Category: Guest Blogs

In college, I took a sociology class on “Stigma and Social Deviance” and one of the assignments was called “Dress Different Day.” Each student was to spend an entire day in attire that would likely be stigmatized in our community. For example, my close friend Pam put a pillow under her sweater to feign pregnancy and walked around smoking all day. She’s since quit. The rule was no matter how uncomfortable you or others became, you had to keep the assignment a secret.

I raided my closet, borrowed an item or two from friends, and decided to spend the day in full-blown ‘club kid’ regalia. (Here’s a Pinterest page if you’re unfamiliar with this 1980s/90s NYC phenomenon.) To be honest, this was only a small enhancement of my typical going-out-to-the-club gear, but it was certainly new for my daylight hours!

After I laced up my platform boots, I realized I had my annual physical at my university’s health service that morning. So, I flung my tiny, spiky backpack over my shoulder and headed over. The waiting room was uncomfortable, but bearable – quick glances, furrowed brows. Triage went well; the nurse was unfazed. I was feeling OK until the doctor came in. She stopped short. She blanched. She looked at my makeup, my piercings, my pleather, and then she wouldn’t make eye contact again. She struggled with her questions. I could feel her discomfort as she examined me. Our mutual discomfort was palpable. I became angry – really angry.

Before I left, I broke character (and the assignment) and filled her in. I needed her to hear just how her behavior had affected me, that she was literal proof of the value of this assignment. Her response? “Oh, thank goodness. We just don’t get people like that here.” Did I mention this was NYC? They most certainly did see people “like that” every day.

It was 25 years before I engaged a primary care physician who wasn’t explicitly a member of the LGBTQIA community. My trust had been totally broken – and it’s not totally repaired.

Philip M. Alberti, PhD, is the Founding Director of the new AAMC Center for Health Justice and has spent the last 20+ years collaborating with local communities and the multiple sectors that serve them to build an evidence-base for effective programs, protocols, policies, and partnerships aimed at eliminating inequities in health.

Several years ago, while working in the safety net system for Louisiana, I received a call from the medical director at a small rural safety net hospital, who needed help to urgently transfer a patient for life-saving treatment. 

The patient was a 45-year-old man who worked in construction for a small firm that did not offer health insurance. He was being treated for an infected heart valve when he suddenly developed altered mental status. A CT scan showed a subdural hematoma, a condition that is treatable with prompt neurosurgical attention. Regional hospitals, including some with available operating rooms and willing neurosurgeons, refused the transfer because the patient was uninsured. The medical director called 17 hospitals that day in a desperate attempt to transfer the patient without success. The patient died later that evening. 

This occurred during the national debate about the passage of the Affordable Care Act (ACA). Several months after the patient’s death, I called his mother to ask if I could tell his story to demonstrate the hard consequence of being uninsured. She agreed (and subsequently testified at a state legislative hearing) but quickly became hesitant. “This is not about Obamacare is it?” she asked. “Because we’re against that.” The abhorrent performance of the health system earned her mistrust that day and that mistrust extended to the federal program that would have literally saved her son’s life. 

While the number of similar cases is no doubt lower in the decade since the passage of the ACA (and the expansion of Medicaid by 38 states and the District of Columbia), 30 million people in the U.S. remain uninsured. Access to health care remains largely a factor of geography for many of them. In Texas, nearly one in four nonelderly adults is uninsured. A few large counties like Dallas support a robust safety net, while many smaller counties provide much less assistance. 

Access to health care that varies by county highlights just how far we still must go to achieve equitable health care coverage in the U.S. A few weeks ago, I rounded with our gynecologic oncology team. I heard stories of uninsured women presenting with late stage cancer – the disease progressing while they attempted to find a provider willing to take on their care. They did not have access to services in their counties of residence outside of Dallas, and found care eventually through the Parkland emergency department.

This “out-of-county care” creates competing tension as the local newspaper attempts to quantify the costs and citizens’ groups question why Parkland provides unreimbursed care to residents of counties that do not contribute to that care. Still, in the absence of comprehensive federal or state policies, the solutions often fall to local providers to make it a priority to create more equitable systems of care so people with treatable conditions do not unnecessarily suffer for lack of access in the shadows of some of the most advanced health care in the world.    

