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Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Chris Queram, a healthcare policy leader, and Beth McGlynn healthcare researcher, focused on efforts to build trust through transparency.

Chris Queram: I’m Chris Queram, the president and CEO of the Wisconsin Collaborative for Healthcare Quality.

Beth McGlynn: And I’m Beth McGlynn. I’m the vice president for Kaiser Permanente Research and also the immediate past chair of the board of the American Board of Internal Medicine Foundation.

Chris Queram: It’s a pleasure to be with you.

Beth McGlynn: It’s great to be with you, Chris. I’ve wondered if you could just tell a little bit about how the collaborative, that Wisconsin Collaborative for Healthcare Quality got started, what the motivation was, what brought you together?

Chris Queram: It the story goes back about 20, 20 or maybe even a little bit more than that years. The late 1990s, the early 2000s, there was a lot of restlessness among the business community and many of the stakeholders aligned with the employers’ labor unions, consumer groups, individual employers, business coalitions, who had been pushing for more information for quite some time. And the primary strategy was to go the legislative route and persuade the then governor to sign a bill that mandated physician groups to submit claims data to a state data agency. And about that same time, public file of hospital discharge data was used to develop a hospital report that was catalytic in the sense that I think it really changed the conversation with some of the health systems. And many of those health systems owned a health plan. So they were familiar with performance measurement through HEDIS, the clinical relevance, the pertinent of the specifications. But we’re frustrated with the fact that the HEDIS results were tied to an individual health plan.

And so there was this bringing together of these diverse groups to see if there could be some sort of a balance struck between the urgency that the demand side of the market wanted to bring to this issue and the desire of the provider organizations to measure in a way that would support their efforts to improve. And after a long series of discussions about how to balance those interests, the idea was to form a collaborative in a multi-stakeholder fashion and work together to make measurement meaningful and sustainable.

Beth McGlynn: That’s great. So one of the things I take from what you’re talking about was not a lot of trust going into the development of the collaborative. Can you talk a little bit about how you were able to build trust amongst those multiple stakeholders?

Chris Queram: I give a lot of the credit. The time I was running one of the business coalitions in the state and I give tremendous credit to the physician leaders who had the idea to bring everybody together and see if there was some way to work together. I have to confess, I was skeptical initially given the resistance that we had encountered and the obstacles that had been erected. But at each critical moment when there was a decision to be made, the clinical leaders would stop and ask those of us from the employer and labor union and consumer communities if what we were talking about made sense. Was it relevant to us? Would we use it? And really, took extra effort to reflect our perspectives in the design of the model. And gradually, trust was established through that process. And we’ve thought it was a better way and we gave the benefit of the doubt to the provider organizations and within a year of the sort of the penultimate decision to do this, the first performance measurement was released, and we’ve gone on from there.

Beth McGlynn: That’s pretty fast. So as a result of this transparency and reporting initiative, do you feel like you’ve seen real improvements in quality in Wisconsin?

Chris Queram: We have. Wisconsin consistently ranks very high among the 50 states on meta measures of clinical quality. We know anecdotally, talking with the leaders, both lay leadership, but also clinical leaders from our member organizations, that the measures are valid, they’re reliable, they’re actionable, they are making a difference in how quality is improved within the organizations. Observationally, we’ve begun to track our measures over time and the steady trend is upward, improving almost all of the measures. A good example is three years ago, we debuted a clinical depression screening measure and the initial results were very low. In aggregate, after one year, there was a 6% improvement and in the three years that we’ve been reporting in that measure now, there’s a 20% improvement. And then last but not least, as esteemed health services researcher, you may appreciate we wanted to contribute to the evidence base. And so we, with funding from the Commonwealth Fund, undertook to empirical evaluations of our work. One qualitative, one quantitative. And as a result of that, we’ve sort of taken the old aphorism that what gets measured gets improved, what gets measured and reported publicly improves faster.

Beth McGlynn: So you’ve talked a little bit about the business community and the provider community in this. What’s the level of engagement with the public or do you have a sense of how the public in Wisconsin has responded to the transparency in reporting?

Chris Queram: It’s been a struggle, to be perfectly candid about that. We’ve experimented with different approaches to try to make our measures and the results more accessible to the public. But the best we can tell through Google Analytics and some of the other tools that we have available, the primary users of our website are the provider organizations and the payers who use it for benchmarking and for different payment incentives. We’ve had some success partnering with consumer reports a few years ago. We repurposed some of our data, and as an insert into an issue of consumer reports, we saw a dramatic spike up in visits to our website after that. But that was unfortunately an experiment that was not repeated by consumer reports and we thought, you know, this is great. We’ll just, those organizations that have dedicated readers and dedicated followers who are really into data and into a numbers, that’s exactly the audience we want to reach. But they’ve moved in a different direction since then. And so that’s been our experience.

Beth McGlynn: That’s great.

Chris Queram: I would love to hear from your vantage point at Kaiser Permanente how transparency drives improvement within such a large complex organization?

Beth McGlynn: Well, it’s an interesting question. I think, in many ways, the transparency particularly in terms of public reporting is almost more important for our organization because we sit in a model that’s a largely prepaid model. And I think that there is, there are concerns, perhaps a lack of trust about whether the organization is withholding care. And so I think that the transparency provides a balancing perspective in terms of really looking at are you doing the best for us that you could possibly do. It has definitely driven pretty significant interventions or pretty significant campaigns, particularly, it’s in the area of management of chronic disease. And I was just talking to someone the other day about our journey with hypertension control, you know, heart disease is major reason for premature loss of life, and we have really seen dramatic improvements in our control of blood pressure.

And I think that started by getting these public reports and saying, wow, we really aren’t doing as well as we thought we could, as we think we should. And so really doubling down on what is at stake. And I think it’s important in our organization to note that, you know, it hasn’t been, it’s not easy. I mean, even with a big organization that has resources to bring to bear to help everybody achieve the kind of performance that we would hope to achieve. It took us a good ten years to get to the levels we’re at, which are some of the best in the country.

Chris Queram: That’s right. That’s wonderful. And is there a link with financial incentives or as is the primary use of the information more intrinsically motivated as opposed to the extrinsic motivators?

Beth McGlynn: I would say it’s primarily intrinsic motivation, although interestingly, for a number of quality measures, the executives in our organization have in their variable comp plans performance on quality measures. I’m not out there getting people’s flu shots or making sure their blood pressure is controlled and yet a part of my compensation is tied to how well we do in those areas. So I think it makes it clear that this is a top priority for the organization. The physicians similarly get a relatively small part of their compensation that’s attached to their quality performance. So I think, but I think when I talk to our docs, they are really clear on what they think is important. And I think this, what this has helped with, is to organize the kind of support systems around them that make it easier for them to do the right thing. And that’s kind of one of our mottoes. You talk about some of yours, which is make the right thing easy to do. And that’s really been many of the changes that we’ve been, that we’ve implemented have been kind of with that in that spirit.

Chris Queram: The other question I have is a lot of the focus that we’ve had over the first 15 or 16 years of our work has been clinical quality. We want to broaden beyond that to begin looking at cost, per capita cost and appropriateness of care. Do you have much experience and lessons that we can learn from how your organization has taken on the cost and the appropriateness of care issue?

