Category: Guest Blogs
Ensuring public trust in medicine within our communities
The early stages of the COVID-19 pandemic were frightening to all, as the disease was unknown in its nature and impact. Each day new information was being shared across the world based on data that were arriving in bits and pieces in the news and in the scientific literature. It was challenging to fully appreciate the dynamic nature of the information as well as the ever-changing landscape of scientific discourse. As the pandemic progressed it became clear that some physicians were using their authoritative power and general respect within public spheres to communicate information that ultimately could result in harm to the public. Physicians began to cross professional lines by promoting and selling unproven COVID-19 therapies for personal profit. Certification organizations and state licensing boards began to take notice, and it was at this point that my story begins with the American Board of Emergency Medicine (ABEM).
The ABEM board had already created a professionalism statement (April 2021) in response to the American Board of Medical Specialties’ Vision Commission recommendations, including the statement that “physicians should refrain from conduct that the Board determines, in its sole judgement, to be sufficiently egregious that it is inconsistent with ethical behavior by a physician.” This would include dissemination of blatantly false information that may lead to undue harm to patients. We realized that some physicians might not fully understand that misinformation might be regarded as unprofessional under ABEM’s standards.
At the same time, we were made aware of some outrageous claims by physicians that the COVID-19 mRNA vaccine altered a person’s DNA. Soon physicians and members of the public contacted ABEM to complain about physicians who claimed to be ABEM-certified who were publicly sharing misinformation. ABEM had never received so many complaints from physicians about other physicians. ABEM-certified physicians did not want misinformation-spreading emergency physicians to undermine the quality of the certification standard.
For full transparency, we needed to communicate the Board’s intention to review these complaints and to potentially take certification actions on those issues that were deemed to break the Code of Professionalism. It became clear that ABEM as a certifying body had a duty to act to ensure public trust and protect the value of certification by stating that “physicians who make public statements that are directly contrary to prevailing medical evidence can constitute unprofessional conduct, which may be subject to review by ABEM.” It was also important that the Board addressed this independently of other licensing bodies, and that it established a process that allowed for due process for physicians reported to the board with such behavior.
There are a number of medical issues for which physicians will have legitimate differences of opinion. The allowance of open discourse in these situations is recognized as critical to further scientific and medical progress, which in fact will ultimately be adjudicated through well-founded principles of investigative research. It became clear, that we, as physicians, must evaluate ourselves and our own professional behavior, and to act to protect our respect for human life, and to ensure public trust in medicine within our communities. It is for these reasons that, as leaders within the house of medicine, we acted to uphold our commitment to the public and to not wait for others to respond.
Dr. Gausche-Hill is the Medical Director for Los Angeles County Emergency Medical Services (EMS) Agency, Professor of Clinical Emergency Medicine and Pediatrics at the David Geffen School of Medicine at UCLA and serves as Clinical Faculty at Harbor-UCLA Medical Center in Torrance, CA. She is nationally and internationally known for her work as an EMS researcher and educator, and for her leadership in the field of EMS and pediatric emergency medicine. She is best known for her study of pre-hospital airway management for children published in JAMA 2000 and her work on the National Pediatric Readiness Project published in JAMA- Pediatrics in 2015. She has won numerous national awards for her leadership in emergency medicine, pediatric emergency medicine and EMS. Dr. Gausche-Hill currently serves as a senior editor for the textbook, Rosen’s Emergency Medicine: Concepts and Clinical Practice, and is the Immediate Past President of the American Board of Emergency Medicine Board of Director.
Optimistic in the face of impotence
If you’re male and in your 40’s, as I am, you’ve likely received many advertisements from “men’s health” clinics promising to restore musculature, virility and happiness with a simple testosterone treatment. As a health care professional reading this, you might roll your eyes in bemusement, but these types of prescribing behaviors are widespread and troubling. And sometimes these types of practices are supported by well-intentioned but under-informed clinicians who have not stayed current with best practices, are compelled by the simplicity of the message that “if it’s low just give it back,” and have come to believe in the “anti-aging” value of androgen replacement in patients with symptoms that could be consistent with hypogonadism.