Fred Cerise served as the Vice President for Health Affairs at Louisiana State University and is currently the Chief Executive Officer at Parkland Health and Hospital System.

My mother had a stroke at home during the first month of the COVID-19 shutdown. My sister and I, both physicians with more than 20 years of health care experience, were blindsided both by her stroke and the health care system’s response, which allowed her to fall through the cracks.

Prior to having a stroke, my mother developed sudden left leg weakness and fell repeatedly, which was new for her. Normally, a patient with these symptoms would be evaluated in the emergency room with a physical exam and a brain MRI for evaluation. After calling her neurologist, however, she was told to monitor her symptoms at home. We were told that her symptoms were likely due to a progression of another chronic condition.

We knew there was broad concern about COVID-19 exposure and her doctors were hesitant to bring her into medical facilities, but we called repeatedly with concerns about her symptoms progressing and hopes to confirm a diagnosis. Without a proper diagnosis, and because my mother was still experiencing symptoms, we decided to bypass her initial physician to obtain an MRI. The MRI concluded that my mother had in fact suffered a stroke, which required medication changes, lab monitoring, and physical and speech therapy.

While my family struggled with her clinical decline for many months, our trust in her health care system was broken after communication broke down. She felt alone in navigating her care—especially after multiple delays. My sister and I—working within our own health systems that were desperately trying to make rapid changes during the shutdown—could understand a level of uncertainty by her care team and the health care system. However, we believed that the system would have safeguards for emergent care. We were shocked by the lack of communication or acknowledgment of the delays, and the lack of help to navigate a path forward. We also could not help wondering: What if she did not have an accent when she initially called for help? Would she have had more success if she was not an immigrant and was more familiar with the workings of our health care system? I am not sure of the answer to these questions. However, I do know that even with two physician daughters empowered by education and training, my mother’s trust in health care was easy to break and will be difficult to regrow.

Dr. Reshma Gupta MD, MSHPM is a practicing internist, Chief of Population Health and Accountable Care at UC Davis Health, and part of the Population Health Steering Board for strategy across all UC Health campuses. She serves as a senior advisor within the Center for Medicare and Medicaid Innovation Primary Care First Program and a Co-Director of Costs of Care Inc.   

A couple months into the pandemic, as my clinic settled into the new normal, my nurse urgently summoned me to see a patient in our drive-through testing site. I ran out to the parking lot to find a Pakistani gentleman in the front passenger seat, his wife in the driver’s seat, and his four daughters packed in the back—all alert and scared. He was coughing and wheezing and had an oxygen saturation hovering between 89% and 91%. After examining him, I concluded that he should go to the emergency room. While he didn’t quite need oxygen yet—as someone in his late 60s with long-term exposures to air pollution—he might have needed it soon, and I preferred him to be closely monitored in a health care facility.

His daughters’ eyes widened at the suggestion. New immigrants to the country, they were mistrustful of the government and hospitals. They were also uninsured and scared about what it would mean for their family’s finances. He asked if there was another way.

After stepping aside to think about their situation, I instructed the family on how to support and monitor his condition at home. I gave them a pulse oximeter that they could use to monitor his oxygen levels. I also instructed them to go to the emergency room or call us immediately if the levels consistently dropped below 88%. And finally, I gave them my personal cell phone number and had them text me to make sure they had the right number.

The next day or two were touch-and-go. They messaged me a few times about his lack of energy and fatigue. I called them once when his oxygen level was briefly low. But, we ultimately decided to keep him at home. And after a couple of seemingly very long days, he turned the corner.

Today the family still comes to see me in clinic and never hesitates to bring me sweets or other small tokens of their appreciation.

COVID-19 changed health care for the better

COVID-19 magnified many longstanding failures of the health care system. Perhaps none of these were starker than the deep lack of trust in doctors, health systems, and public health in general that had already been increasing in the past several years.

At the same time, I’m optimistic. COVID-19 has also accelerated changes to health care that I believe create a catalyst to rectifying this longstanding failure. As I’ve written in my book, during the pandemic, health care became more distributed, digitally enabled, and decentralized.

By distributed care, I mean that care will increasingly happen where health happens: at home and in the community. During COVID-19, we saw virtual visits skyrocket and home visits increase. We provided testing and vaccination at drive-through sites, churches, and football stadiums. By bringing care to patients rather than making patients go to care, we saw them on their terms. We met them where they were – not just physically but often emotionally as well.

