Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on trust in health care and health professions education.
Each year, I enjoy the chance to peek inside trainees’ experiences of becoming physicians by using students’, residents’, and fellows’ Letters to the Editor as my window. The letters selected from Academic Medicine’s 2018 call for submissions reveal a rich, diverse landscape of themes and perspectives on the featured topic of trust. Trainees portray trust through scenes in which patients do or do not share fears and sensitivities with physicians; learners reveal or withhold identities, vulnerabilities, or struggles from peers, faculty, and patients; and education or health care systems facilitate or inhibit the flow of information to guide decisions and improvements. What caught my attention most in these letters is the relationship between trust and transparency. While some letters address this relationship more explicitly than others, altogether they raise questions about the meaning of transparency in clinical learning environments and health professions education, and the implications of transparency for fostering trust.
Transparency as Transmission of Information
On the surface, transparency is one of those ideas that seem too good not to be true. The “transparency pursuit” pervades all aspects of our lives; it “signifies a growing demand for insight, clarity, accountability, and participation.”1(p70) In health care, transparency pursuits are evident in the push toward open access to data, widespread reporting of performance metrics, and the shift from paternalism to autonomy.2,3 Similarly, in health professions education, accrediting bodies urge greater transparency in educational processes and outcomes so that all stakeholders (educators, learners, administrators, and the public) feel confident in the quality of training that health professionals receive.4,5
These discussions of transparency reflect an informational orientation toward transparency.6 From this perspective, transparency is a relatively straightforward process that involves “full disclosure of all relevant information in a timely manner”6(p272) or, as described in a recent report calling for safer health care, “the free, uninhibited flow of information that is open to the scrutiny of others.”7(pxii) Advocates for transparency present it as a solution to mistrust, inefficiency, skepticism, and various other problems attributed to unequal access to accurate information. When some stakeholders have access to information that others do not, concerns arise that such information will not be used in the best interest of all stakeholders. Thus, proponents of transparency tout it as the right approach to “support accountability, stimulate improvements in quality and safety, promote trust and ethical behavior, and facilitate patient choice.”7(pviii)
Consider an example from Dr. Rikhi’s8 letter, “Transparency of Medication Costs: A Method of Building Patient Trust.” He describes a concerning state of affairs in which physicians prescribe medications based primarily on treatment efficacy, with little or no consideration of cost. Of course, physicians know that cost is an important factor in patient adherence, but physicians rarely have access to information about the cost of the medications they prescribe. Patients, in turn, usually discover the cost of a medication when a pharmacist tells them the cost or when they receive the bill. These information gaps result in inefficient, stressful, and potentially harmful delays in treatment. Dr. Rikhi proposes a solution to ensure cost transparency by allowing physicians to choose cost-effective medications through easy access to information about anticipated medication co-pays based on a patient’s insurance coverage. Consistent with the informational orientation toward transparency, he contends that a solution such as this equips physicians with more resources needed to care for patients as whole persons, in context, and thus to move “a step closer in building patient–physician trust.”8
Transparency as a Social Process
While Dr. Rikhi’s8 letter endorses informational transparency, it also speaks to what Albu and Flyverbom6 identify as the social orientation toward transparency. This orientation attends to the relational and dynamic nature of transparency as a communicative act “rife with tensions and negotiations.”6(p277) From this vantage point, the mechanisms for building trust through cost transparency depend less on physician access to cost information and more on the conversation between the physician and the patient about cost. Dr. Rikhi’s letter supports this approach to transparency as well, as he encourages physicians to invite patients to share their difficulties accessing medications, to welcome discussion of socioeconomic factors impacting medication adherence, and to engage in collaborative problem solving around a plan of care.8 In this second approach to transparency, patient–physician trust develops through dialogue about information and co-construction of interpretations and solutions rather than through simple transmission of data.