More troubling, a variety of organizations and groups have been created to reinforce and work to justify these practices – often motivated by commercial opportunities and self-interest. And some of them use “education” to advance their interests. You may think our colleagues should know better than to fall victim to false advertising and specious claims, but that’s not always the case. Unfortunately, it often falls to endocrinologists like me to help these patients work to restore gonadal endogenous function and fertility, though sometimes the effects of exogenous testosterone on pituitary and testicular function are unfortunately permanent.
As President and CEO of the Accreditation Council for Continuing Medical Education (ACCME) I am enacting long-term solutions. While most of the so-called education that would support such practices above occur outside of accredited continuing medical education (CME), ACCME works hard to keep it that way, and ensures that physicians can trust what they learn in CME. ACCME has established standards for accredited continuing education for physicians that is both scientifically valid and free from commercial bias, has a content validity committee of journal editors, conducts inquiries and holds organizations accountable for scientific validity and integrity in their activities. Educators whose programs meet the criteria, and the physicians who learn from them, contribute to improving the quality and safety of medical practice and health outcomes.
With this continuing work from all of us to separate accredited education from that which serves other purposes, I have hope that my practice will not be held captive to commercial interests exploiting vulnerable people and underinformed prescribers. Further, I want to ensure that the intellectual stimulation of accredited continuing education will help me sustain joy and meaning in my practice. And that, over time, our content validity efforts will ultimately promote the advancement of science, combat misinformation, and restore public trust in science and the practice of medicine.
Dr. McMahon is President and CEO of the Accreditation Council for Continuing Medical Education (ACCME®) and an Adjunct Professor of Medicine and Medical Education at Northwestern University. A medical educator, researcher, and endocrinologist, Dr. McMahon joined the ACCME in April 2015 from Harvard Medical School, where he served as Associate Dean for Continuing Education and Associate Professor of Medicine. He taught extensively at Harvard Medical School and at Brigham and Women’s Hospital in Boston, served as Editor for Medical Education at the New England Journal of Medicine, and as Executive Editor for the NEJM Knowledge+ program. He served as an endocrinologist in practice in the division of Endocrinology, Diabetes and hypertension at the Brigham & Women’s Hospital.
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.
Trust that we won’t go back
As a patient with multiple chronic diseases, I have been so grateful for the ability to have telemedicine visits with my specialists. In many ways, these visits have been deeper and richer than in-person appointments. Both the doctor and I seem calmer, not having rushed to travel, and having every note, journal article, and past test result at our fingertips. Our entire time is spent engaging directly with each other.
Still, with all this attention, I ended up in the ER. I needed to be connected to yet one more specialist, but none was accessible on an emergency basis. We were able, though, to re-stabilize me and to set up a productive telemedicine visit where we outlined a very detailed and mutually satisfactory plan.
Thirty days later, a nurse called to schedule the follow up. “What state do you live in?” she asked. “Why are you asking?” I responded. “Because after June 25 the emergency waiver is expiring, and we can’t conduct a telemedicine visit for a patient in another state,” she said.
An in-person appointment was not available for several months – a non-starter for a medical regimen that we were calculating in days. I happen to live four miles away from the doctor’s office and one mile from the state line, so we arranged for a telemedicine visit from a friend’s house a mile down the road on the right side of the border.
What if I had lived 40, or 140, miles away? What if I wasn’t confident and quick on my feet to propose a solution? Why would we undermine a successful, established, efficient doctor-patient partnership and put my health in jeopardy? Why would we increase the patient burden to receive care? Why would we make it harder for people for whom taking time off work means losing income or having to arrange child care (which is impossible to find nowadays)? Why do we wonder why patients don’t trust the health care system that demonstrates that it can deliver high-quality, effective care and then chooses to withdraw it?
Donna Cryer, JD is founder, president and CEO of Global Liver Institute, a non-profit organization promoting liver health and high quality care for all liver patients, and a 26-year liver transplant recipient.