Care also became digitally enabled. We finally recognized that the real role of technology in health care should be to increase the care in health care. Outfitted for the first time with a clinic iPhone, and already calling my patients over FaceTime and WhatsApp for their virtual visits, I found myself messaging with my patients between visits. I texted them about whether they picked up their medications yet, and they would message me to let me know that they tried picking up the medication, but that it cost more than $100 and they couldn’t afford it. Often these exchanges would end with warm appreciation and emojis – of smiling faces or namastes.

Care also became more decentralized. We put more resources in the hands of frontline care teams and patients. My safety net clinic received grants to support proactively calling people who needed the vaccine or canvassing door-to-door. We also empowered patients with equipment like the pulse oximeter we gave Mr. Salim, and we taught patients more about self-care – like how I talked to his family about how to support him and when to escalate care to an emergency room.

COVID-19 changes may catalyze greater trust

The “three Ds” accelerated by COVID-19 (distributed, digitally enabled and decentralized) map well to the “four Cs” the ABIM Foundation has developed for enhancing trust.

Competence. Often what doctors do seem to be a mystery. You don’t know what’s in their head or why they’re doing things. The shift towards decentralization, where patients are given more resources to make their own decisions, will help. Rather than “Hey, you need to go to the emergency room,” we’ll tell patients that we recommend the ER because their oxygen is low and medical guidelines say that oxygen below certain levels are dangerous. For my patient, this led to an acknowledgment that his oxygen level was on the border and that based on his preferences, there was an alternative option his family. This may be no more or less competent from my perspective, but from his family’s perspective, it became clear. I imagine that if his oxygen level did dip below 88% after a day or two, he would have a lot more trust that he truly did need to go to the emergency room, whatever the ramifications might be for his family.

Caring. Often the best way to be caring is to have empathy – to see and understand people as a whole person, and not just a patient in a gown. Virtual care and particularly video visits offer doctors a window into the home. Seeing patients in their own environment helps me understand who they are. Seeing the Pakistani gentleman with his wife and four daughters – something that is often hard for families to do in a clinic-based environment due to logistical and financial barriers – allowed me to tap into my own empathy in order to treat him. He was no longer a COVID-19 patient with respiratory symptoms. He was a father and a provider to the five women in the car with him.

Communication. Communication in health care is often very formal. There is a visit followed by weeks or months of silence before the next visit, and so on. This is not how we communicate with the people we care about. We send emails and texts and have phone and video calls. Digital communication can sustain and strengthen relationships that were originally built in-person. Knowing that he and his family could each contact me – that I was just a text away – was critical to their having enough trust to take care of their father at home.

Comfort. Care that happens increasingly at home and in the community is care that happens on patients’ own turf – sometimes literally. In an era when many lack access to medical facilities or are too mistrustful to step foot in one, the fact that care can start in their own environment can be a great source of comfort, particularly as relationships are still being built.

Many of the changes I described may reverse after the pandemic; the changes so far have been important, but small. COVID-19 is simply a possible catalyst. It is up to us to seize this opportunity to rebuild trust with our communities and our patients.

Building trust is more important and more challenging than ever as our nation attempts to address years of injustice and inequities in health care. Building trust can be awkward when professionalism confronts grassroots savvy, and building trust can be uncomfortable when there are imbalances of power in terms of resources, access to decision makers, and control of activities.

But we have to move forward, experimenting with and acquiring lessons in building trust along the way. For the past 30 years, the Jewish Healthcare Foundation (JHF) has offered a unique brand of activist philanthropy to advance health care innovation, advocacy, collaboration and education in the interest of better population health. Among the most concerning issues locally are the alarming maternal health disparities that disproportionately affect people of color – particularly in the Pittsburgh region. JHF and its nonprofit operating arm, the Women’s Health Activist Movement Global (WHAMglobal), made a commitment to improve maternal and child health outcomes in the Pittsburgh region and across the Commonwealth of Pennsylvania, while amplifying the voices of pregnant women experiencing inequity. To achieve meaningful legitimacy in doing this, we had to assemble the right team. This provided an early challenge.