Beth McGlynn: Well, appropriateness and costs are drivers for us. It’s interesting. The vision of our organization has had the term affordability in it since for… 75 years. We’ve almost been—yeah. So, you know, our mission is to provide high quality, affordable healthcare and that’s been there long before it was as popular as it is today. And actually, our current CEO has affordability as one of his absolute top drivers. And we’ve made commitments as an organization to not only look at the trajectory in the cost of care, to try to keep it at the level of inflation, but over time, to actually try to start making it lower than inflation. And I think the sense with what he says is, you know, if we’re a terrific health plan and nobody can afford us, what does it matter?

Chris Queram: Exactly.

Beth McGlynn: And so this is a huge part of our journey and really taking a look at where are the opportunities are. The nice thing in our system is because of the prepayment and the nature of our integrated system, the incentives between the health plan and the providers are very aligned. When we all do well, you know, we all do well. And so I think that that helps with the conversation. Tell people when I first got to Kaiser Permanente had this very interesting conversation with some of our vascular surgeons who said, you know, we’re seeing patients that we shouldn’t be seeing because they have preventable conditions and we really think we should be investing in some work earlier on. So that these patients never get to us. And I thought, are you really vascular surgeons? I mean, I’ve never had this conversation with a surgeon and. you know, and indeed we have been on the journey that they identified as being important.

And so that kind of is an example of what we’re able to do. And I think there are a lot of lessons to learn. It’s not easy. I mean, I wouldn’t at all pretend that this is easy, but I think it’s… and so we’re looking at a lot of how technology for instance, can be improved the patient experience, making it easier for them to get the care they need and in ways that may be less expensive to deliver. So it’s kind of an everybody wins type situation. So I think it’s opening people to think about a lot of different innovative approaches to healthcare delivery.

Chris Queram: Very nice.

Beth McGlynn: So as you think about the journey ahead for the collaborative, what do you think are the most critical issues you’re taking on? And talk a little bit about the role of trust in continuing to be able to execute on your vision and mission.

Chris Queram: Well, one other element of trust that I didn’t mention is when we were back in those conversations about doing something together to balance that urgency with a desire to be sustainable in this work. There was another commitment made by the health systems to not use the measures that would be developed and reported publicly for competitive advantage instead to use them to support the development of learning collaboratives with the goal of improving care across the state. And I think that sometimes gets referred to as sort of upper Midwest nice. Everybody likes to be nice to one another, say good morning and say goodbye when you’re leaving and work together. But one of our physician leaders put it this way. He said when he was in medical school, it was always his understanding, the way he was taught is that if he found a better way or an effective way to manage a particular condition or procedure, he had a professional obligation to share that with his colleagues.

And there is, I think this belief that best practices are should be shared. It’s the execution and the implementation of them that’s going to be a differentiator as opposed to hoarding that and keeping that. And one of the things that I’ve observed over the last 15 or more years is the environment has changed fairly significantly. And I think a lot of those values still hold. But I think sometimes the tendency is for leadership to focus internally as opposed to what they can do as part of a larger ecosystem. And so I think that’s one of our both challenges and opportunities going forward.

Beth McGlynn: It strikes me in this situation that maybe it doesn’t matter so much if patients are going to the website if they can trust that all of the rest of the system is working on delivering the best possible care to them. So to me, it could be a sign of faith, not just a centrist.

Chris Queram: Absolutely. Well, thank you for the opportunity to visit.

Beth McGlynn: Thanks.

Narrator: Visit buildingtrust.org to learn more.

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Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Robert Shochet, a physician and professor and David Sklar, a former peer review journal editor, focused on efforts to build trust in academic medical settings.

David Sklar: We’re going to have a conversation about trust in medical education. And trust is a, it’s a challenge because as physicians and as folks who are trying to train medical students, we have to make sure that our patients are safe, and we also are evaluating our students at the same time. And on top of all of this, as physicians, many of us are wearing many hats. So we’re moving around and sometimes our relationships with students are somewhat fragmented. So I’m just wondering if you could maybe get us started and talk a little bit about how you’ve tried to overcome some of this in your program at Johns Hopkins.

Robert Shochet: Certainly. So the Colleges Advisory Program started in 2005 and it’s a learning community program that offers continuity for students and clinical skills training and a focus on professional development as well as advising. Entering students are divided into one of four colleges. We have 120 students, so that’s 30 students in each class year in each college and then further subdivided into learning units. What we call Molecules. They’re five students in each molecule and they’re connected to a faculty advisor who becomes their clinical skills teacher and remains their advisor throughout medical school. The program at Johns Hopkins actually started because we were in a very difficult spot with student advising. We had a volunteer advising program and one student in fact set on a climate survey, I just want someone to know me here. Which was quite outstanding and became a rallying call for us.

David Sklar: And why don’t they know him? I mean, it seems like they would have clerkships and classes. So why do you think he felt that they didn’t know him?

Robert Shochet: You know, like you had mentioned, I think there is a quality of rotating teachers and sometimes for certain students, they never really get to be known in a very important and meaningful way by teachers. And I think this is critical really if we’re thinking about students seriously developing their professional identity in a very durable way.

David Sklar: And Robert, I heard you mentioned that you’ve kind of developed these learning communities. Could you explain to us what a learning community is? Because I’m not sure everybody is familiar with that.

Robert Shochet: Sure. Well, the concept of learning communities was really brought to America in the early 20th century to university and it gradually picked up steam and now it’s mainstream in most undergraduate universities. The concept of learning communities in that setting is about integrating classes for students, creating longitudinal connections with faculty and providing opportunities for deeper learning because of a sense of wholeness and coherence to studying subjects from multiple aspects. With several teachers, they get to know well.

David Sklar: And how was it altered for medical students? Were there’s some specific changes that were made so that it would work better for medical students?

Robert Shochet: Yes, I think there are two key leaders in this field. Louise Arnold at the University of Missouri, Kansas City, back in the 70s, created a communities of practice model in the clinic where students over years would work with the same team developing their skills and have an opportunity for authentic and honest feedback from their supervisors and near peers. Erica Goldstein at the University of Washington did something similar but focused on clinical skills, education and professionalism for students within courses. And that created continuity and trust between students and teachers in a new way.

David Sklar: And I know that the learning community is one of the things that happens is we break down the overall class into smaller pieces. In some groups, groupings of four or five, ten, whatever. And I believe in your program, they’re five, although they get together in larger grouping also.

Robert Shochet: That’s right.

David Sklar: And then there are faculty who are especially designated, is that right? And who kind of stick with their group of students over maybe four or five years and certainly, the whole four years of medical school.

Robert Shochet: Yes, that’s absolutely right. We think that breaking students down into smaller groups and then subdividing them further into learning units, create both a sense of social identity at the school and a sense of belonging and then a sense of intimacy and trust within the learning units. And within the learning units, we call them at Hopkins Molecules, five students and an advisor. They stay together for years well beyond the duration of a single course.