This essay was written in July 2021.
Hunting for zebras
My 21-year old niece died in 2017. I visited her at one of the nation’s premier medical centers, where she had received an emergency liver transplant soon after her diagnosis of Wilson’s disease. Although her body accepted the new liver, her brain function never returned and her family withdrew support soon after my visit.
My niece was smart and beautiful. She was an only daughter with three brothers, so she was the light of both her parents’ and her brothers’ lives. She was a very active college senior who, over many months, had returned home on several occasions because of extreme fatigue and unexplained abdominal pain. She was noted to have mildly elevated liver tests, and her symptoms were variably attributed to anxiety, stress, depression, oral contraceptives, and non-alcoholic steatohepatitis linked to obesity. As her symptoms worsened, so did her liver tests. The diagnosis of Wilson’s disease came too late because her clinicians reasoned that the disease did not occur in Black patients; they only tested for the condition after her liver failed.
Wilson’s disease is a rare (1 in 30,000) autosomal recessive genetic disorder caused by loss of function of the ATP7B copper-binding protein. It may present through hepatic, neurologic or psychiatric problems. It has been diagnosed throughout the world, without clear patterns by race, ethnicity or region (except for founder effects in Sardinia and a region in Costa Rica).
The clinicians who commented that “We don’t really think of Wilson’s disease occurring in Black patients” are technically correct. It’s a rare disorder that we don’t necessarily think of in most patients and doesn’t occur at proportionately higher rates in Black patients. But they were completely wrong in opting not to evaluate for the possibility of this disease, particularly given my niece’s age, constellation of symptoms, and chronic, worsening liver tests. Their comments highlight the concept of “statistical discrimination,” a less-discussed contributor to unequal and inequitable patterns of care that result from our racialized approach to medical decision-making.
The landmark Institute of Medicine report “Unequal Treatment” identified three types of discrimination that occur in the health care setting – affective bias, cognitive stereotyping and statistical discrimination. The basic idea of statistical discrimination in health care is that uncertainty about the patient’s severity of illness can induce clinicians to behave differently with otherwise identical presentations for patients with different racial backgrounds. If the underlying prevalence of the illness is associated with race, the doctor might take race into account in deciding about the diagnosis and treatment of a particular patient. In statistical discrimination, physicians apply correct information about a population to reduce their clinical uncertainty about an individual patient. Statistical discrimination may be appropriate if based on reliable data on group differences in the absence of data about the individual, but ignoring information about the individual results in inequities ultimately rooted in the patient’s identity and perpetuated by our racialized shortcuts in medical decision-making.
Many of us have drawn attention to diseases and outcomes that pattern by race and ethnicity, important work because these patterns often mirror inequities in the social and structural determinants of health that contribute to these diseases and must be addressed if disparities are to be eliminated. But as we teach and as we practice, that focus on patterning of disease risks over-emphasizing group effects, a practice that is often reinforced by our own racial biases, and ultimately interferes with good clinical decision-making for the individual patient.
Could an earlier diagnosis have averted the devastating outcome for my niece? It’s hard to know, but it is certainly tempting to speculate since it was neurologic decline that led to withdrawal of support – neurologic decline that was thought to be the result of accumulated exposure as the disease progressed and her liver failed. Wilson’s disease is treatable with medications or liver transplantation, the latter of which my niece was fortunate to receive, albeit too late in the disease course.
My niece loved math and economics and was planning on pursuing a degree in public health once she graduated. She wanted to combine her interest in numbers with her desire to help people. I search to find a lesson in her death that can also help others in medical decision-making overcome our historical and contemporary racial biases.
Whether looking for horses or hunting for zebras, as physicians we must always guard against blinders that lead us to look only in particular places for the zebras. And, as physicians who care for minoritized patients and who observe and comment on how diseases and outcomes pattern by race and ethnicity, reminding ourselves about how patterns themselves can reinforce our own biases, and ultimately affect good clinical decision-making, is critical so that we can provide all patients with the care they deserve.