JHF built philanthropic partnerships to fund grassroots perinatal community-based organizations at the forefront of fighting maternal health disparities. And in 2019, JHF joined the inaugural cohort of the Merck for Mothers Safer Childbirth Cities Initiative, receiving a $1 million, multi-year grant to foster local solutions to help cities become safer, more equitable places to give birth.

With funding from the Heinz Endowments and Merck, through Merck for Mothers, the company’s $500 million initiative to help create a world where no woman dies giving life, JHF established the Pittsburgh Safer Childbirth City Community Fund, which awarded grants of $20,000 to community-based maternal health organizations that are trusted in their communities and have a clear mission toward improving maternal health outcomes for those they serve. These grants ensured that grassroots organizations could establish the platform needed to continue their work and promote maternal health equity in our region. They also built support for our leadership role.

We have moved forward with some tensions, and we are learning to moderate these as much as possible. WHAMglobal convenes health care systems and stakeholders through learning collaboratives, and offers ample opportunities to air opinions. We also established and lead the Pennsylvania Perinatal Quality Collaborative, designing equitable maternal health solutions and directly addressing the implicit biases in maternal health care.

We established a Full Court Press initiative to further advance key policies related to perinatal community health workers and doulas, midwives and the critical Women Infants and Children (WIC) program. JHF organized the 2020 Pennsylvania WIC Stakeholders Collaborative Summit, which identified strategies to reinvigorate the program in Pennsylvania. And in 2021, building on years of work advancing community health workers and doula-work, WHAMglobal convened a statewide advisory group to create more equitable access to doulas and to develop a statewide infrastructure to support the work of doulas and perinatal community health workers in the state.

While we have celebrated progress in this work, there is still much to be done and resolved. Hopefully we can continue to move forward with open communication among those with diverse opinions, and trust in our efforts to allow all voices to be heard respectfully. The COVID-19 pandemic has exacerbated many of these disparities, and our national response has demonstrated that many gaps remain to be filled. We believe that the most equitable solutions will come from respecting the patient experience of historically marginalized voices as we advance better program design, attract philanthropy and pursue policy reforms.

Karen Wolk Feinstein PhD is president and chief executive officer of the Jewish Healthcare Foundation (JHF) and its three operating arms, the Pittsburgh Regional Health Initiative (PRHI), Health Careers Futures, and the Women’s Health Activist Movement Global (WHAMglobal). Appointed the Foundation’s first CEO in 1991, she has made JHF and PRHI into a leading voice in patient safety, healthcare quality, health policy, and workforce issues.

Although many at UT-Southwestern worked together to reduce barriers to opening clinical trials related to COVID-19, obstacles to implementing still existed. To provide access to potential therapeutic medications through a clinical trial, we needed to obtain consent from the participant. We usually do this through an in-person process with the investigator, coordinator, and the patient, but we could not enter patients’ rooms because there was not enough personal protective equipment (PPE). We received permission to obtain electronic consent by DocuSign, a process ideal for those who have an email and cell phone.

In our county hospital, Hispanic patients accounted for 90 percent of the admissions for COVID-19, and often did not have cell phones or an email address. Instead, we used the hospital’s tubing system to send a paper copy of the Spanish-language consent form to the nursing station. The patient’s nurse could pick up the paperwork there, and bring it to the patient to read. We employed bilingual coordinators to help facilitate coordination and translation of complex medical information from the investigator to the patient.

After explaining the study and obtaining permission to proceed, we then obtained a digital signature by DocuSign. We had the patient’s nurse take a donated iPad into the room of the patient, and sent the DocuSign document to an email account we created for the study. The coordinator would then walk the patient through the process of signing their name on the consent form on the iPad. After the investigator signed the consent, DocuSign would then send a completed signed copy to the coordinator, who printed the written consent and scanned it to the patient’s record. Through this elaborate, time-consuming effort, we were able to provide access to clinical trials to uninsured Hispanic patients who faced both language and digital barriers. We promoted health equity to uninsured members of the Hispanic community who were hardest hit by the COVID-19 pandemic in our region.

