Few would deny that trust is necessary for the proper functioning of the health care system, beginning with the trust that patients place in the physicians and other clinicians who care for them, often during times when they are particularly vulnerable. In recent years, however, it has become clear that such trust cannot be assumed.
First, health care is not an island unto itself but, rather, is subject to larger societal trends. As such, it is impossible to ignore that in the United States, public trust in many institutions across society has declined markedly. In 2018, the public relations and marketing consultancy firm Edelman released findings from its annual “Trust Barometer,” showing that the United States fell within the lowest quarter of the 28 countries surveyed regarding trust in institutions, with levels of trust among the “informed public” ranking last among all groups of respondents.1
Turning to the health care sector, we see a discouraging decline in trust on multiple fronts. In 1966, 73% of Americans said they had great confidence in the “leaders of the medical profession”; only 34% said so in 2012.2 In 2015, only 37% of the public told Gallup that they had a “great deal” or “quite a lot” of confidence in the medical system, compared with 80% in 1975. This made “the medical system” the “biggest loser,” suffering the largest decline in trust among all institutions covered in the poll.3
When it comes to physicians, the news is more favorable, although here too it is not difficult to find warning signs. Compared with people in other nations, Americans think highly of the care they receive from their own physician but are more skeptical of physicians as a class. In a survey conducted between 2011 and 2013, the United States ranked third of 29 nations in the satisfaction patients expressed with the treatment they received when they last visited a physician. However, the United States ranked 24th in the percentage of patients who agreed with the statement “All things considered, doctors in the U.S. can be trusted.”3 In the same survey, 69% of the public rated the honesty and ethical standards of physicians as “very high” or “high.”3 In 2016, that number dipped slightly to 65%, while 84% of Americans said the same about nurses.4
There are numerous plausible theories for why Americans’ trust in health care has declined. These factors include:
- the rapid growth of competing and contradictory sources of information;
- research findings that are breathlessly reported to the public only to be withdrawn, or contradicted by subsequent, heavily promoted research findings;
- conflicts of interest and consumer perceptions that medicine is a business like any other;
- an exponential increase in medical advances and complexity, many of which change clinical recommendations;
- the movement to expose quality problems and medical errors; and
- clumsy efforts to restrain health care costs through some poorly devised managed care models in the 1990s.
In addition, we have seen continuing skepticism about the scientific consensus in areas such as climate change and the safety of genetically modified foods. In an era in which balkanized communities receive their news from different television networks and tailored social media feeds, it seems increasingly difficult for Americans to agree on a shared set of facts. Indeed, it has never been easier to spread false information. This creates an existential problem for physicians, whose authority stems from their perceived expertise about a set of medical knowledge. If patients come to doubt the validity of that knowledge, it will call into question the foundation of the patient–physician relationship, which we believe would have a devastating impact on the U.S. health care system and on Americans’ health. We see elements of this dynamic in the persistent skepticism of a vocal minority about the medical consensus that vaccines are safe.
The ABIM Foundation embarked on a series of conversations (which we called a “trust tour”) with leaders from academic medicine, specialty societies and boards, consumer groups, health plans, and other organizations in 2017–2018. These conversations also suggested that trust was a critical and compelling topic. Taken together with the public opinion data explored above and the historical and societal factors motivating public skepticism, we became convinced that enhancing trust should be a critical priority for the medical profession.
Trust is also an issue of particular salience for the ABIM Foundation. Our mission is to use medical professionalism as a tool to improve the U.S. health care system; trust is central to the concept of professionalism defined in the Physician Charter on Medical Professionalism. The charter stresses the importance of patient welfare and patient autonomy, which can be exercised only in the context of trusting relationships.5 Indeed, the charter says that professionalism is the basis of medicine’s contract with society, and states, “Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession.”
Widening the lens beyond the patient–physician relationship, we see that trust is also essential to physician well-being, a prerequisite for professionalism. The satisfaction that physicians take in their practices can be heavily influenced by the trust between them and the health systems and hospitals in which they practice, or between them and the rest of the clinical team. We hypothesize that increasing trust in those relationships could be an antidote to burnout among physicians and nurses, a topic of increasing concern.