Kirsten Bibbins-Domingo, PhD, MD, MAS is the Professor and Chair of the Department of Epidemiology and Biostatistics, and the Lee Goldman, MD Endowed Chair and Professor of Medicine at the University of California, San Francisco. Dr. Bibbins-Domingo is a general internist and cardiovascular epidemiologist whose scholarship includes observational epidemiology, pragmatic trials, and simulation modeling to examine clinical and public health approaches to prevention in the US and globally.
Who gets to ask the questions and who has to answer?
Two weeks before the pandemic shut down New York City, I was in a windowless basement endoscopy center on the east side of Manhattan. It was 12:30 in the afternoon, and I hadn’t eaten or had a drink of water since the night before. I was uncaffeinated, missing a day of work, and wondering if this diagnostic procedure was worth the roughly $1100 it seemed likely to cost me out of pocket, roughly one-third of the median amount that Americans have in their savings accounts.
The administrator was friendly and efficient, and as she was running my credit card, she asked, “Will your wife be picking you up after the procedure?”
Was it worth the trouble to explain that no, in fact, my husband would be picking me up? Did I really need to come out to someone who I did not know and would probably never see again? I let it go, and figured she’d have the pleasant surprise of meeting him after the procedure.
Half an hour later, as I was getting situated in the pre-op area, a nurse was running through a series of questions:
“When was the last time you ate anything?” she asked.
“Last night at around ten o’clock,” I told her.
“When was the last time you drank anything, including water?” she asked.
“Probably around midnight,” I responded.
“Have you been pushed, shoved, slapped, hit, kicked, choked or otherwise physically hurt by your partner or by someone in your home?” she asked.
I knew why she was asking. I had only recently finished research on screening for social needs in pediatric primary care. Thankfully, the answer was no and that’s what I told her. That screening may be worthwhile if it picks up just one person who needs help. But I wondered how many people would feel comfortable telling a pre-op nurse in an endoscopy center about domestic violence – especially after having to decide whether or not it was worth coming out.
The anesthesiologist opened the curtain around the bed, and asked if I had any questions for her before she got started.
“Just one question for you,” I asked. “Are you in-network?”
She was flustered. I knew she would be. Maybe I was even kibitzing a little. But asking doctors about prices has become a bit of a habit for me.
“Um, I’m really not sure…” She was stalling.
Luckily for us both, the gastroenterologist who would be doing the procedure happened to walk by at that moment. “I’m in your network,” she said, “and all the anesthesiologists here bill through me, so she’s in network.” It took the anesthesiologist three tries to get the line into the back of my hand.
As I woke up from the procedure – groggy, hungry and very thirsty – the gastroenterologist launched into a long explanation of what she had found. Mostly nothing, a little something, and maybe it could be this but it’s probably that.
Despite being only half awake, I pressed her to try to understand what she meant. I know from my own research that listening is the top priority when people with Medicaid are asked how doctors can earn their trust – and I bet it’s a top priority for people with employer-sponsored insurance like myself. Clearly in a rush, she said “I have another procedure – call the office and make an appointment.”
My husband picked me up, and brought a bagel. My Flexible Spending Account thankfully covered the bill. And I found a new gastroenterologist.
David Schleifer is Vice President and Director of Research at Public Agenda. He manages and executes Public Agenda’s research, including projects in health care, K-12 education, higher education and civic participation. Along with the rest of the research team at Public Agenda, David’s work elevates the views and voices of members of the public and other stakeholders through focus groups, surveys, in-depth interviewing and media analysis.
The true impact of DEI in health systems
The responses to the coronavirus pandemic of 2020 have many lessons for health equity and the need for health systems to demonstrate a commitment to trustworthy processes and outcomes for people. I would like to dedicate this post to the memory of Dr. Francisco Marty, who embodied the values and behaviors that are needed to achieve equity within health systems.
An infectious disease physician at Brigham and Women’s Hospital, Dr. Marty led the trial for the anti-viral medication Remdesivir at our hospital, which was one of the few options for treatment that existed at the start of the pandemic. Dr. Marty spent hours upon hours working with a multicultural, diverse team to make sure that all hospitalized people had access to accurate information and an opportunity to participate in the trial at our hospital, regardless of their race, ethnicity, age, disability status, or their languages spoken.
