Tag: Trust in Practice
Health Care Leadership
Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Steven Swensen and Don Berwick, both physicians and senior fellows focused on efforts to build trust by better integration of systems.
Steve Swensen: Don, I’m Steve Swensen. We’re longtime friends and colleagues. It was good to spend some time with you here.
Don Berwick: Indeed. I’m Don Berwick President of Emeritus and senior fellow at the Institute for Healthcare Improvement. Great to see you.
Steve Swensen: When I think of trust, I think of you and IHI and I’d love to hear your thoughts about the last three decades at IHI. It started with this cool vision and about that much capital and in one city and 30 years later, you’re a global behemoth that you’ve made your power by influence and change and impact and in that probably had a little bit of charisma or maybe a lot of charisma behind it in a beautiful vision, but trust had to play a role with your staff and the partnerships with patients and colleagues and medical centers in every culture on the planet.
Don Berwick: Well, thanks for the question and for the kind comments. You know, I’m really, I feel lucky to have been associated with IHI and it has grown, but it’s always felt to me to be kind of part of a very big community of effort that you’re in, Steve. And it’s never felt to me like one thing that’s grown, but rather a collective effort that’s just, it’s thrived. To the extent that there’s something in IHI’s genetic code around that makes it successful. And I’ve always felt it’s friendship. The origins of IHI, which go back to the mid-1980s, was actually in a group of about seven or eight friends. We independently had discovered the work of the great scholars of improvement, Deming and Duran and others. We were independently interested in healthcare quality and we found each other.
There was a center point that was Paul Batalden who was cofounder of IHI, and Paul convened us, some of us strangers to each other, as a learning circle. And for a period of a few years, we studied together, we learned together, we wind together when we ran into obstacles. Each of us was in place in an organization, but a little bit lonely there. But we all believed it was possible to improve healthcare, and if we learned the right methods. The glue was affection and I think, I think it was the source of trust also. So we weren’t competing with each other. We’re helping each other and that ethos, it’s really stayed through even to today.
Steve Swensen: Yeah. It’s beautiful. And you probably, can you have friendship without trust?
Don Berwick: Very hard to do. No. I guess you can’t. Once trust is betrayed, a relationship severed. But that idea of relationship, which you’ve written so eloquently about, I think, I think it’s core. If we treat what we’re doing as transactional, it doesn’t work. It just doesn’t work. It’s not sustainable, really. It looks sustainable. It looks clever. It looks macho, but it’s not right. And yeah, just knowing we’re going to help each other and can count on each other, that was, that was really key. It’s still there now and now, I think it’s a global community.
Steve Swensen: Yeah. What a great story. So in its core is quality improvement about trust where the leaders in organizations or systems or clinics or groups say you’re doing the real work and we, instead of giving you the answer, we trust you to figure it out.
Don Berwick: Yeah. Yeah, of course. [Indiscernible] [04:02] famous in one of his last interviews, said qualities about love with we try preferably believe so. I think that there’s a technical side of this that actually roots it for me intellectually because improvement of the type we’re invested in is about, it’s about systems, about interdependencies, complex endeavors where what you do affects me and what I do affects you. When we understand that and we’re going to work together to create a better result for the people we’re trying to help. The core asset is cooperation. Tom Nolan, who sadly died this year, my most important mentor, Tom was interested in change concepts, things that actually make a difference. He said the premiere change concept, the real, when at bottom, the one that matters the most is cooperation. So, which means we help each other because we want to get something done for someone else and how it’s not going to happen without trust. Otherwise, I’ll be afraid you’re gonna take something from me in instead of share something with me.
Steve Swensen: It’s fascinating. We were talking about love and Demi talked about joy in work and cooperation and trust as attributes of some of the most successful businesses.
Don Berwick: Yeah.
Steve Swensen: These are lovely, but soft, psychological, sociological terms is not—
Don Berwick: It’s a contest. Do you think it’s naive? Do you think that you’re being a, you’re going to be taken? Because the world’s mean and you know, there’s a lot of bad stuff out there in the world can be mean and there is a lot of bad stuff out there. So it’s, you know, it’s understandable for people to listen to this conversation and say, boy, what are you guys smoking? But I’ll tell you, I’ve been there, done that. And without that form of bonding, I don’t know how you’d get complicated things done in a sustainable way. It’s not through accountability. It’s not through incentive. It’s not through yelling loud enough. It’s not through trickery. So show me something better. And I think your earlier concept at IHI is that manifestly, it works. I’m gonna say, Steve, you added something big to this because you’ve clarified for me more than any other scholar right now, the relationship between what we just are talking about and meaning because I think the why, why should I trust you? What’s the reason? And the answer is because we’re both want to get done with our lives something that matters to us. And if you don’t connect to that, you’re going to lose heart pretty fast.
