Author: Building Trust

In May, the ABIM Foundation and AcademyHealth convened 75 researchers, clinicians, patients and funders to chart the course of research on trust and health care for the next several years. The meeting, which also kicked off AcademyHealth’s new research community on trust and health care, covered a scan of existing research and identified areas where more is needed. Through guided conversation, participants discussed opportunities and methods to broaden and deepen the field of trust research.

Jodyn Platt, PhD from the University of Michigan and Lauren Taylor, PhD from the Hasting Center grounded the conversation with an overview of their literature review and their initial findings. The scan included looking at research on patient trust in clinicians, clinician trust in other clinicians, patient and clinician trust in organizations and patient and clinician trust in the system. In addition, the review paid particular attention to health equity, confidence in science and building and repairing trust.

Participants went on to have a rich conversation about potential areas of research, and voted on the top 10 areas to explore moving forward:  

Advancing Trust at the Organizational Level

1. How can trust be defined and measured at an organizational level (e.g., between patients and organization, community and organization, employees and organization, and clinicians and organization)?
2. What can organizations do to address influential structural determinants of distrust, such as partisanship and politicization, structural racism, and systems of privilege in order to improve trust with patients and within their systems?
3. Perform an analysis of positive deviance to identify fundamental drivers of optimal trust within organizations with diverse populations, studying signals at different levels (e.g., patient-clinician, system-clinician, and system-community).
4. What are the policies, partnerships, and practices that constitute the trustworthiness of organizations?
   • What is the impact of new organizations in new communities? Mergers? Workforce-community concordance? Patient-clinician concordance? A pipeline of trainees?
5. When organizational policies and values prevent clinicians from providing the care they think they should provide, how does that affect their trust in organizations?
   • What are the downstream effects of the loss of organizational trust on patient and clinician outcomes?

Advancing Trust at the Clinician Level

6. Why is trust in nurses consistently high vs. less consistent trust estimates in physicians—why the disparate scores and consistency? (correlate: why is trust in nurses more global and trust in physicians more personal?)
7. One of the drivers of patient trust is the perception that their doctor cares about them. How does a clinician convey that they care about a patient? What are the things they do or don’t do?
   • What are the behaviors, language, attributes?
   • What makes patients trust their clinician or health care organization more, and what would diminish or threaten that trust?
   • What underlies trust? Where is the locus of trust, mistrust, confidence?
8. What is the level of trust clinicians have in patients and their caregivers, and what interventions might most meaningfully increase that trust?

Advancing Trust at the Patient and Community Level

9. What are longitudinal trends in trust at the population level, and what factors affect change in trust?
10. What are the frames (e.g., patients, communities, institutions, or policies) for advancing trust that would have the biggest impact on health equity?
    • How can we center the community and their needs?

Additionally, participants discussed the importance of the study setting, populations of focus, measurement, methods, potential partners, and possible interventions and outcomes applicable to the research topic.

AcademyHealth and the ABIM Foundation plan to build on these topics by fostering a community built around research on trust and advocate for these issues to receive attention and funding. To learn more or join the community, contact Kelly Rand at krand@abim.org.

Janice Tufte resides in Seattle and is a patient collaborator involved with health systems research, evidence production, clinical practice quality improvement and human readable digital informed knowledge generation. She recently co-authored a paper currently under review with the Journal of Health Design that discusses the importance of collectively designing research and is working with AcademyHealth’s Paradigm Project in developing a new research prototype.  Learn more about Janice at www.janicetufte.com.

Susan Perez’s research focuses on understanding consumers’ decision-making processes in order to develop healthcare policies, information, and resources to promote high value decisions. Dr. Perez has conducted studies that classified approaches to processing Internet health information among vulnerable populations; addressed statewide overuse of healthcare services; identified approaches for patients and providers to discuss the cost of care; developed a statewide campaign to address variation in C-section rates by working with both patients and hospitals; and illuminated consumers’ views of cost sharing, quality and network choice. Prior to joining the faculty at the California State University, Sacramento Department of Public Health, Dr. Perez completed a postdoctoral fellowship in quality, safety, and comparative effectiveness research and earned a doctorate in Nursing Science and Health-Care Leadership program at the University of California, Davis. 

Gwen Darien is a longtime patient advocate who has played leadership roles in some of the country’s preeminent nonprofit organizations. As executive vice president for patient advocacy, engagement and education at the National Patient Advocate Foundation and the Patient Advocate Foundation, Gwen leads programs that link PAF’s direct patient services to NPAF initiatives to help ensure access to equitable, affordable, quality health care.