After reviewing the data for participation after the conclusion of the trial, we found that Dr. Marty succeeded in enrolling a diverse group of people to receive this important care. Without his commitment to ensuring that trial participants were represented fairly and equally, many may not have had the chance to participate simply because of the color of their skin or their age.
As we reflect on what is needed to build trustworthy health systems, it is important to note that structural changes are needed, including better systems for data collection and addressing social determinants of health. The work of incredible individuals like Dr. Marty also demonstrate that diversity, equity, and inclusion in health systems is deeply impactful and an important strategy for achieving trustworthy care.
Cheryl R. Clark MD, ScD is a hospitalist and health equity researcher at Brigham and Women’s Hospital. Dr. Clark’s research focuses on social determinants of health as contributors to health status and utilization in the U.S..
My harrowing journey to Angela’s world, and what I learned about earning her trust
My son K.C., 14, is creative and funny. His room is a riot of color and texture, filled with rainbow pride flags, stickers, collectables, bright stuffed animals, string lights, and superhero posters.
Colorful as he is, sometimes people see in him only one of those colors: brown. He is Hispanic. He has beautiful brown skin, thick brown hair, and chocolate brown eyes. The rest of our family is Caucasian; we adopted K.C. upon his birth to Mexican-American parents.
When K.C. was 7, at a suburban science fair for grade schoolers, K.C. made a beeline for one display, a Rube Goldberg contraption created by two college engineering students. It mesmerized K.C., who stood at the front of the exhibit while six other kids, all white, crowded behind him. The college students hosting the exhibit began engaging the kids, asking questions and offering freebie trinkets.
K.C. had a question, but the exhibitors didn’t respond, even as they answered question after question from kids standing behind him. K.C. wanted a trinket, but exhibitors distributed them to other kids behind him, somehow missing K.C.. Exhibitors posed challenge questions but ignored K.C.’s efforts to answer. My child was quite literally overlooked as the exhibitors peered over his head to engage the white kids.
I don’t believe this was intentional on the part of the student exhibitors. But I was seized with outrage. I made my way to the table and demanded the exhibitors pay attention to my child. They looked at me blankly with eyebrows raised.
When I got home I burst into tears. This really hurt. It was the first time I truly felt the impact of racism from the perspective of a victim—the wincing pain of your child being dismissed and ignored and the frustration of being treated as a crazy lady for pointing it out.
At work the next day, I recounted the story with a colleague I trust, Angela, an African American mother of two kids around the same age as K.C. “Welcome to my world,” she said.
I asked her about that world. She gave an example: a traffic dispute when a white woman called her the N-word.
Angela is misunderstanding me, I thought. What happened to K.C. wasn’t like that. Nobody aimed a racist slur at my child; that would be “real” racism. But my story and hers are both real racism from Angela’s perspective. That’s when I realized that, for Black or brown people, being ignored and being insulted are different in form but identical in function. They are acts that reinforce bias and disdain.
I asked Angela how she picked physicians for her kids. To begin with, she picked an African American doctor. That doctor was part of a practice with white physicians, and as her kids grew older she had to occasionally to see some of them when her chosen doctor was unavailable. Now, years later, she trusts all the physicians in the practice to see her kids. But it took years.
I asked her what they did to earn to her trust. She recounted that they looked her and her kids in the eye and listened. They didn’t rush through the appointments as if they had something better to do. They got on the phone when Angela called with a concern. They didn’t make her languish pointlessly in the waiting room.
Many clinicians would see these as small things. But the weight of history tells Angela—and K.C.—that small things are big signals of the true level of respect doctors have for their patients. Lapses in the small things trigger memories of mistreatment, invisibility, disdain, and indignity. They are as insulting as a slur.