Steve Swensen: Yeah. And leaders play a central role and have that happen. Whether you’re the founder, president, CEO of IHI, or whether you’re a nurse manager, the relationships you have with the people on your team are fundamental and the behaviors that you have as a leader make a difference in the wellbeing of your staff. And that then translates into better care for patients. You know, Marine taught us that you cannot give what you do not have and if you’re distressed in some way then patients suffer from experience and outcome and higher costs and less safe environments.
Don Berwick: Yeah. You know, ask you a question because I think one verge of vision of leadership is that you get other people to do things that, you know, you’re smart enough and good enough at using the levers that you can kind of make people do stuff so that you align efforts and things like that. But you know, I don’t, I’m not so sure. I think that leadership is much more about releasing people to do what they want to do. Again, that sounds a little naive, but I think—well, Demi used to say all people want us to be proud and joyous in their work, as you said, and the smart leader makes it possible for that. It doesn’t command it.
Steve Swensen: Yeah. It’s a social process to engage colleagues and teams of colleagues to meet challenges together. And the leader behaviors that are fundamental for this are basically are participatory management where it’s not the sage coming in with the answers, it’s he or she humbly listening and inquiring and engaging the team so that everyone collectively configured out together. And then that engages them, and you see higher levels of fulfillment and meaning and purpose because now, you’re a respected and trusted part of the team and then you don’t care about your job description anymore because you come to work because you can’t wait to work with people to get something done.
Don Berwick: Yeah. I once called a friend of mine who had been promoted to a much more senior job and say congratulations in being the boss and he said, you’re never the boss.
Steve Swensen: You’re never the boss.
Don Berwick: And I think that’s take home.
Steve Swensen: Yeah. And if you think you’re the boss, then you failed because then you’re being more impressed with a number of the back, the name of the back of your jersey instead of the name of the front of your jersey. And you’re, you made the title, you made the salary, but you won’t have the results.
Don Berwick: So one of the things I admire so much about your work at Mayo was you were able to take rather area ideas about leadership and converted into a leadership index and really discover some strong relationships quite formally. What spurred you to do that?
Steve Swensen: It’s a decade ago now that we started working on this. I was, that year I was appointed to head up organization and leadership development. And we look, we’ve been serving all 60 some thousands of our staff every year since 1981. And that year when I started in that role, we saw that there was a huge variation among physicians in their levels of satisfaction, fulfillment, and professional burnout. And so we said, well, why is this such a variation?
Don Berwick: And you could measure those things.
Steve Swensen: We could measure those things. So we measured those down to the unit level. We also measured leader behaviors, but we never did anything with them. And then we talked about this among all the chairs one morning, every Wednesday, all the chairs would meet with our CEO. John knows where the time and we all have had a cardiologist, said, well, let’s look for the positive deviance. So what were the departments and growth groups that had the highest levels of fulfillment and satisfaction and the lowest burnout? And then we ended up linking that to the behaviors. It turns out we did a deep dive, 130 different units and found that 47% of the variation was due to the leader behaviors.
Don Berwick: How much variation was there?
Steve Swensen: It was staggering. We had a twofold difference of professional burnout between the highest and lowest areas. And then so on the 60-point scale, the staff would answer questions about their leader. And for every one point up, single point up, there was a 9% higher level of professional fulfillment satisfaction. And for every single point upwards, there was 3.3% lower rates of burnout. So we knew we were, and it was statistically significant. And so we started managing that.
Don Berwick: So what were the elements of the index?
Speaker2: Index are, Don, the behaviors are common sense. They’re not rocket science. They’re just not, they’re just not common practice. Appreciation. Thank you for what you did with the team today for this family. It made a difference. It wasn’t your job description but thank you. I’m interested ideas. I communicate transparently. What do you want to be doing five years from now and how can we help your dream come true? And no, we should invite her. Everybody on the team should be welcome and comfortable and respected. So basically, inclusion and appreciation and transparency, those simple behaviors. If the staff thought their chair live those authentically, they thrived.