David Sklar: Okay. Now how do you how do you keep these programs from getting into the problem of the faculty member being also an evaluator? Because you know, one of the things that our students are very concerned about, and I think one of the areas that’s really broken down trust has been a really kind of frightening aspect of what they call the sort of step one climate where they’re worried about the score they’re going to get on the step one exam for the National Board of Medical Examiners. And they’re also worried about the grades that going to get. And all of that is somewhat tied up in the relationship they have with their faculty members. So how do you kind of protect the faculty members from getting into conflict with the students over that evaluation process?

Robert Shochet: Well, specifically for the learning communities, we have a negotiation with each faculty member that their primary responsibility is to serve as advocates and coaches for their students that they’re assigned to longitudinally. So if they find themselves in a different teaching role, traditional teaching role…

David Sklar: Like in a clinic.

Robert Shochet: Like in a clinic or on a clerkship then they’re asked not to be the one who does a summative evaluation of a student so that they’re there’s any sense of favoritism on the one hand or any kind of disengagement or mistrust from their advising relationship.

David Sklar: Is there individual evaluations though of their experience with the student on the clinic in the clinic?

Robert Shochet: In our learning community, we have them teach the clinical skills course in first year and they write a detailed narrative that’s descriptive of the student’s development during the course. But that’s not used for their summative grade. It’s really used as a learning piece, a learning essay for the students.

David Sklar: You know, one experience I had, I an emergency physician and I had a resident that was, she was very early in her career, but I can remember writing one of—and we write these kind of every shift little evaluations, and I can remember writing one for her and trying to give her some constructive feedback. Her communication skills weren’t very good with a particular patient. And the patient ended up being very angry based upon the interaction that she had with this particular resident. And I remember writing an evaluation and I told her also about that. But the next week, she came into my office and was crying and very upset and told me that no one had ever said anything critical about her skills before. And I tried to explain to her that it was really meant to try to improve her interaction with the patient. How do you deal with those kinds of things? Cause because I can tell you that it was difficult to regain trust with that student after that that experience.

Robert Shochet: Well, I can tell you from a role of an advisor with students, students bring their evaluations to us from their other teachers and we help not only to decode the evaluation because sometimes students think that they’re doing wonderfully, and the evaluation actually doesn’t say that. And on the other hand, when evaluations are fairly critical, we try to understand them together and put them in context and learn from them.

David Sklar: And do you think they able to accept them? Because my experience with medical students is that they’ve gone through life generally, you know, getting a lot of very positive feedback. Most of the time, you know, they get all the you know, the five stars, whatever. And so if you try to give them any critical feedback, there’s often some defensiveness and it’s very difficult to do that in a way that doesn’t impair the relationship that you’re trying to develop with that student or resident. And so how, how do you do that?

Robert Shochet: Well, you know, it’s interesting. In our learning community, in our course first semester, students say about the Molecules that it becomes their safe place to fail. And in many cases, it’s their very first time in school taking the kinds of risks that can lead to failure without feeling a sense of humiliation. Ultimately, I think that students are, from a personal standpoint, still in development as adults when they’re in medical school and becoming more mature adults, being able to accept your vulnerabilities and weaknesses is, you know, it’s part of growing up, I think.

David Sklar: You know, one of the concepts that now is developing in medical education is the concept of entrustment and the idea that as a physician faculty member, I’m going to begin to trust a student or a resident to be able to do things with patients, even though I’m ultimately responsible, that I give them more and more freedom in a sense to be able to do things because I’m trusting them that they can do them well and that they won’t harm the patient. And there’s various ways in which people look at this in terms of, do I need to be in the room with the student or the resident? And if it’s a surgical thing, do I actually watch everything, or do I kind of be at a distance? So how do you feel about this entrustment model? Is this something that you believe is sort of the future as far as our relationship with our students and residents?

Robert Shochet: Yes, absolutely. I do believe in the entrustment model. And you know, I think it’s as challenging for the teacher as it is for the student or trainee to maintain the appropriate level of tension between autonomy and supervision. And but that’s part of the art of teaching, I think.

David Sklar: And one of the issues with entrustment, I know that most of the emphasis has been, can I trust the student or the resident to do certain things independently? But then we also have to have them trust us. And not all faculty are necessarily trustworthy as we know that there are, have been experiences of faculty members being abusive. You know, either saying things, doing things physically, mentally, and many, many of our students feel somewhat mistreated at times. So how do you address that particular problem? Because I think it is a problem, unfortunately, in medical education.

Robert Shochet: You know, I’m a big believer that educational systems are really deliberately developmental for both teachers and for students. And teachers develop over time. I’m a big Parker Palmer fan and the way he would talk about courage in teaching would really, what he really meant was being able to open yourself up as a teacher to be transparent and show your inner workings to the student. And that requires genuineness and honesty and humility. And then, I think the other thing that truly helps build trust is being learner-centered, really being able to understand the learner from their perspective and working in the best interests of the students.

David Sklar: Well, thank you very much, Rob. Sir. I think this has been a very rich conversation and thanks for explaining to all of us about your program. It really sounds wonderful.

Robert Shochet: Thank you very much, David. I’ve enjoyed it.

Narrator: Visit buildingtrust.org to learn more.

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Narrator: The ABIM foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Brian Park, a physician and professor and Richard Frankel, a professor of medicine focused on efforts to build trust through relational leadership.

Brian Park: Rich, it’s great to meet you. So I’m Brian Park. I’m an assistant professor at the Oregon Health & Science University in Portland, Oregon. I’m also the director and co-founder of the Relational Leadership Institute at OHSU as well. It’s great to meet you.

Rich Frankel: It’s great to meet you too, Brian. So I’m Rich Frankel. I’m a professor of medicine at Indiana University School of Medicine and a senior researcher at the Regenstrief Institute, which is part of the school of medicine. And I am the director of the A SPIRE Fellowship program. A SPIRE stands for the Advanced Scholars Program for Internists in Research and Education.

Brian Park: Wonderful.

Rich Frankel: Yeah. Great. So what a great opportunity having read your challenge essay and I wanted to start by asking you, how did you get interested in the Relational Institute?

Brian Park: Yeah, absolutely. Well, you know, before I started medical school, my prior career was actually in filmmaking. I wanted to be a screenwriter. And the way that my brain always works was through stories. And so I had moved up to New York City to be a filmmaker because that’s what I thought that you did to be a filmmaker. And you know, the freelancing life was just not fit for me. So I was looking for other jobs and happened to stumble backwards into a job at a diabetes clinic in Harlem, New York City. And I absolutely fell in love with that work and I fell in love with that community cause I learned so much about the ways that social determines of health impacts health and how I learned all of those lessons were through the stories that I heard from patients, their families, community members. And I got a funny notion in my head of, oh, this is what medicine is. I’ll apply to medical school. Very quickly within my first semester of medical school, I remember, I think, I was thinking to myself, I have made a huge mistake. I felt completely like a fish out of water in medical school. And everything that I’d learned about narratives were gone.

And I remember I got together with my mentor in internal medicine at that point, Dr. John Song. And he had sat down with me just to catch up over lunch. And he had said, you know, Brian, you can do anything in healthcare. There’s clinical medicine, education, research, advocacy, whatever you want. And I remember that was just this really enabling moment for me where I felt like I really could do whatever I want to. So that started my journey of seeking out my true north. And I think for me, that was really the intersection of narratives and health equity. And so that’s really been what my career has been focused on.