A three-time cancer survivor, Gwen came into cancer advocacy to change the experiences and outcomes for the patients who came after her and to change the public dialogue about cancer and other life-threatening illnesses.

Gwen serves on a wide range of program committees and workshop faculties. She is the Chair of PCORI’s Patient Engagement Advisory Panel and serves on the Board of Trustees of the USP. Gwen also writes about her experiences as an advocate and cancer survivor.

Grantees selected to rebuild trust, tackle health care diversity, equity and inclusion in medical education and training.

The U.S. health care system has fallen short in numerous aspects of diversity, equity and inclusion (DEI), such as insufficient diversity among clinicians and poorer health outcomes among underserved communities. Bias and discrimination in health care have slowly but steadily eroded trust in the entire system, including in clinicians directly responsible for care. Today, several leading physician organizations announced the awarding of grants to help address the root causes of distrust in the provision of care.

The Alliance for Academic Internal Medicine (AAIM), the American Board of Internal Medicine (ABIM), the ABIM Foundation, the American College of Physicians (ACP) and the Josiah Macy Jr. Foundation have awarded a total of $287,500, split among 32 projects at medical schools and training programs.

Grantees will use this funding to support programs that incorporate DEI into internal medicine education and training.

Grants will be distributed at the $20,000, $5,000 and $2,500 levels, depending on the scope of the program. Examples of funded projects include:

• George Washington University will build community trust by increasing colon cancer screening rates among Black and Hispanic patients by identifying barriers that contribute to lower screening rates among those populations. Community health advocates and physicians will also collaborate to develop and provide educational programs for colon cancer screening.
• Hennepin Healthcare will prepare all medical trainees to incorporate trauma-informed approaches in their practices, creating a detailed curriculum and framework for competency progress in trauma-informed care.
• Magnolia Regional Health Center/University of Mississippi Medical Center will expand the curriculum for primary care residents to include education about community-focused health topics and about patient mistrust and physician bias through a series of lectures, reflective narratives and community-based initiatives.
• University of Pittsburgh Medical Center (UPMC) will increase internal medicine residents’ understanding of social issues faced by their patients and the local community. Residents will participate in a walking tour of the neighborhood surrounding UPMC Mercy to identify community resources while engaging in conversation about displacement and systemic racism, food access, housing and more. In conjunction with a local nonprofit, residents will also plan and give an interactive presentation on timely health topics for community members.
• UT Southwestern Medical Center will build a training program for internal medicine residents to work directly with the Hispanic community in Dallas to increase influenza vaccine uptake. Residents will participate in a year-long practicum facilitating patient focus groups about preferences, perceptions and mistrust in order to design a culturally specific, community-engaged approach to lead the vaccination program.           

“The Alliance is proud of this initiative advancing DEI in undergraduate and graduate medical education. The critical work of the 32 grant recipients will resonate throughout AAIM’s member institutions and across the internal medicine community,” said L. James Nixon, MD, chair of the AAIM Board of Directors and vice chair for education in the Department of Medicine at University of Minnesota Medical School.

“We congratulate the recipients of this grant and look forward to their efforts to advance DEI and to create more equity in health systems by incorporating DEI into the fabric of internal medicine education and training,” said George M. Abraham, MD, MPH, FACP, president of ACP. “Dedicated work in this area will benefit medical professionals and the patients they treat so that our health care system can be more just and equitable. The results of these grants will also benefit organizations, trainees, internists, their patients and their communities.”

Sponsors reported strong interest in this initiative, receiving 170 proposals from health systems and universities for programs designed to address increasing distrust and issues of bias and diversity in the U.S. health system. According to a recent survey from NORC at the University of Chicago, 59% of adults say that the health care system discriminates at least “somewhat,” and that 49% of physicians agree. Black patients say they are twice as likely to experience discrimination in a health care facility compared with their white counterparts.

“As physicians, we strive to provide every patient with the care they deserve, but there’s a long way to go before we have achieved the equitable and fair health care system that every American patient deserves,” said Richard J. Baron, MD, president and CEO of ABIM and the ABIM Foundation.

With additional funding from the Josiah Macy Jr. Foundation, a second round of grant funding—which will emphasize inter-professional projects that incorporate members from across the care team—will be announced later this year.