Don Berwick: Did you ever worry that you were being too soft, that this stuff is too nice and that there’s an edge to leadership where you have to really, you know, be strong and commanding? Or is it, is this really the heart of it?
Steve Swensen: Well, when we got criticized by a board member when we went with our results and our plan saying this is soft science. And I said, no, it’s not soft science. It’s rigorous science with controlled studies and key values. But it’s about social scientists, about psychology. It’s about sociology and people and behaviors. But it matters. And look what we’ve shown. When we work on those leader behaviors, burnout rates plummeted over a three-year period while the national rate went up nine points.
Don Berwick: Yeah. I remember reading your first quantitative paper on this and the relationship between the variables you talked about and the burnout levels was stunning. I mean, really, really strong correlation.
Steve Swensen: So rigorous science of randomized controlled trials with, you know, common salady in meals. It’s a soft science, but that we’re people—we have, that’s the nature or not.
Don Berwick: So what’s the—explain this common salady concept, which I first learned from you.
Steve Swensen: It is a great word and it means a precious thing for human beings. It’s sharing a meal with someone and it makes a difference in our wellbeing and our ability to take care of patients in a better way. In the randomized controlled trials, you know, one of them we showed our cortisol levels went down.
Don Berwick: Which is a measure of stress.
Steve Swensen: And we measure stress and we saw that demotion, that social isolation went down and emotional exhaustion went down and cynicism about the organization went down all by having professionals and colleagues have a view of someone in a conversation. And that, is that soft science? Well great, bring it on. Because we know that that makes a difference for patients. And that’s so.
Don Berwick: So you said earlier that the science is clear, the results are strong, it makes sense. And yet it’s not, these behaviors are not as widespread as you wish they were. Why not? What’s in the way? It seems so obvious.
Steve Swensen: They aren’t. And I think it’s starting to spread that there are people that are measuring it. So many of our healthcare organizations on their planet have a razor thin margin and there is an inducible rock solid return on investment for patient-centered quality improvement and for working on engagement of professional burnout and joy of work. But it doesn’t show up on the balance sheet tomorrow or next week or next month. It shows up next quarter and next year.
Don Berwick: They’re alongside.
Steve Swensen: You do. And so that’s where, that’s part of the problem.
Don Berwick: You think it’s harder to be nice?
Steve Swensen: You know, I think it’s everybody has more fun and there’s more joy in work, in collegiality if you do that, but it’s not the last generation of what bosses did. You know, you’re not, the reason we pay you is if you’re not supposed to have fun at work.
Don Berwick: Yeah. I remember going to a group suggesting that joy in work become a goal and that group laughed me out of the room. You gotta be kidding. And I, you know, made me sad. You know, you were asking earlier about IHI’s successes. You know, one of the most satisfying eras was the campaigns we ran, the 100,000 Lives campaign, you remember? That was I think 2004 to 2006 or something like that. And it was an amazing experience. We had our board and the staff had looked at our results. We were a little impatient with spread. And so we, and we had some changes that we thought would make a difference in survival in the American hospitals. And so we just called it out. We said, how about, hey, would you like to join? Would like to save, you know, tens of thousands of lives through adopting some changes?
And that one of the lessons I learned through that period that always comes back to me when I read your work, is we had no power. There was nothing that that little organization could have done to order anybody to do anything. We couldn’t pay them. We couldn’t create contingencies. We couldn’t reward them or punish them. All we do is invite them. And that idea of invitation to do something that your heart wants you to do, it was so powerful, Steve. We had 3,100 hospitals. We had, every meeting I remember going to all over the country was like, it was like I don’t know, a festival of commitment to something really important.
Steve Swensen: And you saved countless lives and as important or more important, you engaged thousands and thousands and thousands of healthcare professionals in a long-term passionate need. I remember going home from that meeting with Dave Herman that was just new in the quality leadership to Mayo said, we’re doing this and we’re starting tomorrow, and we can’t wait to get going. And Mayo that, you always make decisions and committees and groups, and we said, we’re not waiting. This is so important. We have to do this right now. And we did. And no one objected. And because it was, because you inspired us, and we trusted you and it made a difference.
Don Berwick: Yeah. I mean, of course, they who saved the lives of watching these hundreds and hundreds of people around the country dig in and try to do this. It was, it was amazing. We released something and I wish we could hold onto that and build on that.
Steve Swensen: With the power of the spirit and passion, it unleashes so much good. And I think that’s, that doesn’t happen unless people trust leaders. And that’s a wonderful case study for now that can work.
