Broken hands on broken ploughs,
Broken treaties, broken vows,
Broken pipes, broken tools,
People bending broken rules
Hound dog howling, bullfrog croaking,
Everything is broken.
—Bob Dylan, “Everything Is Broken”
For many patients, Bob Dylan’s lyrics may as well have been written about the U.S. health care system. While everything may not actually be broken, there has certainly been an erosion of trust in physicians during my career. In 1966, 73% of Americans reported having great confidence in the leaders of medicine; in 2012, that number had fallen to 34%.1
I see this lack of trust most keenly in the eyes of patients when they show up in the emergency department after being told they cannot get an appointment in a private doctor’s office for weeks or months, even though their problem is getting worse. They are scared about the problem and feel that no one cares. By the time I see them, after they have waited several hours in the emergency department, their fears have grown. Before I can even begin to help, I have to work on the relationship of trust. I sit down and begin to listen. Sometimes the story will unfold in fragments, a few words about a pain and then a long discourse about the waiting room, the long wait and the many people who have asked the same questions again and again. If I am not too busy with other patients I listen, but it can be difficult to find the time. Usually the whole story will eventually come out; after that there will often be blood tests and x-rays, and more time will pass. I may have an answer in the end or I may not, and I may have to ask the patient to trust me that my evaluation has been complete even if there is no definitive answer. But how can I ask for their trust after all they have already endured? This can be an especially difficult request if the patient is from a group that has historically been underserved. There is a long history of disparate treatment for underserved patients.2 Once trust has been broken, it is difficult to repair.
To repair trust with our patients, we should begin by modeling trusting relationships with our students and residents in the learning environment, cultivating behavior that can extend into the care of our patients with careful, graded entrustment decisions. ten Cate et al3 have described modes of trust between clinical supervisors and trainees. They identify entrustment as presumptive (based on credentials), initial (based on first impressions), and grounded (based on prolonged experience), and they examine factors involved in entrustment decision making that are associated with the trainee, the supervisor, the context, the task, and the relationship between supervisor and trainee. While medical education has made substantial progress in recognizing the importance of trust as part of the compact between students, teachers, and patients, we continue to struggle with how to create learning environments that build the trust of our learners. The balance between patient safety and learning has also been a source of tension between learners, patients, and faculty. Academic health centers have unique challenges in creating trustworthy relationships with various communities.
Because trust is such a fundamental part of the relationships throughout health professions education and care delivery systems—relationships between patients and doctors, learners and faculty, doctors and nurses, communities and hospitals—we have decided to make trust the focus of the next New Conversation. Our New Conversation about trust in the health system will focus on trust in the health professions education environment. We would like to consider the following question: What can academic health centers do to reestablish trust with our patients, students, health professionals, and communities? This could include the admissions and selection system for medical school and residency; assessment, promotions, and remediation systems; supervision and feedback in the clinical environment; patient safety, communications, and quality improvement; or continuing professional development and maintenance of certification. We also encourage submissions that address trust between the community and academic health centers since that relationship is integral to the success of the learning environment. Finally, we hope to see submissions related to trust between various members of the health care team—doctors, nurses, physician assistants, pharmacists, and hospital administrators—as well as trust between payers and health care professionals.
I ask that you submit contributions on this fourth New Conversations topic—guided by the questions, examples, and goals stated in this editorial—to be considered for publication in the journal. Please submit contributions through the journal’s online submission system, Editorial Manager (www.editorialmanager.com/acadmed), using the article type “New Conversations.” Submissions should be scholarly contributions that follow the journal’s regular submission criteria for Invited Commentaries, Perspectives, Research Reports, Articles, or Innovation Reports. (For more information about those criteria, please see the journal’s Complete Instructions for Authors at http://journals.lww.com/academicmedicine/Pages/InstructionsforAuthors.aspx.) Submissions will be peer reviewed.
We will carry on the conversation outside the pages of the journal as well. Our blog AM Rounds (academicmedicineblog.org) will feature a series of discussions related to the New Conversations contributions that are published in the journal. I also encourage you to discuss New Conversations on Twitter using the hashtag #AcMedConversations by offering your opinions, posing questions, and responding to the opinions and questions posed by your colleagues. We will be using the journal’s Twitter handle, @AcadMedJournal, to do the same.
I will consider New Conversations submissions at any time, starting immediately—there is no deadline for submitting a contribution. Although we may not publish New Conversations contributions in every issue of the journal, we hope to have many of them to share in the pages of the journal and beyond as this fourth New Conversation unfolds over the course of 2019.
David P. Sklar, MD
1. Blendon RJ, Benson JM, Hero JO. Public trust in physicians—U.S. medicine in international perspective. N Engl J Med. 2014;371:1570–1572.
2. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2003.Washington, DC: National Academy Press.
3. Ten Cate O, Hart D, Ankel F, et al; International Competency-Based Medical Education Collaborators. Entrustment decision making in clinical training. Acad Med. 2016;91:191–198.