Tag: Building Trust

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.

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

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

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

Advancing Trust at the Organizational Level

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

Advancing Trust at the Clinician Level

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

Advancing Trust at the Patient and Community Level

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Organizations receiving grant funding include:

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

*Awarded two grants.

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

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

About the ABIM Foundation  

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

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

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

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.   

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

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

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

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

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

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

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

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

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

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

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.