Don Berwick: I know we’re almost out of time, but I gotta ask you one question on top of it. Is your experience with the work you’ve done at Mayo on burnout and the leadership index, is this a globally useful, that have you gone to other countries and found the same dynamics at work, or is this pretty much an American model right now?
Steve Swensen: I think the two core improvement efforts which one is a quality improvement, you know, core that the IHI’s white paper. The two core strategies for addressing professional burnout are universal as long as you have human beings working. It’s basically identifying frustrations as a team and then fixing the processes or helping leaders be more humane and sensitive and participative at the end. I think that no matter what the language or culture, it’s that’s universal, like the language of quality improvement.
Don Berwick: And it probably goes way beyond healthcare for sure.
Steve Swensen: It does, yeah.
Don Berwick: So does your use of and teaching about the leadership index itself build trust? And if so, how does it do that?
Steve Swensen: You know, I think it does. So imagine if you had a leader who authentically appreciated you, was genuinely interested in your ideas, opened the books for you to see all of the information, all the data, all the blemishes and warts, had a special interest in your career and worked with you to become better and included everybody, regardless of genome or phenome or creed, how could you not trust someone like that?
Don Berwick: The other thing is it strikes me, maybe, maybe I’m wrong, that the leader who believes your science has to trust the workforce. You’re going to be seeding quite a bit of control or the illusion of control and you better trust them or that’s not going to go well.
Steve Swensen: All right. So if you’re looking at really interested in their ideas, communicating transparently and doing this together, that is a surrogate for I trust you.
Don Berwick: One of my early teachers in the field of improvement was a guy named John Dowd, who was a protege of Dr. Deming’s, and he was, he taught me so much, and I remember one of the things Dowd told me once was, if you’re a leader and you don’t trust your workforce, don’t even start. He viewed it as a precondition for improvement.
Don Berwick: Profound. Don, it’s great to visit.
Steve Swensen: Great to visit. Thanks.
Narrator: Visit buildingtrust.org to learn more.
Serving Underserved Communities
Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Kyle Christiason, a physician and Donald Wesson, a physician and health system chief executive, focused on efforts to build trust by understanding marginalized populations.
Kyle Christiason: Don, I’m Kyle Christiason. I worked with UnityPoint Health in Iowa and Wisconsin and Illinois and I practice medicine there about halftime, but the other half of my work is helping lead the Accountable Care organization and one of the biggest in the country. And we’re proud of being heavy into risk and the idea that we get to collectively own the wellness of a population that we serve.
Don Wesson: So owning the wellness of the population you served. I love that because that’s in our name. So I am Don Wesson. I’m a nephrologist by training and a recovering basic scientist, literally. I’m president of the Baylor Scott and White Health and Wellness Center.
Kyle Christiason: I notice that you had the in the title.
Don Wesson: Yes. And that’s by design because we are trying to design methods of population health for this very low income, predominantly minority community in the southern part of Dallas. We recognized a long time ago that the most expensive patients to manage in our system came from these five zip codes that we serve. And so nine years ago, the organization thought, well, why don’t we try some proactive measures to try to reduce the rate of folks with very expensive to manage chronic disease came into our system. And most of these the patients, in fact, 85% of our patient population is uninsured and recognize that Texas as a state that did not expand Medicaid.
And so in addition to the altruistic mission of our organization, has a very pragmatic role of trying to reduce the proportion of patients from this community coming in to see us with very expensive to manage healthcare needs and address them proactively. And we’ve had some success in doing so but continue to try to refine the models that would allow us to be able to manage a community, which I really find interesting because I was trained as a physician to manage individual patients. But now having to scale up to figure out how a health system can manage the health and wellness of a community.
Kyle Christiason: So that, yeah, it goes from a reactive legacy of health care. We’re here when you need us, come to our big shiny and tower to one that you are reaching out to a community to make some connections and be proactive about their health.
Don Wesson: That’s correct. That’s correct. And in order to do so, we have to learn that community and have to be able to gain their trust. And over the decades, we’ve done plenty to earn their mistrust and now we are having to work in a way that allows us to be able to gain their trust. And as we were discussing earlier, there was a time when our community members could not come into our health system to see if they were turned away from our health system and direct it toward the county system that supports the poor in our area. But now, the law says, thankfully, that we can’t turn them away. And so now , the thought is, well, since we can’t turn them away and they’re very expensive to manage, let’s see how we can proactively manage not just the individuals but manage the community in a way that keeps them healthier, such that there is less of a need for them to come in to use expensive services in our system.