In our University Hospital, we were able to go to patients’ rooms (either in the ICU or on the floor) but not enter them, due to PPE shortages. If the patient did not have an email, we could communicate by phone or a video conferencing application on the hospital’s computer system. Together with the nurse, who was in the room with the patient, we explained the study, answered questions, had the patient sign their consent, and the nurse sign as the witness. The nurse then brought the consent to the window or door so a member of the research team could take a photograph. Subsequently, we obtained iPhones, which the nurses used to take a picture of the consent and upload it directly into the chart. In those studies that required a physical exam, the nurse was able to record heart and lung sounds through a Littman stethoscope, which the investigator listened to from the hospital’s computer system. We have used technology and teamwork to find innovative ways to perform research procedures during this unprecedented time. We have tried to build trust with our patients and our staff by working with them to provide access to therapies for COVID-19.

Mamta Jain is a board-certified Infectious Disease specialist and Professor of Medicine at UT Southwestern Medical Center. Her goal is to provide access to novel therapies through clinical trials. She has focused her efforts in medically underserved populations to help provide access to treatment for infectious such as HIV, hepatitis C, influenza, and now COVID-19.

I trusted the science but this time I had a hard time believing it. It was with great skepticism that I read in numerous articles that 50% of patients were not taking their medicines as prescribed. I thought: “Not my patients – my patients trust me, they’ve known me for decades, they know I care.” Having the honor of practicing in the same neighborhood on the west side of Chicago for more than 30 years, I was proud of the relationships I had developed with patients.

When I assessed my patients’ adherence as part of my evaluations, I was always met with an affirmation that they were indeed taking their medicines. So I decided to test the literature. I would ask my patients if they were really taking their medicines as they said they were.  Repeatedly they answered yes.

Too much trust in my effectiveness in conveying the importance of my medical recommendation was the problem. What was I missing? Were my patients truly that different from the rest of the nation? As I reflected, many of my patients’ outcomes were not at goal despite being on appropriate effective therapies. Could I be wrong? Could my patients be hiding their true medication behaviors? How was I to find out?

With some trepidation, I changed my approach. I shared with a patient named Calvin: “Your blood pressure is still not under control, yet you tell me you are taking your three medicines. I have read that many patients—almost half—do not take their meds as prescribed. Are you really taking your three meds every day?”

He looked at me and paused, clearly hesitant to respond. Encouraging him to share his true medication-taking behavior, I promised not to admonish him if he was not taking his meds as prescribed. “But the last time I told you I wasn’t taking them, you yelled at me!” he said.

I had too little trust in my patients. I only uncovered their non-adherence after I changed my attitude and began to trust that patients were making rational decisions in not taking their medicines. Only after thanking them for sharing, and often apologizing for my past admonitions, could we uncover their individual reasons for non-adherence.

Much to my surprise, their reasons for non-adherence were myriad and quite rational. Only when trust was just right could we move forward and address these reasons. As adherence increased, blood pressures and sugars began to drop and multidrug therapies were deescalated as patients were controlled with fewer drugs taken regularly.

Dr Brown is a practicing internist in Chicago. She has served on the ABIM Board, as Governor for the ACP and currently as Director of Practice Redesign at the AMA. From her decades of experience she has found trust between physician and patient to be a necessity to delivering effective patient care.

During a late-night shift in the Emergency Department (ED) in April, I took care of Mr. S, a man in his early twenties who presented with a sickle cell vaso-occlusive crisis. COVID-19 testing had returned negative. The carefully composed steps in his hematology care plan had begun to ease his pain. Yet his oxygen levels were hovering just below a safe level for discharge. In addition to further workup, he would need to stay the night, at least while requiring oxygen. Mr. S asked me to call his parents who could not visit him in the ED. They would not be pleased, he warned me; they wanted him home. After discussing the difficult balance of risks – those of staying in the hospital during the COVID surge or going home without oxygen – Mr. S and his parents ultimately agreed to him staying overnight. Even so, Mr. S’s father’s parting words were “if my son gets COVID in the hospital, it’s on you.” These words and the profound distrust they conveyed echoed in my head throughout the evening.

A few weeks later, on a late Friday afternoon during my telemedicine clinic, Mr. J was describing by phone what could have been a gout flare in his knee or, far more troubling, a case of septic arthritis. After staffing with my attending, I explained my concerns to Mr. J and recommended he go to the ED. I talked him through the new layout and triage process. Unlike Mr. S’s family, I knew Mr. J well – I had taken care of him in inpatient and outpatient settings since I was an intern. An elderly man from Puerto Rico, his experiences with gang-related violence decades ago had left him with PTSD, depression, and severe anxiety. When I told him I was graduating from residency, he said he wanted to give me one of his late mother’s rosaries. By Monday, he had not visited the ED and I reached back out. He said he simply could not overcome the fear of getting COVID-19. The red-hot pain, redness, and swelling in his knee had fortunately resolved over the weekend. For Mr. J, his distrust in the hospital’s ability to keep him safe superseded the trust we had each built over the course of three years.

