Author: Lauren A. Taylor, PhD, MDiv and Andrea Yarkony, MBE
The puzzle of trust in emergency medicine
The expansive literature on health care trust seems to find consonance in a few key claims — trust is facilitated by familiarity, takes time to build, and benefits from an incremental approach. If these claims hold, we should not expect to find much (if any) trust circulating in emergency departments (EDs). These are places where strangers are let into patients’ most vulnerable moments, often for one brief, high-stakes encounter. And yet, emergency medicine clinicians report that trust is central to their work.
We recently had a chance to engage with a group of emergency medicine clinicians at NYU Langone Health on this topic. We asked, “how much time do you spend thinking about trust?” The question was met with urgent nods and the response: “a lot.”
The presentation closed with clinicians contributing their own “hacks” for building trust with patients. Doctors shared the ways they keep critically ill patients from refusing care, including saying things like “I am scared for you. I wouldn’t keep you here if I wasn’t.” ED physicians also described more routine gestures. One sat level with the patient to meet their eyes. Another asked patients about what they do for work and whether they have kids — questions to ensure they felt seen as humans with lives outside of that hospital room. Clinicians reach for these go-to lines because, by their own account, they need them to do their jobs. This phenomenon is hardly unique to the NYU Langone ED. In a 2015 Annals of Emergency Medicine essay, Virgil Davis reflected on how patients must trust emergency physicians to perform lifesaving procedures. Describing a difficult patient encounter, he worried his mismatched socks discouraged their trust.
To the extent that any of these hacks work, they challenge the traditional trust literature. Researchers are therefore faced with a puzzle: how can we explain the presence of trust in a clinical setting where many of the most commonly-cited facilitators of trust are absent. The patient has no prior relationship with their physician, they share limited time together, and the whole encounter is rife with uncertainty. So how can trust take root?
The concept of “swift trust” may help bridge the gap. Debra Meyerson, Karl Weick, and Roderick Kramer coined the term in management literature to describe the trust behavior that emerges in temporary organizations like film sets. Film sets are not EDs, but the settings share similar obstacles to traditional trust formation, and they may share similar origins of swift trust. Meyerson, Weick and Kramer’s conception of swift trust has a decidedly different basis than the kind of trust we typically think of in health care. Swift trust is based on contextual factors and inferences about the type of person a trustee is likely to be instead of the trustor’s direct assessment of a clinician’s competence, integrity or other characteristics. On a movie set, for instance, swift trust with the new sound engineer is facilitated by the tacit endorsement of the director who hired her and one’s past positive experiences with other sound engineers.
It appears that no peer-reviewed papers make use of “swift trust” in an emergency medicine context. This gap in literature is worthy of attention, as swift trust may be a missing piece of the puzzle. Exploring what makes for swift trust in EDs can not only help to improve emergency medical care, but also enhance our understanding of what trust is and how to build it.
Lauren A Taylor, PhD, MDiv is an assistant professor at NYU Grossman School of Medicine, where she researches trust and a variety of other organizational ethics issues. She holds a doctorate from Harvard Business School and a master’s from Harvard Divinity School.
Andrea Yarkony, MBE is a research associate at NYU Grossman School of Medicine and Teaching Fellow at Harvard Medical School Center for Bioethics. She holds a master’s degree from Harvard Medical School.