Kyle Christiason: Emergency department, admissions.
Don Wesson: Exactly.
Kyle Christiason: I mean, the high cost is high acuity care, maybe conditions that could have been better managed further upstream and before the illness has progressed or you expand that to a population then before conditions become really heavily prevalent within a population.
Don Wesson: Exactly.
Kyle Christiason: So, was it, it fits with our altruism as physicians. Was it a financial pressure that really helped kind of push the effort to seek how we can get ahead of those conditions or reach out to that population? Tell me how the leap was made because that’s different than many, many health systems around the country.
Don Wesson: Well, and in part it was financials. So I’m a nephrologist by training and what we’ve recognized, not just our health system, but most health systems have recognized that measured per patient. Chronic kidney disease is the most expensive to manage chronic disease there is.
Kyle Christiason: More than oncology? More than some of the things we might think of.
Don Wesson: That’s correct. So if you think about oncology or you think about cardiovascular disease as a disease entity, they are more expensive than chronic kidney disease. But if you measure it per individual, then chronic kidney disease is the most expensive chronic disease to manage. So our system thought, well, if that’s the most expensive disease entity to measure, to manage, then the more of those individuals that come to our system, the more expense that will be for us. And as I said, most of our patients are uninsured.
Kyle Christiason: Yup. So that’s on you.
Don Wesson: So it’s on us to try to manage them proactively because as they come into the system, they are very expensive to manage, and we get little to no revenue for these uninsured individuals. So, in addition to the altruistic proactive route, there certainly wasn’t an economic and financial initiative that was related to this because we were trying to figure out how can we lower expenses. So my conversation with the CFO, the chief financial officer, relates to the expense side of the income state. And he is constantly saying, we’re looking for revenue for the system, and my retort to him is that we’re managing the expense side of the income statement.
Kyle Christiason: yeah. And that really connects because you’re talking about better care, earlier care, better care. So, so that of course is better for the population and for the patients. You focused on chronic kidney disease as your first foray into this because of its great opportunity or…
Don Wesson: Actually no. So my particular focus is chronic kidney disease, but my center got started with a focus on diabetes. So as I said, chronic kidney disease is the most expensive to manage per patient. But when we as a system measure it across a disease entity, overall, it was diabetes and continues to be diabetes. And with all of the additional heart disease, kidney disease, blindness, high blood pressure, all of those things that come from diabetes collectively looking at the whole cadre of patients that we measured, it was diabetes. And so it actually started with a focus on diabetes. And when you recognize that much of the management of diabetes that lends value has to do with nutrition and has to do with physical activity. We don’t use that four-letter word: exercise. When it relates to those two things, those are the things that patients do outside of the doctor’s office. And so we recognize much of what was related to improve diabetes management happen outside of that 15-minute doctor visit. How well they ate. Whether or not they increase their physical activity. All of those things that science shows enhances the management of folks who had diabetes.
But that was not occurring. And since those things were incubating in the community, outside of our control, that influenced them coming in to see us. And so we looked at ways by which we might structure nutrition management, structure physical activity management, outside of the health system. And so that has been the predominant focus of our system, working proactively in the community through what we call trusted agency institutions in the community.
Kyle Christiason: What would be some examples of that?
Don Wesson: Well, we have focused primarily on churches and with the realization that we had a bad history in our trust from the community as I mentioned. However, we figured if we partnered with institutions in the community that already had the trust of the community, then we could leverage their trust for our benefit in terms of the service delivery of the care that we were providing. But also in terms of our research enterprise. Because as I mentioned, we are trying to design effective models of care, and in order to show that this care is both effective and cost effective, we have to have our research enterprise document that. And so in an effort to do that research in the community, we needed the trust of them. I mean, recruiting patients for these long-term studies requires that we have the community’s trust to be able to do that. So I’ve talked a lot about what we’re doing and the struggles that we’ve had and the struggles that we’ve had to overcome. So Kyle, tell me about the challenges that you’ve had and how you’ve gone about addressing them.