And so the Relational Leadership Institute really started for me when I saw that there was, the kinds of leadership models I was being exposed to in medical school as a resident in family medicine, they were really limited. There were a lot about the executive leadership skills of leaders. And those things were really, really important. But as I thought about the best mentors, the best leaders in my life, like this mentor I mentioned to you, Dr. Song, I mean certainly there were master strategists and skill builders and at the same time, they understood the relational components of leadership so well. And I remember at that moment in residency, I got really interested in the literature of what makes a good leader in healthcare. What makes a healthy team in healthcare? And the evidence very quickly shows that the most effective leaders and not just healthcare but cross all industries, what they do very well are not just the what and the how of changed the technical skills of change. But what I like to think of is that the who and the why of change, these relational components that really enables a team promotes psychological safety.

So that was kind of an aha moment in my own trajectory. And I said, this is a gap in leadership training in healthcare that I have not been getting. So maybe we try to fill that gap. And I was really fortunate. I had so many partners at OHSU who are wanting to work with me in that work and build a community around that. And that’s how the journey began.

Rich Frankel: That’s wonderful. Yeah. Yeah. Brian, could you talk a little bit about the mechanics of the institute? What are the elements that go into it?

Brian Park: Absolutely. So the Relational Leadership Institute or RLI’s a three-month leadership learning collaborative where we’re really trying to help participants rec-enter psychological safety, trust and relationships and health care. And we do that by delivering through a hybrid learning model when we’re doing large group didactic, small group practice skills and having people do homework or we call it work-work, little activities that they can practice back at their place of work. Just these little ways of inculcating into their way of being an existing on a team, characteristics of high performing teams, things like shared power, growth mindset, psychological safety. And we’ve been blown away. We’ve had four cohorts now and we’ve had amazing evaluation results. 100% of our participants reporting that they have learned things that have helped them in their work, seen significant improvements on wellbeing scores, a sense of community score as well, and relational skill competencies as well. So it’s really great to see that we’re making an impact for this program.

Rich Frankel: So tell me about the growth of the program and where it stands right now.

Brian Park: Sure. When we started in 2016, we launched as really a grassroots movement at OHSU, just a small group of us really interested in relational leadership. And through word of mouth, we had 18 participants of folks who are just really interested in relational leadership and we jumped in thinking this could fall flat on its face or it could, it could work, and we’ll see where it goes. And that first cohort was such an amazing experience, you know, so many people sharing with us. One participant shared with us in the very last session, I’ve been waiting my whole career for a community like this. And so when we got those kinds of evaluations back, we felt a responsibility to keep it going. So it’s almost been, you know, with my other background has been in community organizing and really building that community and building a mini social movement at OHSU around the importance of relationships.

Yeah, it’s just been a tremendous way to just continue building more and more interest around that work to the point that we’re now about to launch our fifth cohort and we’ve had over a hundred participants go through our lives and experience. And we’re just on the brink of this fall of expanding to the University of North Carolina, Chapel Hill and University of Utah as well. So we’re in this really fortunate position where I think that the demand is outstripping our supply. So we’re really wrapping our minds around that.

So yeah, we’re in a good spot. But you know, I’m really excited to sit down with you because I think one of the eternal challenges that I felt ever since that I’ve been in healthcare and medical school and a lot of that I’ve made a huge mistake feeling for me was that feeling that I had a recognition that so much of us, we get into a career in medicine because we feel as though humanism and compassion for our patients and community is so critical. But immediately, I remember my first semester of medical school, I felt that that didn’t always exist amongst physicians or in the care team, that trust between medical student and attending physician, between physician and physician. Has that been your experience and how do you feel as though we start chipping away that? How do you rebuild trust, not just between physician and patient, but between physician and physician within that care team?

 

Rich Frankel: Well, as you know, the part of the trust challenge involves the question of physicians’ trust of one another. And interestingly enough, there’s virtually no literature on this topic. There’s lots about physicians and nurses, physicians and patients, physicians and administrators. But when we did a literature search, we came up with almost nothing on physicians’ trust of one another. So that was sort of a touchpoint for us in terms of trying to figure out why isn’t there a literature on this topic. And so we started to elicit stories from colleagues last year. We elicited a number of stories from colleagues here and we heard a lot about the lack of trust that some physicians are experiencing. And we believe that that relates to lack of… to burn out and lack of resilience. And I prefer the term ‘resilience’ to ‘burnout’ because resilience is, I’m sure you would agree, is a more positive term. It’s something that you can move toward. Whereas burnout has this negative connotation, negative connotation to it.

So I started my career in 1979 in Wayne State University. And there was a very unfortunate incident in which a third year resident was treating an elderly African American woman who was dying of pancreatic cancer. And unbeknownst to others, this resident’s father was dying of pancreatic cancer in Arizona. And against the protests of the medical residents, attending nurses who were there, this person drew a bolus of potassium chloride, injected the patient and killed her. And the residents had gone to the department chair asking to start a resident support group. And the chair who was a very wise man but didn’t see much value in resident support, said, I don’t think we need it.

After this unfortunate incident, and after we interviewed people, all of whom said we knew something was wrong, but there was no mechanism for getting the information to people who could have intervened. The chair reversed himself and said, I think we need resident support groups. So for 12 years at Wayne State and then another 11 years at the University of Rochester, I ran a resident support group and tried to create the context in which there were safe space for people to talk about what was troubling them. And I think that’s one of the places where trust can be built, creating a space where people can speak from the heart as well as from the mind.

And I remember one resident who had injected a patient, was doing a femoral stick and got an artery instead of a vein, injected the patient and the patient died. So she came into the residence support group and it was clear she was distressed. And when she was asked, she said, you know, 36 hours ago, I killed a patient and I haven’t been able to sleep. And I’m questioning whether medicine is the right profession for me. And she was just, she was distraught. And so spontaneously and without any prompting, each of the 18 residents who were in the room at that meeting started to tell stories about the mistakes that they had made. And it all came right from the heart and none were as serious as killing a patient, but they spoke to how it felt to make a mistake and how it felt for them to, you know, having made a commitment to do no harm, that they had done harm. And at the end of the group, I turned to the resident, I said, is there anything that you need or want from the group? And she paused and she said, I sure could use a hug. And 18 people got up and there was a group hug.

Brian Park: Wow.

Rich Frankel: 20 seconds, maybe. The next week, she was at the resident support group. And people ask, so how’s it going? And she said, well, you know, I went home, and I slept for 14 hours straight and I woke up feeling refreshed and knowing that I had right made the right choice to go into medicine. I think that’s the ultimate kind of trust that we can build in the profession where people can reveal their vulnerabilities and share their vulnerabilities and be stronger, not weaker as a result of doing that. And so, you know, we hear a lot about the negatives where people distrust one another, but as we were talking about a little earlier, I think there’s great reason for optimism. I think the young people who are going into medicine these days are hungry for this kind of connection, this kind of relationship. And in order to give trust to others, you have to receive trust yourself. And unfortunately, the medical education system has an exactly operated to bestowed trust on young physicians and in training.