“This past year has made it ever more clear that building trust with our patients is central to a health care system that will truly meet the needs and provide the most effective care for all,” said Holly J. Humphrey, MD, MACP, president of the Josiah Macy Jr. Foundation. “I commend this initiative in tapping what is our greatest resource – the creativity, commitment and passion that diverse members of care teams bring to the cause of achieving equity in health.”

Organizations receiving grant funding include:

• Baylor College of Medicine
• Brigham and Women’s Hospital
• Columbia University Medical Center
• Community Memorial Health System
• Dartmouth Hitchcock Medical Center
• Emory University
• Florida Atlantic University
• George Washington University
• Hennepin Healthcare
• Hofstra University
• Icahn School of Medicine at Mount Sinai
• Magnolia Regional Health Center/University of Mississippi Medical Center
• MedStar Georgetown University Hospital
• Mount Sinai West Hospital
• NCH Healthcare System
• Oregon Health & Science University Hillsboro Medical Center
• Riverside University Health System
• Rutgers New Jersey Medical School
• Stamford Health
• Stanford University
• University of Arizona College of Medicine – Phoenix
• University of California Davis
• University of California San Diego*
• University of Illinois, Peoria Campus
• University of Maryland
• University of North Carolina
• University of Pittsburgh Medical Center
• University of Texas Southwestern
• University of Washington School of Medicine
• UT Health San Antonio
• UT Southwestern Medical Center

*Awarded two grants.

###

About the Alliance for Academic Internal Medicine
AAIM represents over 11,000 academic internal medicine faculty and administrators at medical schools and community-based teaching hospitals in the US and Canada. Its mission is to promote the advancement and professional development of its members, who prepare the next generation of internal medicine physicians and leaders through education, research, engagement, and collaboration. Follow AAIM on Twitter @AAIMOnline.

About the American Board of Internal Medicine
Since its founding in 1936 to answer a public call to establish more uniform standards for physicians, certification by the ABIM has stood for the highest standard in internal medicine and its 21 subspecialties. Certification has meant that internists have demonstrated – to their peers and to the public – that they have the clinical judgment, skills and attitudes essential for the delivery of excellent patient care. ABIM is not a membership society, but a physician-led, non-profit, independent evaluation organization. Our accountability is both to the profession of medicine and to the public.

About the ABIM Foundation  

The ABIM Foundation’s mission is to advance medical professionalism to improve the health care system by collaborating with physicians and physician leaders, medical trainees, health care delivery systems, payers, policymakers, consumer organizations and patients to foster a shared understanding of professionalism and how they can adopt the tenets of professionalism in practice. To learn more about the ABIM Foundation, visit www.abimfoundation.org, connect on Facebook or follow on Twitter.  

About the American College of Physicians
The American College of Physicians is the largest medical specialty organization in the United States with members in more than 145 countries worldwide. ACP membership includes 163,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter, Facebook and Instagram.

About the Josiah Macy Jr. Foundation
Since 1930, the Josiah Macy Jr. Foundation has worked to improve health care in the United States. Founded by Kate Macy Ladd in memory of her father, prominent businessman Josiah Macy Jr., the Foundation supports projects that broaden and improve health professional education. It is the only national foundation solely dedicated to this mission. Visit the Macy Foundation at macyfoundation.org and follow on Twitter at @macyfoundation.

During July’s Building Trust webinar Public Agenda shared how they crowdsourced ideas to build trust with patients and what they learned from the exercise.

Patients play a vital role in building trust in health care. Public Agenda and the Patient Advocate Foundation also facilitated a series of discussions with patient and consumer advocacy organizations for Building Trust, which yielded five principles patients and consumers believe will build trust and improve the health care system.

Dhruv Khullar, MD, MPP, Weill Cornell Medical College, joined Richard Baron, MD, president and CEO of the American Board of Internal Medicine and the ABIM Foundation, for our June 15 Building Trust Conversation Series to discuss COVID’s impact on trust in health care.

ABIM Foundation’s new ‘Building Trust’ effort will look at increasing equity and reducing systemic racism in U.S. health care

A clear majority of adults say the U.S. health system routinely discriminates, according to a survey conducted by NORC at the University of Chicago. Fifty-nine percent (59%) of adult consumers say the health care system discriminates at least “somewhat,” with 49% of physicians agreeing.  