Kyle Christiason: Now, one of the things that, that I think resonates with what you describe is the focus. You chose diabetes as a very intentional focus. We were recognizing in in our community, which is Northeast Iowa, relatively rural, we were seeing a significant marginalization of the LGBTQ population. These folks were traveling two hours, three hours, six hours, just to access basic primary care. And so the research that we did was consistent with what the national findings are, which are really appalling, as in addition to the social stigma LGBTQ folks also experience discrimination within healthcare. And it’s along the lines of the perception that physicians are using harsh or abusive language that, that we blame patients for their health conditions. And even up to one in five physicians flat out refusing to care for someone because they identify as transgender.
And it was these types of disparities then that lead to all kinds of health complications. So increased risk of depression and anxiety and suicide attempt, utilization of hospital services, similarly delaying basic care until a very high acuity at high cost need was there. So it was these disparities and really legacy of poor experiences that prompted us to explore, see what we could do. And so with the effort of focus groups, trying to understand what would be the ideal scenario, if we could create something from scratch, what would that look like? And that led to the creation one and a half years ago of a dedicated LGBTQ clinic to stage a safer and more welcoming place to access healthcare, primary care. So a lot of the care we do provide is transgender related. But it is a full primary care clinic. Immunizations preventive screenings for cancers along with comorbid conditions.
I think the exciting part of the clinic experience has been very affirming for patients, new for many of them, never having a provider asks them about their pronouns or honor the name that that person would want to use. Just really kind of food and shelter type of things. You know, when that core hierarchy of need is not met, in other words, you in health care not seeing my most authentic self, then you’re not, you’re showing that you don’t care about that part. Well, then that neither should I care about my health. The flip of that then is our patients tell us that when you honor simple things like my pronouns or my name and see me for my authentic self, show me love and compassion as an institution of healthcare, I now flip that equation and that translates to me as I should, I will also show myself love and compassion and care for myself and wellness. So it’s been a fantastic experience for our patients. Another important benefit, although truthfully unforeseen, is for the caregivers themselves.
Don Wesson: That’s was going to ask about. I can imagine.
Kyle Christiason: It’s been amazing.
Don Wesson: The recipients of the care being excited, but I was wanting to ask about what the providers of that care, what their experiences are like.
Kyle Christiason: So it’s kind of our own little contribution to fighting burnout, what we’ve learned is that when we are very intentional about many steps in the clinic process, we begin the clinic with a centering exercise of some sort. We all come in from busy days and we kind of descend on one space where we’re co located with the full team that’s done all of the sensitivity training and bias training. So that’s kind of the core training for this group. But we’re busy. We come together and we’re just, we get our clinic rolling. We center with something like an education or a quote or something that brings us together and we practice this enough that we get right into our groove and we’re ready to go.
Don Wesson: All right.
Kyle Christiason: And then after the clinic has done, we finished with two steps. One is a rapid cycle improvement process. What didn’t go well tonight. We call them pain points, and we not just encouraged, but we expect each team member, from scheduler to the lab tech to the pharmacist to the nurses and physicians, look relentlessly, seek out inefficiencies, moments where there was a near miss and the experience, so to speak. What didn’t go as well as it could have been. And it might be simply how we write down vitals. It might be how we communicate someone’s pronouns to someone else on the team. So again, we’re looking for ways to improve the experience. At the end, we finished with what we call joy bombs.
Don Wesson: Joy, J-O-Y? Joy bombs? Okay.
Kyle Christiason: And it is a moment where everybody can share something that really brought them joy.
Don Wesson: And everybody being who?
Kyle Christiason: Anybody on that team. So this is a full team, robust huddle. Again, from scheduler to a provider.
Don Wesson: Wow..
Kyle Christiason: Anybody is encouraged. And so it’ll be moments, it’ll be moments like I remembered it was somebody’s birthday today and I said, happy birthday. And she loved that. To a patient’s sharing with a provider recently that I want you to know because you showed me love and compassion in this setting, I want you to know that I chose to not kill myself. Because of what you’ve done for these last few months for the first time in ten years, I don’t feel suicidal. And it’s those kinds of affirmations that we actually think are just as important as the objective measures of success that we have. Because those moments, again, they really connect our physicians and everyone on the care team. We’re all vulnerable to burnout, but this is how we finish our clinic.
And so at the end of the day, we finished with joy bombs and that’s how the team is going back to their homes, engaged, you know, and refreshed already, instead of this typical or traditional model of working like crazy all day long, tired, a little bit upset and frustrated going home to my family with that mindset. We flipped that. Now, we’re sending everybody back home feeling something that’s really reconnecting them to medicine and their purpose in what they’re doing in a way that they hadn’t been feeling for quite a while.