 

Brian Park: Yeah. I just loved the story that you shared because of what the emphasizes to me is that trust is—I mean, we heard earlier today trust is a bi-directional street, but trust is a structural issue in the culture of medicine and even languages around resiliency, I sometimes resist it because it places the onus on the individual. Whereas I think what your story beautifully articulated to me is that it’s really about a community that changes. And as I think about the work that we’ve done at the Relational Leadership Institute, as you said, people are hungry for community. It’s as though, you know, people come back to our program, not only because of the content and the skills, but I think once you find likeminded people with a shared vision, it’s hard for people to unsee that or to unfeel that feeling. It’s like they carry that with them everywhere.

And I remember so many folks have shared with us that they just stick around because it’s the only place in medicine where they can get that feeling again. And I’m curious about how do we get more and more people to feel that feeling. You know, we can tell people to meditate or do yoga or to find structural interventions around spending less time around the EHR. But there’s this whole gap in this conversation around how do we share these stories where we’re being honest and vulnerable about all the mistakes that all of us have made. Where we have these proverbial group hugs that you’ve outlined for us. I’m curious about that. How do we do that more?

Rich Frankel: So from a structural point of view, we can start with entry into medical school. Who are we selecting to go into medical school? We’re selecting people who have great content knowledge and great content understanding. We don’t put as much emphasis on the relational aspect of what they’re capable of or what they already have. So I think that’s, you know, that’s one place. I think these are skills that can be taught, learned, and put into practice. And you know, there’s a lot of concern about intergenerational differences.

Brian Park: Yes.

Rich Frankel: And here we are two people from two different generations talking about trust, which spans generations. And so I think that looking for those places in which we’re more alike than different is another great way of inviting people in and not just saying, well, you’re a young person. You don’t know what it’s like on the wards. I’m an old person, I’m an old pro. Well, let’s put that aside and say, what do we have in common?

Brian Park: Absolutely.

Rich Frankel: What we have in common is our humanity and our love of the work that we do.

Brian Park: Yeah. I think we’re kindred spirits in that way and that you just said, I believe that this can be taught, these relational components can be taught. I so believe that. You know, I mean, that’s the crux of the work that you and I are both doing. And I’m always reminded of how, you know, ultimately, when we take our white coats and our stethoscopes off, we’re humans just like everyone else. And as social creatures, we’re all hardwired for connection and community and seeking out what connects all of us. And I think the conversation you and I are having in the work that we both do; we continually return to that. Well, and it’s almost like how do we help other people to jump into that with us too.

Rich Frankel: So overall, it sounds like the people in your program feel like there are better doctors, better healthcare professionals for being involved in RLI. How about you? Do you feel like you’re a better doctor for leading this program?

Brian Park: That’s a great question. I feel like a better doctor and I think the ways that I know that are that when I go to work, I don’t feel this boundary between my professional identity and my personal identity, my values underlying both of of those identities are present and the same. And so I feel like I can, I had the fortune of showing up to work every day being who I am without these alternate notions of what it means to be a physician or provider. I think that’s the joy that I get to find in my own work.

Rich Frankel: And that’s a wonderful description where the mask of professionalism and everyday life sort of drop away. And you’re the same person in the exam room as you are in the lunchroom or at home.

Brian Park: Absolutely. Yeah.

Rich Frankel: Great.

Brian Park: Yeah. Well, thank you so much for talking with me, Rich.

Rich Frankel: Yeah. The pleasure is all mine. Thank you. Keep up the great work that you’re doing as well. Thanks for everything you’ve done. So we’d never met face to face before, but I feel like if the camera could catch it, I’d love to give you a hug.

Brian Park: Oh, that’d be awesome. That’d be great.

Rich Frankel: Why don’t we do it?

Brian Park: That’s great.

Narrator: Visit buildingtrust.org to learn more.

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Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Anton Zuiker, a communications director and Dana Safran, a data scientist, focused on efforts to build trust through storytelling.

Dana Safran: Hi, Anton. I’m Dana Safran. It’s great to get the chance to talk to you this afternoon. Just by way of background, I’m Head of Measurement at Haven, which is a fairly newly formed joint venture of Amazon, Berkshire Hathaway and JPMorgan Chase. And my background is in measurement science. I’ve been doing that work for many years, first in academia, then at Blue Cross Massachusetts and now most recently at Haven. And how about you?

Anton Zuiker: Dana, thanks. It’s great to see you. Anton Zuiker. I am the communications director for the Duke University Department of Medicine. I’m a journalist, medical journalist by training. And I’m very interested in stories. I’m actually coming to the end of my decade of narrative in which I’m trying to become a better storyteller and listener. And so it’s been great to meet you and tell you about some of our work.

Dana Safran: So we’re here today to talk about trust and I know you have been doing some very interesting work at Duke on trust and wonder if you could just tell me a little bit about what you’re doing, having clinicians and patients talk about trust and then sharing that out. Tell me a little bit about that work.

Anton Zuiker: Sure. I mentioned I’m a journalist, a communicator. That means I have the luxury in some ways of time, which is an interesting commodity in a hospital. I sit at a desk, at a computer. I also have the opportunity to wander the hallways and talk to people and listen to stories. I have long wanted to find a way to give patients and their families a way to record their life histories, their oral histories to pass on their knowledge. I see patients sitting in the hospital often for hours at a time, sometimes for days and weeks at a time. So we started with this idea of how could we allow our patients and their family members and our visitors an opportunity to tell their loved ones about each other, by extension to tell us the clinicians, the providers that educators at Duke University. This is informed by many other examples. StoryCorps is the most popular. People love the StoryCorps, stories that they hear on a national public radio on Fridays. Of course, oral history and talking story, we called it in Hawaii or story on in Vanuatu where I was a peace corps volunteer is a common thing of sitting what we’re doing right now, talking to each other and seeing each other and feeling that the emotion or seeing what brings joy to someone.

So that’s the basis of this. Realizing that I have the time of how could I and my colleagues design a program to give people a chance to talk. Now, I’ve done some reading including some of your own research about time for healthcare providers is a very different thing. There’s not enough of it, as they’re working in electronic medical records or they’re rushing from one patient to another. And so we also tried to take this concept of a listening booth, physical space, kind of like in this room that we’re in, to set it up with some nice microphones and to invite people to take some time to have a conversation and to listen. So interestingly, we didn’t approach it with trust in mind. Trust is a byproduct of listening and I’m wondering what your research, what your work tells us about that. Your paper talks about there is optimism.

Dana Safran: Yeah. So that’s an interesting point. And you’re so right that trust can very much be a byproduct of listening or a mistrust, the absence of it. So I find what you’re doing so interesting because the opportunity for human beings to really hear each other and for a person to feel known, I think, is part of what helps to generate trust. In the research that I was involved with, not just before my current role at Haven, but before my role that proceeded that at Blue Cross Massachusetts, when I was prior to that in academia, and really studying trust and trying to measure patient trust and understand how it’s formed and what outcomes it helps to generate, both as we called it business outcomes, like loyalty to a practice or malpractice risk, reduction of malpractices or health outcomes, adherence to clinical advice and improved health and wellbeing.