About one in every eight adults (12%) say they have been discriminated against by a U.S. health care facility or office, with Black individuals being twice as likely to experience discrimination in a health care facility compared to white counterparts. The survey shows that experiences of discrimination affect trust in U.S. health care. People who report being discriminated against in a health care setting are twice as likely to say they do not trust the system.

The American Board of Internal Medicine (ABIM) Foundation is spearheading the Building Trust initiative, a national effort to focus on building  trust as a core organizational strategy for improving health care. It is working collaboratively with all health care stakeholders, including patients, clinicians, system leaders and others. Nine years ago, the ABIM Foundation created the Choosing Wisely initiative, which was nationally recognized for promoting conversations between patients and their clinicians about curbing the overuse of unnecessary medical care.  

“Just like the deep impact of systemic racism being felt in all aspects of society, any form of discrimination fuels mistrust between patients and the health care system patients rely on to treat them,” said Richard J. Baron, MD, president and chief executive officer of the ABIM Foundation. “Health care stakeholders must collaborate to identify and address contributors to bias, which worsen health outcomes, especially for people of color.”

Apart from gaps in trust in the health care system, instances of discrimination are similar when looking at relationships between individual patients and their doctors. About one in eight patients (12%) say they have experienced discrimination by a doctor, with Black individuals being almost twice as likely as the general population to report discrimination by a doctor. More than one in five Black patients (21%) report discrimination by a doctor, versus 11% of Hispanic adults and 8% of Asian adults.

Although the survey shows patients and physicians enjoy mutually high levels of trust with each other overall, Black and Hispanic adults are significantly less likely to say their doctors demonstrate trust-building behaviors. For example, 86% of white adults say they believe their physicians trust what they say, compared to 76% of Black adults and 77% of Hispanic adults. Eighty percent (80%) of white patients say their doctor spends an appropriate amount of time with them, compared to 68% of Hispanic adults and 73% of Black adults. Seventy-seven percent (77%) of white adults say their physician cares about them, compared to 67% of Hispanic adults and 71% of Black adults.

“Achieving greater equity and less discrimination in health care requires more understanding about what it takes to build truly trusting relationships,” said Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation. “Patients, clinicians and system leaders all want more equitable care and better outcomes, and part of the solution lies with increasing trust.”   

Despite a clear majority of patients believing discrimination in health care is common, the survey shows 81% of physicians give their employer a good grade—either an A or B—in their efforts to address health equity. Physicians say they are optimistic that their health system will improve diversity and equity in the next five years. Sixty-two percent (62%) say their own health system will improve equity in patient outcomes in the next five years. More than half of physicians (56%) believe diversity in the physician workforce will improve over the next five years. Fewer physicians (49%) think diversity in health system leadership will improve over the same period.

The NORC research is comprised of two surveys, one with physicians and one with consumers. The physician survey is a non-probability sample of 600 physicians. The consumer survey is a probability-based sample of 2,069 respondents with oversamples for Black, Hispanic and Asian respondents and has a margin of error of +/- 3.15 percentage points. Surveys were conducted between Dec. 29, 2020, and Feb. 5, 2021. Last month the ABIM Foundation released research demonstrating diminished trust among physicians and consumers in health system leaders and government agencies during the COVID-19 pandemic.

Poll shows gaps in public’s trust in health care systems and clinicians—and how COVID affected how physicians gauge trust

The ABIM Foundation officially kicked off Building Trust, a dynamic initiative to improve health care by fueling conversation, research and promising practices that help increase trust between patients, physicians and other stakeholders on May 21, 2021.

New polling data from NORC at the University of Chicago provide a look at the current state of trust in health care in the United States. Declining trust affects nearly every facet of society, and health care is no exception. To improve relationships between heath care stakeholders and bolster clinical outcomes, leaders from all parts of the health care system are coming together to consider how to elevate trust and improve care.

Speakers included:

• Richard J. Baron, MD – President and CEO of the American Board of Internal Medicine and ABIM Foundation
• Daniel Wolfson – Executive Vice President and COO of the ABIM Foundation
• Caroline Pearson – Senior Vice President at NORC at the University of Chicago
• Christa Fields – Manager, Health Care Strategy at NORC at the University of Chicago

Panel discussion:

• Jackie Judd –respected health care journalist and former Vice President and Executive Producer of Multimedia at the Kaiser Family Foundation (moderator)
• Donna Cryer, JD – Founder, President and CEO of the Global Liver Institute
• Neel Shah, MD – Founding Director of the Delivery Decisions Initiative at Harvard University’s Ariadne Labs
• Fred Cerise, MD – President and CEO of Parkland Health & Hospital System

ABIM Foundation leads effort on “Building Trust” among health care stakeholders

Significant gaps in how physicians and patients view trust

New research shows a significant decline in physicians’ trust in leaders of health care systems during the COVID-19 pandemic, and notable differences between how physicians and the public perceive trust in U.S. health care. The research was conducted for the American Board of Internal Medicine Foundation by NORC at the University of Chicago.