I’d love to think I’m free of the bias that so enraged me at the science fair. But ever so gently, Angela reminded me of the time I excluded her from meetings on a project she was involved in. I thought it was a small oversight, not in any way racially motivated, yet I overlooked her in the same way those college students overlooked my son. Intentionally or not, I caused her harm, which is not a small thing at all.
Building an equitable and inclusive delivery system will require the trust of patients who are accustomed to being overlooked and treated as inferior. They may view routine lapses and errors as disrespectful to them on a profoundly personal level. Their trust will be earned only with respect for a different worldview.
Leah heads The Leapfrog Group, a national nonprofit founded in 2000 by employers aiming for giant “leaps” forward in patient safety and quality. She has advocated to put patients first over a 30-year career spanning a rural hospital network, the New York City Mayor’s Office, and the National League for Nursing. She grew up in Maine though she dislikes lobster and winter sports, and she lives in the Washington, DC, area with her husband Sam and two sons.
Losing and building trust in assisted living homes
Last fall, my mother stopped being able to walk independently. She had multiple myeloma, and because she also had Alzheimer’s disease, she had no idea that she could no longer walk on her own. When she tried to stand up, a home health aide would lunge towards her, panicked, trying to prevent her from falling. My mother perceived the aide’s concern as an effort to control her, and it infuriated her. She so much wanted to maintain her independence.
Years before, she had mentioned a file folder with information about the assisted living home where my stepfather spent the end of his life. He had been treated exceptionally well there, and my mother had told me that she kept the information in case she ever needed that level of care. Unfortunately, she now did.
My sister and I quickly moved her to one of the assisted living organization’s small, 8-resident houses. The next morning, before I could even really exhale, I received an email: “Mom had a small fall this morning. No injury! She is doing fine.” Minutes later, the staff person explained by phone that my mother’s fall didn’t constitute a true fall, because an aide was there and broke her fall. When I visited later that day, though, the story had changed. There had been no staff person by my mother’s side.
When I sat with my mother that afternoon, she complained of back pain. The pain had become constant with the myeloma, and it was surely exacerbated by the fall. When I asked for my mother’s pain medication, the response was that they could not give it to her. There was no order for it.
That is when I started to get frustrated. I had brought her Tramadol to the house, and her pain was being managed by the same hospice organization as before the move. The hospice nurse had even visited earlier in the day. My mother had been without pain medication for over 24 hours (for the first time in weeks), and no one had let me know. I had, though, gotten an email asking me to bring over a remote control for her television.
I tried reminding myself that we had moved her in very quickly and maybe the rocky start would ease as she settled in. The problems, though, unfortunately continued.
Several days later, my daughter visited and reported that my mother was struggling to take her medication with water; apparently the staff had not read the form where I had indicated that medications should be given with apple sauce or yogurt. Ten days in, I learned that they had not given her any laxatives despite her not having had a bowel movement.
On a drive home after she had been there almost two weeks, I had a realization that was so obvious that it was embarrassing. For years I had been interviewing people to explore what built their trust in doctors and other health care providers. The assisted living home, I realized, was lacking the exact three attributes that I had found in my research builds patient trust: competence, communication, and caring. The staff had repeatedly made mistakes, they did not communicate with me, and I realized I had seen only one staff person smile or laugh since mother had arrived. As a result, I had no trust in the assisted living home.
Without trust, I needed to move my mother out. I reached out to the assisted living organization’s lead nurse, whom I did trust. We had spoken extensively during my mother’s time there, and she too was disappointed by the care my mother received. I told her that I was going to move my mother to my house. She asked me to please give another of their homes a try. She told me that the mistakes my mother had experienced are not consistent with the culture of the larger organization (which was confirmed by the hospice nurse and by my stepfather’s prior experience). She said she would make sure my mother had a good experience at the new house and would work to improve the culture at the house where my mother currently was. She promised that they would communicate with me so much that I would get sick of hearing from them.