And what we learned was that there was a tremendous interconnection with patients feeling known, what we called in my work, whole person care, and tried to measure that sense of whole person care, communication and trust. So all those are relational aspects of care or just of human interactions in general can really contribute to trust. And we definitely saw that trust and a sense of being known a whole person orientation to care contributed to all the outcomes that each of us wants out of the system. Clinicians want it, patients want it, payers want it. Employers who are buying insurance on behalf of their employees want it. And that is, you know, better health, better adherence to clinical advice, a good care experience, all of those things.

Anton Zuiker: Can you tell me more about that about being known? Our approach is to set up a conversation among two people and to record it. And if they consent too, then share that recording is a podcast that anyone can listen to and learn and be inspired by. And what we’ve seen is that people at Duke who have listened to that then have some, larger or more informed idea of who that those people were. Is that what you mean by being known?

Dana Safran: It is. And let me come back to that and try to answer it for you but let me understand a little better. Cause what you’re doing I think sounds so important. And I want to understand it and have our listeners understand it. So tell me a little bit more about who’s listening and who’s speaking. So first, is it patients and families alone or also clinicians and others who work in at Duke who sit in the listening booth and share their stories. And then tell me a little bit more about how those stories get heard.

Anton Zuiker: Our listening booth project was a pilot project and we decided to focus on our workforce. Wellbeing, burnout, resiliency, very important issues at Duke University Medical Center, and others, I think. We focused on our workforce. We invited them to come in in pairs or threes or fours. People who knew each other, had some connection in some way, to come into our booth, our space, and to have a conversation of their choice, of their questions. And so that was the primary reason, to give someone a space and time to have that conversation by recording it and then creating a podcast episode that’s available online or on a phone to anyone in the world. Ours is publicly available. It allows other people to hear that conversation. Those conversations show vulnerability, show gratitude, show how people find support from their colleagues at work and how they find pain in losing loved ones.

So our pilot project was satisfying to us all, to the people who had those conversations because it feels good to talk and to be listened to. It was satisfying for people who listen to the podcast who knew Dr Tony Galanos but didn’t maybe know that he had lost his adult son recently. And maybe that helped them understand why he was grieving at work. What we found from Twitter and social media is that people who had no connection to Duke or to these doctors or patients who told their stories also felt grateful for them having told their story and shared it through a podcast.

Dana Safran: That’s a really remarkable thing that you’ve done because, you know, I think part of what we wrote about in terms of patients trust in organizations and also organizations trust in patients and how that needs to be rebuilt. In the end, it comes down to just the very essence of what you’re trying to do, which is have individuals really understand that there’s a shared human experience. And so the idea that clinicians have gone first and told their stories is so interesting to me because I think, you know, as much as, you know, consumerism is trying to take hold in healthcare, there is still a great respect and admiration and kind of emotional distance often between patients and the clinicians taking care of them, and the opportunity for patients to perhaps hear the story of clinicians and understand them as human beings, I think, could go a long way to building trust or rebuilding trust to the extent that there’s been some loss of trust between patients in the organizations and people that take care of them. I’m curious if you think so.

Anton Zuiker: I do. I work as a communications director in the Department of Medicine and it has 750 faculty members. And so I get to learn about them and to know them and to ask them questions about not just their research careers or their clinical work, but also their personal lives. And I think in little by little trying to say in many ways, it’s okay to share your story of who you are because when I’m a patient and I walk in, I want to find a connection. You talked about finding the interconnections in research and in relationships. Interestingly, when I looked at your professional bio, I saw that you had worked for Blue Cross Blue Shield and I saw a connection cause my first job out of college was for Blue Cross Blue Shield of Hawaii. And I then eventually worked for Measure Evaluation, which is a global health monitoring and evaluation program. And so even though I’m a journalist, I go by stories and words. I’m fascinated by the empirical, the numbers, the research that you bring to this. And I guess that’s my selfish question for this interview is how can I use that to make my project better? How can we measure, try to measure trust better, measure listening better, in order to build trust, not just a [indiscernible] [12:01]?

Dana Safran: Well, I think that the way that you measure trust is by asking people questions. And you know, when I was in the business of trying to measure patient trust in the physicians taking care of them, I conceived it as having three main ingredients. That a patient had to believe in the clinician’s knowledge and expertise. They had to believe in the clinician’s ability to use that on their behalf. And they had to believe in the clinician’s desire to use it on their behalf as opposed to use it on behalf of their organization or on behalf of themselves. So a kind of fiduciary trust. And so we designed questions to try to tap into whether individuals had each of those points of view about the people taking care of them. So I don’t know how well you feel that that framework might map onto the work that you’re doing, but perhaps it does. And if it does, then maybe you could be asking individuals those questions about their relationships with each other.

Anton Zuiker: Yes, thank you. I can, I can apply that.

Dana Safran: Yeah. Oh, great. Great. Well, one of the other things that, you know, your comments spark in me is that you talked about my work in measurement and you know, there’s a really important aspect of trust and measurement too. Because I think that, you know, when I began the work that I was doing in measurement, it was largely for academic uses. You know, quality measurement was not something that was applied in anything really other than academic studies. And now of course, they’re very high stakes uses of quality measures, and a tremendous amount of mistrust sometimes of the data, sometimes of the measures, sometimes of those who are using the measures in ways that clinicians or organizations are afraid of or suspicious of or just plain feel is wrong.

And so in the work that I’ve done, you know, going on 30 years now, I really recognized that we not only want to measure trust in the relationships, but we want to have the measures themselves and the ways that we use those measures be trusted to. And that’s a critical part of what I think has to continue to happen as we make healthcare better, as we strive to, you know, produce better outcomes for patients, better experience, lower costs. We have to use measures. But we have to do that in ways that the stakeholders feel are fair and accurate and using data and information in ways that advance the shared goals and not in ways that are punitive or unfair.

Anton Zuiker: This has been fascinating. I’m wondering if there’s a way to have a voices of Duke health conversation about measurement of trust that would be compelling and informative and inspiring. You’ve given me some things to think about and to take back to our project for our next phase.

Dana Safran: Oh, that’s great. That’s exciting. I have a question too. Do you expect that in the next phase—it sounded when we began that part of your vision is that patients will tell their stories and maybe caregivers will tell their stories. Is it part of your vision that the actual clinicians taking care of those patients hear those stories so as to know the patients better without the patients telling them directly? Or is it more, you know, just broadly that you want human beings in the patient role and in the clinician role to hear stories of others and know them?

Anton Zuiker: That’s a really good question. I’m informed in part by a project that’s happened across a number of VA medical centers in which they actually do record an hour long oral history of a patient and put that into the medical record with the idea that the clinician does listen in whole or in part to that oral history before then walking into the exam room to have that that professional encounter. So yes, I think that’s part of it. Part of it would be to have a bank, a voice bank, in some way, that providers would listen and know more about their patients. And conversely, that patients would be able to know a little bit more about the nurse or the doctor or the PA that they’re about to see when they go for their appointment.

Dana Safran: That’s a wonderful idea because it comes back full cycle to where we started this conversation. And the fact of feeling known is so important to human beings. And knowing another, I think can’t help but draw forth empathy because you start to understand that shared human experience. So I’m really excited about what you’re doing and the opportunity that it could go a long way to creating a foundation of trust, both clinicians and patients and patients in the people taking care of them.