The ABIM Foundation released the research to coincide with the launch of Building Trust, a national effort that focuses on increasing trust among health care stakeholders, including patients, clinicians, system leaders, researchers, and others. Nine years ago, the ABIM Foundation created the Choosing Wisely initiative, which was nationally recognized for promoting conversations between patients and their clinicians about curbing the overuse of unnecessary medical care.

In a year of unprecedented pressure on health care, nearly one in three physicians surveyed (30%) say their trust in the U.S. health care system and health care organization leadership decreased. Only 18% report increased trust.

This is in stark contrast to the overwhelming trust physicians have in their fellow clinicians. Physicians report high levels of trust for other physicians and nurses (94% trusting doctors within their practice; 85% trusting doctors outside of their practice; and 89% trusting nurses)—but only two-thirds (66%) trust health care organization leaders and executives. During the pandemic, physicians report increased trust for fellow physicians (41%) and for nurses (37%).

“Health care is fundamentally grounded in a series of human relationships, and the strength of those relationships determines how well health care works,” said Richard J. Baron, MD, president and chief executive officer of the ABIM Foundation. “The pandemic bolstered trust among clinicians, but intensified physician mistrust of health care organizations. American health care has a trust problem and rebuilding it is essential.”

Overall, 78% of people say they trust their primary doctor. Significant differences exist, however, between different groups of people, with older adults (90%), white people (82%), and high-income individuals (89%) being much more likely to say they trust their doctors. Among people who report lower trust in their doctors, 25% said their doctor spends too little time with them and 14% said their doctor does not know or listen to them.

The survey shows stark differences in how physicians and patients view aspects of a medical appointment that affect trust. Nearly all physicians (90%) believe patients can easily schedule appointments, but nearly one in four patients (24%) disagree. Almost all physicians (98%) say that spending an appropriate amount of time with patients is important, but only 77% of patients think their doctor spends an appropriate amount of time with them.

In spite of these trust gaps, consumers trust clinicians—doctors (84%) and nurses (85%)—more than the health care system as a whole (64%). About one in three consumers (32%) say their trust in the health care system decreased during the pandemic, compared to 11% whose trust increased.

The survey shows that government agencies have trust-building work to do. The research reveals that 43% of physicians say their trust in government health care agencies decreased during the pandemic.

“Trust in organized institutions has been declining for years and health care is not immune,” said Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation. “Building trust requires engaging stakeholders across the health care spectrum to better identify what’s happening and share practices that increase trust between different parties. Trust is an essential part of medical professionalism and ultimately contributes to better patient outcomes.”

Focus areas for the ABIM Foundation’s Building Trust initiative include increasing relational and organizational trust, increasing equity and reducing systemic racism in U.S. health care, and the imperative of trusting science and facts, free from politics.

Leaders from all parts of the health care ecosystem will come together through the multi-year initiative to discuss how to elevate trust in health care. The effort will include significant research, dialogue and experimentation involving all parties.

A key component will be a Trust Practices Network that identifies, tests, and shares practices with the goal of building trust between health care stakeholders. The practices include interventions like:

• SCAN Health’s use of a peer advocate program to build caring relationships with plan members and encourage them to receive needed care;
• Northwestern Medicine’s African American Transplant Access Program, which strives to build trust with Black patients and increase the likelihood they will seek needed transplants and complete the necessary evaluation to be included on the transplant waiting list; and
• Scripps Clinic’s “One Thing Different” program, which gives staff and physicians the autonomy to do one thing of their own choosing to make a difference in the lives of their patients, relying on self-reflection and soul searching to improve care and enhance trust between staff and leadership.

More than 50 organizations have already contributed trust-building practices.

The NORC research was conducted between Dec. 29, 2020 and Feb. 5, 2021. The physician survey is a non-probability sample of 600 physicians. The consumer survey is a probability based sample of 2,069 respondents with oversamples for Black, Hispanic, and Asian respondents and has a margin of error of +/- 3.15 percentage points.