We decided to give a different home a try and, remarkably, they were able to rebuild our trust. When I first visited I sat down with the house manager and explained my mother’s desire for agency. She listened. And she described having worked with many similar residents. Once my mother moved in, I received multiple daily emails with updates and photos, and I did quickly get sick of so much communication. On my visits, there was laughter. One week the house manager told me that my mother, instead of eating her green beans, put them in her water glass. I explained that my mother never really did like vegetables.
The next week, my mother fell into a deep sleep. The house manager told me that green beans had been served again the day before. She said that to humor my mother, she threw a couple green beans onto the floor, and my mother smiled.
My mother never woke up. I will forever be appreciative of the house manager giving my mother a final moment of happiness.
Jessica Greene is a Professor and the Luciano Chair of Health Care Policy at the Marxe School of Public and International Affairs, Baruch College, City University of New York. Her research focuses on patients’ interactions with the health care system, from what builds patient trust in health care institutions to patient awareness of state Medicaid policies. Her mother, Stefanie Greene, died December 16, 2020.
Respect builds trust within the health care environment
A pharmacist in the Oncology Infusion Center noticed something odd about a chemotherapy order. This was for an established patient, but the drug combination was different than usual. The pharmacist checked for an indicator of a new regimen; there was none. She called the oncology nurse, who quickly notified the charge nurse. The charge nurse contacted the nurse working with the treating oncologist, who walked the order to the treating physician and confirmed that, indeed, the chemotherapy order was incorrect.
The team member did not hesitate to question the medication order, quickly communicating with colleagues who acted with equal urgency. The genesis of this behavior is a culture of respect – a working environment characterized by teamwork, trust, communication, continuous learning, and a shared focus on patient safety. No organization can simply hope for a culture of respect. Creating one means gathering input – from the front lines to top leadership – and then developing the core attributes of respect and the guiding behavioral expectations.
In 2011, mandatory service training for all team members at Virginia Mason Medical Center in Seattle yielded groundbreaking feedback: team members wanted to work on improving behavior with each other. A leadership team began surveying team members, asking questions such as: What specific actions show respect? What does respect feel like when you experience it? What makes you feel disrespected at work? Hundreds of responses poured in. An analysis of the responses identified four behavior-centered themes: communication, appreciation, consideration, and teamwork.
An advisory group comprised of team members from across the organization produced 10 Foundational Behaviors that demonstrate respect and build trust: Be a team player; Listen to understand; Share information; Keep your promises; Speak up; Connect with others; Walk in their shoes; Be encouraging; Express gratitude; Grow and develop by committing to personal development and seeking feedback to enhance self-awareness and your abilities.
We added a live theater production with a local improv acting troupe, portraying respectful and disrespectful workplace scenarios, to our Respect for People (RFP) training. More than 5,000 team members – from physicians to board members – completed the training in just four weeks.
As RFP took root in our organization’s cultural rituals – from staff onboarding and CEO messages to team huddles and online education – the leadership team continued to develop its own guideposts through queries such as: How do we encourage others to speak up? How do we show appreciation for everyday work? How do we role model and hold others accountable?
A survey conducted after RFP training revealed that 77% of team members agreed or strongly agreed with the statement: “I feel a greater sense of personal ownership for how I respect, support and appreciate coworkers.” For the 54% who agreed or strongly agreed with the statement, “I have noticed a positive change in my work environment,” the culture shift at Virginia Mason Medical Center was well underway.
Respect, a precursor to trust, is critical to optimizing our work as an effective health care team. Research has illuminated the importance of also treating our patients with respect. We know patients can suffer emotional harm when they don’t feel respected. This, in turn, can negatively affect their health care outcomes. Like many other types of harm in health care, emotional harm is preventable.
Our RFP initiative has a significant strategic benefit and helps us continue to attract and retain the very best people, while also contributing to better patient care. Most importantly, we know it’s simply the right thing to do. Just as we care deeply for our patients, we also care for our team members and strive to treat everyone with the respect they deserve.
Gary S. Kaplan, MD, is co-CEO of Virginia Mason Franciscan Health, a member of the ABIM Foundation’s Trust Practice Network. Katerie Chapman is president of Virginia Mason Medical Center in Seattle.