Anton Zuiker: Thank you. Well, this has been a really good conversation. I’ve enjoyed it. I’ve inspired to it, to take some of the research and make our project better and to tell the story of measuring of trust of the work you’re doing.

Dana Safran: Thank you so much. Thanks for sharing your work.

Anton Zuiker: Sure.

Narrator: Visit buildingtrust.org to learn more.

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Transcript

Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Lolita Alkureishi, MD, a physician and Gwen Darien, a patient advocate, focused on efforts to build trust by empowering patients.

Lolita Alkureishi: Well, my name is Lolita Alkureishi. I’m an associate professor at the University of Chicago. And I’m a pediatrician.

Gwen Darien: That’s great. My name is Gwen Darien, and I lead patient advocacy and engagement for the Patient Advocate Foundation and the National Patient Advocate Foundation. And I am a long-term patient advocate and a three time cancer survivor. So I have multiple lenses and I have multiple questions to ask you about your really kind of incredible work.

Lolita Alkureishi: Cool. I’m excited.

Gwen Darien: So I wanted to start out with just exploring a couple of two theme or this sort of theme that I think is the overall theme that you’ve talked about, which is the way of using an HER (Electronic Health Record) to build, facilitate communication and to build trust. Because I think that’s sort of the heart of what you’re doing here. And so this is the foundation of the story and this is the foundation of what you’re doing. And so if we could just start there, that would be great.

Lolita Alkureishi: Yeah. So you know, the way that I came about making this comic was when our clinics went live with the EHR and it was a process and, you know, I got to be IT flying the wall, you know, just watching patient interactions. I was trained as a super user. And so I was in the room as my colleagues were seeing their patients and I was able to witness firsthand how this thing was really changing that dynamic and not in a good way. And it’s really what inspired us to look at, you know, what are the ways that the computer or the EHR impacts that patient experience on both ends and not just the behaviors and the nonverbal communication and the verbal company communication, even though that’s super important, but how does it impact it from the perspective of the patient? What do they think? And that really helped us identify the things that we wanted to stay away from and then the things that actually helped, ways that you could promote. The engagement, promote shared decision making, really make it a collaborative tool that could be used together. And that was kind of the birth seed of it all for us.

Gwen Darien: Because I think that, I don’t think I’ve ever heard anybody say that an EHR could be a way to facilitate, build trust. We usually think of it as the barrier to trust and barrier, the distancing and the mediator to communication. So that was really—that’s fascinating about this project.

Lolita Alkureishi: Yeah. And we called it the positive deviance. So when we did our literature review and we found all these studies, there was a small core group of studies that had these positives and it was exactly that. The using shared decision making tools real time with the patient so that, you know, you’re reviewing stuff and what do you think. And just really fabulous little examples but not many, because so much of, you know, what you see is ah, it’s so burdensome and so many clicks and you know, just the weight of charting and all that and it’s all very negative. But there are these little positive areas that I think are inspiring. And as much as we can capitalize on those and not be weighed down by the negativity, I think that that’s one, that’s interesting—ways that it’s not just the EHR. Like you have a computer with internet, use it, capitalize on it. I tell our medical students build your tech toolkit of tools, websites, apps. This is my go-to handout. Like just think creatively. If you were in the other chair, what would you want? What would help you understand what’s going on? Tap into that and just build your resource kit.

Gwen Darien: I think it also speaks to sort of the difference in the way that people interact with their doctors. And then they used to, in their healthcare providers and doctors and advanced practice nurses. And I mean, a long time ago, you expected your doctor to know everything and if they didn’t know everything, you didn’t trust them. Now I have to say, so I had an interaction with my oncologist, and she said to me, and she’s highly trained, I love her. And she said to me, let me just make sure, let me just make sure that the guidelines haven’t changed for this drug I wanted to give you. So rather than 20 years ago, I would’ve said, oh my God, you don’t know anything. I need a new doctor. I was saying, wow, she is a really careful doctor. She’s using the EHR and she’s using the internet. So this idea of what we can learn from the internet has also changed what practice has been. And I think that’s another really fast, that’s another really interesting part of this project was this idea of using the internet.

Lolita Alkureishi: Yeah. And it’s almost like, you know, we’re in this together, let’s journey together, let’s figure it out together. And that’s the whole thing about, you know, sharing the screen. Let me bring you with, let’s send this prescription together. Like this is your chart, so you should, you should own it. You should feel like you can get involved. And that discussion doesn’t have to stop when that clinic visit is done, let me tell you about the portal and you can access your entire care team. That conversation, that dialogue can extend beyond, you know, the 15 minutes in the confines of that room. So yeah, I think it’s really almost like a gateway to let’s create your chart together. Let’s come up with the answer together and it feels less heavy, I think. It’s I’m not doing this alone. You’re not doing it alone. We’re kind of doing it together. So let’s do it.

Gwen Darien: Yeah. So let’s hold that thought one second and then step back to do this the context a little bit around it. Because I think one of the things, I was really struck by the conversation about sort of hold it, what is it honoring the golden moment?

Lolita Alkureishi: Yes.

Gwen Darien: Because I think that one of the ways, I think that people sort of jump to the middle of the conversation often in this. So many of us and many patients, and you may have had this experience of patients, is that the physician doesn’t come in and talk to you. They immediately look at there, they immediately look at the computer screen and then turn to you. And so one of the things that I think was so successful about the way that you presented this, and then I want to talk about the comic and some of the other aspects of it, was that you put it in the context of the whole visit so that you, there were ways of setting it up so it didn’t feel like a barrier. It felt like a tool.

Lolita Alkureishi: Yes. Yeah. And so exactly, honor the golden minute. So when you walk into the room, even though you know you need to log on, don’t make that the first thing you engage with because that tells you, oh yeah, you’re there, but I need to focus on this. This thing has my attention and it has it over you.

Gwen Darien: It’s more important than you.

Lolita Alkureishi: Yes, it has it over you. And just physically, the act of like the first touch is so important in medicine, the physical act that you touch that first and you don’t touch your patient is just so wrong.

 

Gwen Darien: That’s a critical point.

Lolita Alkureishi: It’s so important. And you know, I can pull up your chart and in fact, I should’ve reviewed it beforehand so I can kind of set the stage. I can figure out, you know, why I think you’re there. But let me open that up to you. You tell me why you’re here. What can I do for you? And then exactly, like you said, when it’s the right time to bring it into the conversation, then you do so naturally and you don’t, and you don’t let it dictate the conversation. You guys determine the conversation and then you pull this in when you think it can enhance it.

Gwen Darien: So that’s what you mean my patient centered EHR use.

Lolita Alkureishi: Yes. Yeah. Finding a way that you could use it that’s unique to each patient. Some patients might not want to engage with it and that’s okay. And some may, what is that? What are you clicking there? And some people may be overly interested in it. Gauging that and then using it to provide them their specific education, making it specific to them, honoring their values, their wishes, but HER patient centered care that allows them that opportunity.