Don Wesson: It’s interesting, Kyle, that the experiences are similar, and I mean we’re both dealing with an underserved community and each of us had to make a proactive on treaty to that community to try to gain their trust. And so it sounds like you’ve reached out to the community. What have you heard from them that says this is the way by which we would like for you to conduct our care?
Kyle Christiason: It’s been an intentional bi-directional dialogue from the very get go. So with the launch of the clinic, we started with focus groups. What would this clinic look like if you could idealize it? If you could create it from scratch, what would it look like? What would be necessary? And so that continues to inform us. So we seek input from patients every visit. So we have, we created a survey, short survey, only three or four questions and right to the nuance of what we’re trying to get at. More or less, how was your experience and what be done differently next time to make it better?
Don Wesson: Wow.
Kyle Christiason: And so we have a greater than 60% return rate, which is really high by survey’s standards. And yes, we like the numbers and the scores, but it’s the sentences that people write in at the bottom that really influence us and make us change things. So their input continues to be essential. And I think that’s important for all of us. In medicine, we often measure our success by our own industry to find standards. And we’ve often left the center of the whole reason we do this out of the picture. And we focused on our measures, our assumptions.
Don Wesson: You know, I didn’t realize it. Well, certainly, we get individual input, but it reminds me of an interesting story. So we meet with the pastors of these churches. So there’s 31 churches that we partner with now and we meet with them quarterly. In fact, we just met with them last week before I came. And we solicit their input as a group, as to how we can best deliver the care, much of which is being done at their churches. And I can remember, this was a couple of years ago, one of the pastors said, you know, Doc, we love this, these physical activity classes that you do, that Zumba stuff. We like it, but that secular music that you guys use for that, that ain’t working for us. You think that you can do the classes using gospel music? And we said yes because gospel music rocks as well. And so we changed the music format, but the same activity we were doing, we did not change. We just changed the music format to gospel music, and they changed the name of it from Zumba to Praise and Flow. And that’s now our most popular physical activity class that we do within the system. And so I keep reminding myself of that because that’s an opportunity for us to gain input from those that we serve as to how best we can serve them. And had we not been having these quarterly meetings and they felt comfortable enough to offer it.
Kyle Christiason: That’s why I’m curious about. So you made it safe, comfortable, almost an expectation that we want your feedback. What can be better about this? Okay. That’s something that I think we need to continue to think about and keep front of mind is how do we make this, make sure that we are getting the connection there and something that we’re seeking the input of patients and families and the community that we serve.
Don Wesson: Absolutely. And so that’s an ongoing process right now because we recognize that in order to gain the trust, we have to do these proactive measures that we’ve just talked about. But to maintain the trust, we need to have it be a continuous process and not just episodic.
Kyle Christiason: Yeah. Yup. You got to keep showing up.
Don Wesson: Yup.
Kyle Christiason: That sounds like partnership. And again, I’m inspired really by what you describe as nontraditional partnerships in medicine, and you know, that when we, in healthcare, to lead the journey to transformation of that experience and redesign that experience that we do collectively own the wellness of the communities in which we live. And we should be the ones leading that, but we can’t do it alone. And you’re describing partnerships with our community that is just, it’s a wonderful thing.
Don Wesson: Well, and I liked the marginalized community, at least the previously marginalized community, that you have been working with. You’ve also given me some insights as to how we might use some of the techniques that you’ve just described in our community back in Dallas. And so, thank you.
Kyle Christiason Yeah, likewise. It’s been a real pleasure. Terrific. Thank you so much.
Don Wesson: Thank you, Kyle.
Kyle Christiason: Appreciate this conversation.
Don Wesson: Absolutely. Thank you.
Narrator: Visit buildingtrust.org to learn more
Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Christine Sinsky, a physician and AMA official and Melinda Ashton, a physician and chief quality officer, focused on efforts to build trust by eliminating inefficiencies.
Christine Sinsky: Well, hi Melinda. I am so thrilled to meet you. I’m Chris Sinsky. I’m a general internist. I also work at the American Medical Association as vice president of Joy in Medicine.
Melinda Ashton: Chris, it’s so nice to meet you. I’ve been looking forward to this. I’m Melinda Ashton. I’m the chief quality officer at Hawaii Pacific Health and also a pediatrician.