The social orientation toward transparency questions assumptions underpinning transparency as a source of trust through full disclosure of information. The social orientation contests the notion that sufficient precautions can be taken to ensure that (1) information is objective and comprehensive and (2) all who view information see it as accurate, understand it as unequivocal, and interpret it in the same way. An inherent tension exists between the filtering and framing necessary to make information accessible and the desire for full disclosure of unadulterated information. To achieve trust, this tension must be negotiated. In other words, the value of transparency for garnering trust depends on communicative processes mediated by relational and contextual factors. As an example, consider Dr. Wu’s9 letter “Rebuilding Trust in the Surgeon–Patient Relationship: Need for Transparency.” Dr. Wu believes that patients “deserve to know more about their surgeon.” This call for transparency prompts important questions about what data would be most informative for patients, how this information would be shared with patients and by whom, and how the information would affect patients’ decisions and trust in their surgeon (or in surgeons in general). I imagine that the consequences for trust would be quite different if a patient viewed a handout in the waiting room showing key operative experience and performance metrics, selected by the institution, for the group of surgeons in the clinic versus if a surgeon discussed her experience and performance directly with a patient. Both transparency scenarios involve communication processes and similar data, but the interactions and communication media differ in important ways, as I discuss next.
Transparency and Trust
When understood as a social process and communicative act, transparency’s relationship to trust depends on three components. Using a window metaphor, the first component is the scene outside the window, or the content. The scene presents information that can change depending on the weather, the season, and the mobility of objects. It displays different information up close versus from a distance. Similarly, the content displayed in health care is dynamic and tells parts of a story, but not all of it, depending on who shares the information, what power they hold over the opacity of the glass, and what audience they have in mind. The source of the information may have well-intentioned reasons for concealing or controlling the flow of information. However, if the source has a particular agenda and viewers find out that the source intentionally obscured information, transparency will seem a façade and will not engender trust. The credibility, reliability, and stability of the information also influence its perceived trustworthiness.
The second component of transparency is the viewer peering out the window. Where the viewer stands; how familiar the viewer is with the scene; and what knowledge, values, and assumptions the viewer holds all influence the viewer’s interpretation of and emotional responses to the information supplied by the scene. Different viewers will notice and focus on different parts of the scene, resulting in diverse interpretations, reactions, and valuations. For example, consider the operative performance data mentioned above. A surgeon in the clinic might view the data with an eye toward her own specific data relative to others and the previous month’s data. By contrast, the patient may compare the group’s data with the data of surgeons in another clinic or against his own standard of acceptable performance. The surgeon and the patient have different frames of reference and will see different things in, or draw different conclusions from, the same information.
The third component of transparency is the window itself, or the medium. The window frames the scene in a particular way and limits what the viewer sees. Warped, cracked, or tinted glass distorts the scene compared with what the viewer would see from an open window. Similarly, when patients, learners, health professionals, or the public receive new information, the delivery mechanism matters. Information is shaped by the medium. When shared through a conversation, the medium provides space for questions, clarification, correction of misconceptions, and reconciliation of different interpretations of the information, but also runs the risk of one party persuading another to see things in a particular way. Information presented in reports, on dashboards or websites, or in raw form in databases or spreadsheets can be interpreted in many ways or may be ignored because the viewer finds the medium too complicated, overwhelming, ambiguous, or impenetrable to be of worth. Consequently, the information may undermine rather than inspire the viewer’s trust in the source.
Implications for Health Professions Education
As the quest for greater transparency in health care and health professions education persists, I hope thoughtful consideration of the implications for health professions education will not be lost. As viewers of many new types of information about clinical performance at the individual, group, and organizational levels, trainees and practicing clinicians will need training and support to know how to interpret, evaluate, and apply the information to their own practice and to system improvement efforts. Perhaps even more important, they need training in how to discuss information about performance metrics, cost, or evidence of bias with patients, peers, supervisors, and leaders. Such training could be part of larger “trust education” initiatives,10 provided they address all three components of transparency—the content, the viewer (e.g., the patient, peer, or supervisor), and the medium (e.g., the health professional communicating the information as well as any materials or resources used during the communication).
Perhaps transparency is too good to be true, at least as a straightforward trust-building strategy. Conceptually, I think the push for transparency signals a desire to find ways to nurture healthy relationships grounded in honesty and trust. This Invited Commentary offers one frame through which to view some of transparency’s complexities in trust-building efforts. As reflected in trainees’ Letters to the Editor, education has a key role to play in these efforts.