Gwen Darien: So let’s talk about how you came to do this comic and it’s a way of helping to create this really more patient centered way of using an EHR.

Lolita Alkureishi: Yeah. So this is the comic that we created. And it’s called computers in the clinic, your role. And so we set it up ABC format, super simple, super easy. A, ask to see the screen. And so there’s an example of where the provider isn’t doing that. And then another one where they are doing it. B is become involved. So review your records with your doctor that you can ask questions and then C is my personal favorite. And that’s call for attention. If you feel you have something important to discuss, if you feel like the provider’s too focused on the computer and isn’t paying attention, you can wave your hand and say, hey, redirect back to me. So yeah, and it’s colorful, it’s visual, it’s fun.

Gwen Darien: And it’s available to anybody.

Lolita Alkureishi: It is. Freely available to anybody that wants to use it. They’re cool.

Gwen Darien: They are cool.

Lolita Alkureishi: They’re very neat. In fact, when we were passing them out, like as part of this study, people were like, what’s that? I didn’t get one. Let me see that. And the kids loved them. And so it’s fun. It’s engaging. It doesn’t take a lot to explain it. In fact, we didn’t explain it. We just gave it to them. So in terms of the resources to implement something like that, they’re really minimal. It can convey your message really clearly. And it’s a narrative which I like because it’s all building the narrative. It’s a story to let you tell your story. And we have a diverse patient population, so we needed something that could appeal to, you know, somebody that had a PhD and somebody that didn’t finish high school and everything in between. So it was a cool, fun kind of vehicle that we could do that. And we created not just the patient comic, but we created one for providers

Gwen Darien: Yeah, that’s what I was gonna ask you to that. So you created the two of them.

Lolita Alkureishi: Yeah. So the provider one, the title of it is ‘Which Would You Prefer?’ And on one side, it gives a not ideal way of using the computer with a patient. And then on the other panel, it shows you a more ideal way. And it’s the same as this comic. It’s three different core kind of behaviors that we found both through our own experience and in the literature. And we put the comic up in their workspaces. So where they were charting, there was a big one on the door. You see it when you go in, you see it when you come out. Because even though we had built, you know, curriculum to train providers and we did this big like four-hour CME thing with the Cleveland Clinic, we did standardized patients and that is very intensive. And the people that were coming to the training were already really good communicators. They were just, you know, up and get to the next level. And the people that we weren’t able to get was the busy doctor that’s in the room, that’s charting. And so we thought, well, let’s just put them up in their workspaces and don’t even have to explain it. It’s right there. And it’s just a little primer to say, you know what, when you walk in the room, just think about the person on the other side, which would you prefer? How would you like it?

Gwen Darien: Right. And because all doctors or patients at some point or another.

Lolita Alkureishi: We all are patients.

Gwen Darien: Everybody.

Lolita Alkureishi: We all are. And our husband is a patient and our kids are patients and yes, the shoe will be on the other foot.

Gwen Darien: So tell me a little bit, one of the things that was really interesting I that to me was the… how this seemed to close the gap even more from patients who were in traditionally underserved populations.

Lolita Alkureishi: Yeah. So that finding that in persons that were of minority ethnicity, so African-American, Hispanic patients, found the comic more empowering. It encouraged them to get involved more. They actually took steps to get involved. Self-advocacy things like if the provider was paying too much attention to the computer, it gave them more than our white patients kind of the courage and the authority to do so, to say, hey, I’m over here. Can we focus this back on me? Or asking, can I see that? Can I see this in my chart? And same goes for patients that had lower educational attainment, that they were more likely to take part in these, I call them EHR self-advocacy behaviors. I think probably because these populations, not just in medicine but in life, have made me not had that kind of opportunity. They didn’t know it’s their right. As compared to other populations. So maybe these are more vulnerable, more marginalized populations. And you know, I personally don’t maybe necessarily need the comic because I know that’s my right. I could do that. That’s my chart. I can get involved. But if I don’t, I haven’t been invited to this discussion, this conversation, this is almost like the invitation to say like, no, this is your right. It’s everybody’s right. Let’s engage together.

Gwen Darien: So I think that it is, I mean, one of the things that we were talking that we’ve been thinking about and talking about is this notion of power differential. So it sounds like the comic helped equalize the power differential and gave the patients, particularly the underserved patients, a sense of what their power was in this relationship.

 

Lolita Alkureishi: Yeah. Yeah. And I think what really speaks to that were some of the open ended comments that we got from patients that really got at the core of it. It wasn’t so much the computer, but one of the most striking comments was somebody said, I really liked the comic because I didn’t know I could ask questions. Which is like what? You didn’t know you could ask. Of course, you can ask. This goes beyond the EHR and the internet and this is like at the core. Of course, this is a partnership and if you don’t trust in that, if you don’t think you can ask questions like we’re not going to get anywhere.

Gwen Darien: But I think many patients don’t think they can ask questions and they aren’t invited to ask questions. So I think this was the other thing that I found really pretty, really kind of very progressive and groundbreaking about this is that it really facilitated that notion of being able to ask questions. Cause I don’t think it’s just traditionally underserved population. I think it’s the difference of being in a gown in the doctor’s room. I mean, it doesn’t matter, your self-advocacy skills fly out the window no matter who you are. But this idea that you were given this sense of the doctor and your healthcare provider in the system trusted you enough to give you the permission to ask the questions and see the screen. That’s a really powerful thing to see because I don’t think we’re not used to that. We’re not used to seeing the screen. We’re not used to somebody showing us our chart. That stays away from us. It doesn’t come towards us. And I love that idea of this kind of triangle and this space of being able to, being able to really ask questions and not just being given permission to ask questions, but being encouraged, being told you’re a partner, that you’re not just a subject or an object. So this is really, this is really great. I mean, and it’s also so simple. That’s the other thing.

Lolita Alkureishi: It’s so simple.

Gwen Darien: I mean, it’s just incredible. It’s so simple.

Lolita Alkureishi: It’s what your grandmother would tell you. It’s what your mom would tell you. It’s like, you know, use this as a positive. When it’s not the right time, don’t use it and use it with me. Because it’s ultimately their chart. In fact, we should be asking permission.

Gwen Darien: Right.

Lolita Alkureishi: Can I open up your medical chart? Can we cocreate your narrative together?

Gwen Darien: Right. So what’s next?

Lolita Alkureishi: So we’re looking at ways that we can try and scale this up so that it’s not just, you know, in certain departments, but that it’s part of our message. This is who we are. This is how we’re going to involve you, and this is what you can do to kind of get engaged in that process. This is a relationship.

Gwen Darien: And do you think of it beyond the EHR? I mean, the EHR was the impetus for this and the Genesis of this, but it seems like it is potentially a blueprint for other….

Lolita Alkureishi: Yeah, yeah, yeah, for sure. And at the heart of it all, it’s trust.

Gwen Darien: Yes. All right. Lolita, thank you for such an incredible conversation that was really, I look forward to seeing how you’re going to use this. I look forward to seeing how you’re going to scale it and I look forward to the fact that these simple solutions can make a really profound change and trust and communication. So thank you so much.

Lolita Alkureishi: Thanks so much for having me.

Narrator: Visit buildingtrust.org to learn more.