59% of U.S. adults say health care system discriminates at least “somewhat,” negatively affecting trust
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.
Poll: Physicians’ trust In health system leadership declines during COVID-19 pandemic
ABIM Foundation leads effort on “Building Trust” among health care stakeholders
Significant gaps in how physicians and patients view trust
New research shows a significant decline in physicians’ trust in leaders of health care systems during the COVID-19 pandemic, and notable differences between how physicians and the public perceive trust in U.S. health care. The research was conducted for the American Board of Internal Medicine Foundation by NORC at the University of Chicago.
The ABIM Foundation released the research to coincide with the launch of Building Trust, a national effort that focuses on increasing trust among health care stakeholders, including patients, clinicians, system leaders, researchers, 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.
In a year of unprecedented pressure on health care, nearly one in three physicians surveyed (30%) say their trust in the U.S. health care system and health care organization leadership decreased. Only 18% report increased trust.
This is in stark contrast to the overwhelming trust physicians have in their fellow clinicians. Physicians report high levels of trust for other physicians and nurses (94% trusting doctors within their practice; 85% trusting doctors outside of their practice; and 89% trusting nurses)—but only two-thirds (66%) trust health care organization leaders and executives. During the pandemic, physicians report increased trust for fellow physicians (41%) and for nurses (37%).
“Health care is fundamentally grounded in a series of human relationships, and the strength of those relationships determines how well health care works,” said Richard J. Baron, MD, president and chief executive officer of the ABIM Foundation. “The pandemic bolstered trust among clinicians, but intensified physician mistrust of health care organizations. American health care has a trust problem and rebuilding it is essential.”
Overall, 78% of people say they trust their primary doctor. Significant differences exist, however, between different groups of people, with older adults (90%), white people (82%), and high-income individuals (89%) being much more likely to say they trust their doctors. Among people who report lower trust in their doctors, 25% said their doctor spends too little time with them and 14% said their doctor does not know or listen to them.
The survey shows stark differences in how physicians and patients view aspects of a medical appointment that affect trust. Nearly all physicians (90%) believe patients can easily schedule appointments, but nearly one in four patients (24%) disagree. Almost all physicians (98%) say that spending an appropriate amount of time with patients is important, but only 77% of patients think their doctor spends an appropriate amount of time with them.
In spite of these trust gaps, consumers trust clinicians—doctors (84%) and nurses (85%)—more than the health care system as a whole (64%). About one in three consumers (32%) say their trust in the health care system decreased during the pandemic, compared to 11% whose trust increased.
The survey shows that government agencies have trust-building work to do. The research reveals that 43% of physicians say their trust in government health care agencies decreased during the pandemic.
“Trust in organized institutions has been declining for years and health care is not immune,” said Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation. “Building trust requires engaging stakeholders across the health care spectrum to better identify what’s happening and share practices that increase trust between different parties. Trust is an essential part of medical professionalism and ultimately contributes to better patient outcomes.”
Focus areas for the ABIM Foundation’s Building Trust initiative include increasing relational and organizational trust, increasing equity and reducing systemic racism in U.S. health care, and the imperative of trusting science and facts, free from politics.
Leaders from all parts of the health care ecosystem will come together through the multi-year initiative to discuss how to elevate trust in health care. The effort will include significant research, dialogue and experimentation involving all parties.
A key component will be a Trust Practices Network that identifies, tests, and shares practices with the goal of building trust between health care stakeholders. The practices include interventions like:
- SCAN Health’s use of a peer advocate program to build caring relationships with plan members and encourage them to receive needed care;
- Northwestern Medicine’s African American Transplant Access Program, which strives to build trust with Black patients and increase the likelihood they will seek needed transplants and complete the necessary evaluation to be included on the transplant waiting list; and
- Scripps Clinic’s “One Thing Different” program, which gives staff and physicians the autonomy to do one thing of their own choosing to make a difference in the lives of their patients, relying on self-reflection and soul searching to improve care and enhance trust between staff and leadership.
More than 50 organizations have already contributed trust-building practices.
The NORC research was conducted between Dec. 29, 2020 and Feb. 5, 2021. 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.