The Board of Trustees of the ABIM Foundation considered all of these factors while embarking on a strategic planning process during 2016 and 2017 that was designed to choose a new focus area for the foundation. This strategic planning process was similar to the foundation’s 2010 strategic review, which had led to a focus on resource stewardship and ultimately to the creation of the Choosing Wisely campaign,6 which is a partnership between the ABIM Foundation and more than 80 specialty societies that seeks to prompt conversations between clinicians and patients about—and ultimately to reduce—unnecessary care. In both processes, the board sought an area of focus that was closely linked to physician professionalism, that was critical to improving the health care system, and that was not already a major area of philanthropic focus. The foundation board believed that trust met all of these criteria, and believed that the foundation could play a vital role because of its success in Choosing Wisely and elsewhere in convening multiple stakeholders on difficult issues that require respectful conversations.
The ABIM Foundation is distinct organizationally from the American Board of Internal Medicine (ABIM) but derives its nonprofit status from being a “support corporation” to ABIM. In thinking about focusing on the issue of trust, the ABIM Foundation was informed by recent experiences of ABIM. As has been widely reported and acknowledged by ABIM itself, over the last five years, ABIM suffered a loss of trust from its diplomates.7 This obliged ABIM to think carefully about what had gone wrong, why trust was lost, and what steps could be taken to restore it, reorganizing its governance and its work to address directly issues raised by its community. While ABIM remains in the process of “trust restoration,” the foundation’s new focus is not directly connected to that; rather, the foundation believes that what happened to ABIM is exemplary of a risk facing all health care organizations today, and that much can be learned and shared that would help medical organizations maintain trust with their communities.
What Can Be Done?
At the ABIM Foundation, we are now in the process of planning how we can play a useful role in improving trust in health care. We are guided in this exploration by the following statement: “ABIM Foundation seeks to enable trustworthiness in all relationships as a means of supporting and protecting professionalism, which in turn is necessary to achieve excellence in the health care system.”
The expansive approach suggested by this statement extends beyond the patient–physician relationship or any other particular dyad. Rather, we are taking a global approach, with interest in enhancing trust in all key relationships (e.g., physicians and the systems and practices in which they work, systems/practices and health plans/insurers) and in addressing trust issues among clinicians and patients related to technology and misinformation.
We continue to consult with experts and learn about dimensions of trust. These experts have offered a number of suggestions, including:
- making trust-building an explicit part of medical education and modeling it for residents and trainees;
- developing an evidence base linking trust to clinical and financial outcomes to demonstrate its importance and encourage more institutions to make trust an organizing principle for health care institutions;
- improving how we measure trust; and
- building trust with communities of color and low-income Americans, who tend to be least trusting of clinicians and health systems (for understandable reasons).
We are also reaping ideas from testimonies from medical students and residents, like those published as Trainee-Authored Letters to the Editor in the next few issues of Academic Medicine. These submissions show that students and trainees worry about how they can gain the trust of their patients as they develop competencies in doctoring. They also demonstrate how trainees are thinking about trust and its importance from their earliest days in the profession. They teach us about how power imbalances between faculty and trainees affect trust, and about the importance of allowing for interactions that are free of ridicule or intimidation. These lessons will inform our approach not only in academic settings but also in other settings in which such imbalances are present.
At the ABIM Foundation, we have launched our own Trust Practice Challenge, in which we have solicited written descriptions of trust-building practices that have shown promise in various practice settings. We have cast a wide net, working with a variety of partners to uncover examples across the health care spectrum. We will include strong entries in a compendium of successful and scalable practices that we will produce and disseminate. In addition to the Trust Practice Challenge, and in conjunction with our annual ABIM Foundation Forum, we will also solicit videos and essays from health care leaders that describe how they have built trust. We will then ask forum attendees—about 150 individuals from health care practice and delivery, academic medicine, research, journal publication, and philanthropy—to flesh out potential concepts to advance trust. We expect that the Trust Practice Challenge and the ABIM Foundation Forum will reveal a set of practices that the foundation could support.
Meanwhile, we are also focused on combating medical misinformation. In early 2019, the ABIM Foundation hosted a meeting that brought together leaders from health care and the media to discuss the feasibility and desirability of particular approaches to restoring trust in valid scientific evidence. Potential ideas include:
- creating an “early warning system” that would seek to uncover important areas of misinformation as false claims are gathering steam;
- developing partnerships with specialty societies to create physician and consumer guidance about false scientific claims and how to address them; and
- formulating a strategy for identifying and cultivating “unexpected messengers” who could speak out about health care misinformation issues.
Through these and other efforts, we are explicitly focused on building a movement that will engage a wide variety of organizations and individuals. Our list of desired partners includes, but is not limited to, physicians, other clinicians, and the organizations that represent them; media organizations, journal editors, and individual journalists; educators and trainees; and patients and consumer organizations. In short, we hope to catalyze a coalition that will address trust, a concept that is fundamental but too often ignored.