Mr. S and Mr. J are both affected by multifold inequities in our health system, Mr. S as a Black man with sickle cell disease and Mr. J as a Latino man with mental health problems. They both come from neighborhoods that were hotspots for COVID-19 and had carefully avoided infection. Personal and institutional distrust affected the way they navigated non-COVID care within a pandemic-era hospital system and how they interacted with me, a white trainee. Concerns about infection likely shape every patient’s decision-making about visiting hospitals now. However, I fear that for people who have experienced medical bias or substandard care in the past, concerns about safety within the hospital space could pose devastating barriers to care. Learning about the mortality disparities in COVID-19 further validates distrust. Ongoing research has begun to examine decreases in standard care services provided during the pandemic ^[i],[ii]. A focus on inequities must inform this research. Interventions to address the findings must emphasize safety and trust in marginalized communities; for example, by providing more community-embedded services.

At every turn in the way the COVID-19 pandemic has played out, the American medical community has only retroactively recognized the inequities that compound each other to lead to Black and Brown people dying at much higher rates than their white counterparts. We must probe beyond the COVID-19 diagnosis to fully understand inequities in pandemic-era care.

Alyse Wheelock is a first-year fellow in Infectious Diseases at Boston Medical Center, where she also completed internal medicine residency.

[i] Garcia S, Albaghdadi MS, Meraj PM, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol 2020 April 9

[ii] Lange SJ, Ritchey MD, Goodman AB, et al. Potential Indirect Effects of the COVID-19 Pandemic on Use of Emergency Departments for Acute Life-Threatening Conditions — United States, January–May 2020. MMWR Morb Mortal Wkly Rep 2020;69:795–800. DOI: http://dx.doi.org/10.15585/mmwr.mm6925e2external icon

My passion for running began as a means to an end. At the time I started running, I was a wrestler, and I ran as a way to build endurance and control weight. But over the years, things changed.  This means to the end became the sustaining quality and foundation for my physical activity, and remains so some 30 years later.

Running requires consistency, support through rest and good nutrition, and the discipline to keep putting one foot in front of the other in a rhythmic but often mundane process. In many ways, it’s a lot like what I’ve experienced as we’ve worked to pursue a culture of trust at the American Physical Therapy Association during my first four years as chief executive officer.

Trust is a term you hear a lot in organizational settings.  At a recent association leadership conference, one speaker described trust as jet fuel; another described it as “the core competency of leadership.” Trust, in other words, was a resource, or a skill that could be honed. Or maybe, somehow, a little of both. 

I think those experts missed the fundamental properties of trust. Trust isn’t something to be expended, or a set of techniques to be applied to situations — it’s a process, a practice, a pursuit.  Trust isn’t a business book chapter or PowerPoint buzzword that should be covered before moving on to the next topic—trust is an ongoing exercise that empowers organizational and individual fitness.

Both at my association’s level and for me as an individual, exercising trust has become a daily pursuit to seek a higher level of functional fitness. It’s like running: it has to be consistent in approach, supported in behavior, and disciplined in application.

And there are no shortcuts. If we could’ve purchased hi-test trust fuel or sent staff to a continuing education weekend for a certificate in trust, we would’ve been all-in.  Instead, we knew we’d have to commit time, effort, discipline, and a posture of learning.  We needed to learn to walk the walk and talk the talk of building trust. Trust would become a form of exercise, with the goal to gain flexibility, strength, and endurance to enhance the credibility of the organization to its community of stakeholders.

However, before we could begin our exercise program, we needed to take stock of our current state of fitness. And we needed to gain insight into the best ways to move. We needed to reflect, reconcile, and then seek results.

Our reflecting began with an effort to better understand the perspectives of our stakeholders and the perceptions of potential partners.  We engaged outside consultants who offered us sound, research-driven information on the perspectives and perceptions of key audiences. Those insights helped us build a strategic plan and new brand promise that seeks to close our trust gaps, including becoming a more relevant, credible, and consistent source of information, programs, and services.

