How about patient portals that actually provide the patient the history and physical exam, office notes, consultations, and not euphemistically provide "transparency" with a list of lab results instead? I consider 80% of the patient portals that I have accessed with the patient's consent to be dummied-down patient versions (DDPVs) of the medical record. These are meant to placate the patient. They have no reflection of cognitive work done by physicians to enhance patient outcome.

    8. The patient does need a navigator aka ombudsperson, translator because there is such poor communication between physician and patient and also because of the glaring deficiency of communication of results as noted in item 3 above. I am consulted by patients with malignant conditions because they are not getting the time to talk to their physicians to discuss their medical status. I obtain full medical records and abstract data into a usable medical record whose focus is on resolving medical problems. I call this resolve and not "revolve". There is a glaring lack of follow-up and resolution that perpetuates the patient's ill health which leads also to staggering healthcare costs. This issue of "trust" would likely be a non-issue if today's healthcare was more effective, efficient and led to optimal outcomes.

    9. Patient involvement in designing solutions to fix the erosion of trust definitely ties into items 3 and 8 above and if these issues were fixed then this recommendation would be unnecessary. Instead of more communication between patient and physician, we have an increasing buffer between the caregiver and care-receiver. Personnel are hired to act as intermediaries to "protect" the physician's time. In my opinion, a large part of this problem of trust is due to a combination of a shortage of the number of physicians plus the lack of a resolution-oriented medical system. This current era of computer technology which should enhance patient outcome has led instead to the use of "cut and paste" of portions of the medical record to create the appearance of comprehensive office visits to enhance physician and organization income while patient outcome falters. Just recently, I reviewed a 3,000-page compendium of one patient's medical records, of which at least 70% was simply "old stuff" just cut and pasted into the patient's office visits and even consultations. Too often, current so-called medical care is blatantly a revolving door.

    I suggest fix item 3 and re-examine the functionality of EHR (electronic health record) combined with the creation of a new position called Patient Navigator. That should get the ball rolling and clarify why medicine has devolved and not evolved.
    CONFLICT OF INTEREST: None Reported
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    Trust To Do What?
    THOMAS MORGAN, MD | University
    Trust is indeed vital to health care. What is missing from the article, however, is any explicit definition of exactly what physicians and other health care providers should be entrusted by patients to do? What patients want is for physicians always to follow the Golden Rule, as implied by the adoption of safety checklists by surgeons who realized that that's what they would want for themselves or family members. Patients continue to believe in the myth that the right thing to do is defined in the context of a fiduciary doctor-patient relationship through a process of shared decision-making. However, that is not how large, bureaucratic health care organizations operate. Such organizations use a much more diffuse system of utilitarian ethics in which the right thing to do is defined by what leaders consider the greatest good for the greatest number of patients. Following procedures set by the organization, including cost-containment and rationing efforts, is how health care leaders define "the right thing." Patients may trust their physicians, but how can they trust aloof leaders in closed boardrooms that don't follow the Golden Rule, instead making tough, utilitarian decisions that may sacrifice the individual for other aims?
    CONFLICT OF INTEREST: None Reported
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