Reflection led to reconciliation. As an organization, APTA had grown through advocacy and the advancement of science that confirms the efficacy of physical therapy. The profession had achieved independence in its educational enterprise including accreditation, and it has become a recognized health care profession at the state and national levels. But that growth came at a price: the erosion of trusting relationships with many of the health care professions with which we must collaborate to best serve our patients. We needed to reconcile our hard-fought independence with the greater value of interdependence, and we needed to embrace trust as the means by which we could achieve that optimal goal. This required some long-overdue conversations with organizations that were opponents in past turf battles, to move from a posture of competition to collaboration.    

But ultimately, we needed to deliver results. Reflection gave us a playbook and a brand that we would seek to deliver. Reconciliation engaged other organizations, shifting foes to friends in the pursuit of shared goals. Results are the practices, programs, and outcomes that will validate our exercise program.   

Those results are emerging. The one thing we have discovered so far is that exercising trust is worth the effort. We are improving, learning, and seeking new strategies of engagement with stakeholders, from patients to other professional societies. This is how we grow and improve our fitness for service, and our fitness to deliver the best possible care.  

As we grapple with the future of health care, we can be certain that trust will play a central role at all levels.  We can no longer rely on white-coat symbolism. We need to turn to a pursuit of partnerships with individuals in care, and with communities impacted by what we do. 

Building trust by identifying, scaling, and sustaining successful practices will require the rhythmic process of putting one foot in front of the other, over and over and over again.  The commitment to inclusion, learning, and communicating with others necessitates that we don’t think of trust as a commodity, but as a way of doing—a steady, consistent, disciplined effort to stay fit, healthy, and prepared for the challenges ahead.

Several years ago, I was invited by a large hospital system in the Midwest to facilitate a conversation between a group of physicians and nurses who, according to the vice president for clinical affairs, “were at war with one another.”

The origins of the war were murky, but there were frequent complaints from both sides about a lack of trust and conflict between the two groups that stretched back years.  At the beginning of the day, and as people were milling around in their respective tribes, the VP pointed out one nurse and one physician to especially watch out for, “… because whenever they’re together distrust and conflict aren’t far behind.” 

These two warring professionals became my “canaries in the coal mine.”  If they could somehow manage to find common ground, anything might be possible.  

After a short introduction and description of how using an us versus them logic was ultimately enervating, eroded trust, and was a potential source of burnout, I invited the group to think about the things they loved about their work and/or lives, and to speak them into the circle in which the room chairs had been arranged.

People talked about aspects of their work they loved, their children, their families and friendships, hobbies, and the like.  When it came to the physician I’d been warned about, he started off by saying, “You know, I’ve been practicing medicine for the past 30 years and I still enjoy it somewhat, but what I really love is playing the organ in my church.  I live for Sundays when I can get lost in the music and the sound of the organ in such a special space.”

The nurse, who was the next to speak, turned and said, “That’s really amazing because in the 25 years that we’ve worked shoulder to shoulder together, I never knew anything that really grabbed you outside of work.”  With misty eyes she went on to say, “Like you, I enjoy my job as a nurse, but to me at this point it’s just a job.  What I really love, is playing the organ in my church, and for exactly the same reasons!”

There was a brief silence followed by smiles and clapping in appreciation of the moment that had just occurred.  The nurse and the physician, too, were smiling at each other, recognizing at that moment, in fact, they were more alike than different. More importantly, they each took a risk and trusted a process designed to tap into what we’re like when we’re at our best.

Throughout the day, during small and large group exercises, there was a noticeable shift in the tone and content of conversations within and between the two professional groups.  It was as if what had happened to the two “canaries” had come home to roost as a model for how to take risks, speak from the heart, and trust in one another’s good will and intentions. 

Creating trust among medical professionals is not only possible, it is the bedrock on which our day-to-day work is based.  It is also an antidote to the isolation and fear that so many health professionals feel and that threaten to undermine trust in one another and of our institutions.

Frankel is Professor of Medicine and Geriatrics at Indiana University School of Medicine where he directs the ASPIRE Fellowship, (Advanced Scholars Program for Internists in Research and Education). He is also a senior scientist at the Regenstrief Institute, Indianapolis, and holds an appointment in the Education Institute at the Cleveland Clinic.