Christine Sinsky: Great. Great. Well, I first learned about you in your New England Journal article and the work that you’ve been doing about getting rid of stupid stuff and I wonder if you can tell me a little bit more about what you did and why.
Melinda Ashton: Yeah. It’s a funny story really. I had seen over the years that there were the occasional documentation thing in the chart when I was reviewing a chart where I was pretty sure that whatever was being documented wasn’t actually really accurate to what occurred. And then we bumped into a couple of more worrisome areas where we had clearly allowed to be created in our EHR documentation requirements that just were plain stupid. And so we talked to our—I’m a member of the executive team, we talked to the rest of the executive team and said, maybe we should do something about this. We’ve stumbled on these. I wonder what else is out there. And we decided that we would create this program at our place where we just invited anybody who was, you know, using the EHR in any way to tell us what was just plain stupid. None of that was intentional, of course. We sort of started off by saying stupid is in the eye of the beholder here, you know, what we now are saying is stupid was well intentioned when it was started. And we’ve been really pleased and surprised by the amount of interest and involvement from our staff and outside of our hospital as well. Health system are it.
Christine Sinsky: Well, one of my favorite examples was a nurse had mentioned that she thought it was odd that she was having to document the status of at the umbilical cord in the teenager.
Melinda Ashton: Yes.
Christine Sinsky: And perhaps you can tell me more about that.
Melinda Ashton: Yeah, that was one of the very early nominations as we call them. And we were just beside ourselves. I mean it was hard to believe that we had had this particular documentation requirement in our EHR for patients in the pediatric hospital that we have for at least ten years. And this was the first time that we heard from a nurse that she really would hope that we would take away the need to document that the cord was absent in the patients that she cared for, which were adolescent and oncology patients, almost never newborns. All that was was a simple failure to put in the age restriction that was intended when we built the EHR. And it was just mind boggling that for year after year, patient after patient, a nurse who was actually very strong advocate of her patients hadn’t spoken up for her own behalf to say, please make this go away. And as soon as she did, we made it go away.
Christine Sinsky: But you had a process, right?
Melinda Ashton: Right.
Christine Sinsky: I’ve been through two different EHR implementations, actually three, if you count our hospital implementation, and I and others filled out many forms for suggestions for enhancements or improvements or getting—we didn’t have that term—getting rid of stupid stuff. But after a while, you learned that that was a futile exercise and yet there’s something different in what you did that made it not a futile exercise.
Melinda Ashton: I think that is one of the things that we’ve heard that has made it a bit different than others. Now, we are well past implementation, we implemented our EHR back in the 2004 to 2010 time range. So it’s been a long time. At that time, we had our IT staff got really good at building because they built four separate hospital implementations, each one a bit different. They got very good at that. So over the ensuing time, what happened was, they were really good at responding to requests for improvement. And now, what we found is some of those improvements actually have turned out to be, you know, unintendedly bad. At the same time, the EHR, any EHR is so complex that any implementation, I think, is likely to miss some of these little things. And so we found a few of those. Not as many as perhaps we thought we might, but those are the fun ones. Those are the ones that you just sort of shake your head and say, how could that possibly be true? But those have been there, just some, but many of them have been things that, you know, a group of folks thought was a really good idea to do something. And then, you know, years later, you look at it and you think, oh, that was, that did not work out as intended. That was kind of stupid. It results in a lot of road work by nurses, by therapists, by staff, like just pulls into their time for talking to their patients, relating to one another, doing the work they really should be doing.
Christine Sinsky: You know, we’re here at this conference around trust and I’m thinking about my own experience when I and other physicians did raise examples of things that could be eliminated, could be changed, ways to make the usage faster, quicker, more efficient, and almost feeling as if there was a social cost to be paid for those who raise those objections. And yet I’m understanding what you did as having been a source of building trust among the physicians and among the other clinicians. And I wonder, am I right on that?
Melinda Ashton: Yeah, I think you are. I mean, I can’t tell you how many nice emails I’ve had from people that rarely say nice things. And so I think that, and we’ve heard a little bit of a hey, I said something, and you changed it kind of a building of trust, I guess. In that term, the difference I think is first of all, we had executive sponsorship of this. This was something that our CEO on down really bought into. Our CEO, for example, found one of his own examples of something that was completely stupid that have been going on for years and years that he was willing to go out and talk about.
And so that was helpful. We had a couple of really good examples to start us off. I think that was helpful. And then our partnership with the IT was critical, and we already had an infrastructure. We had work groups that were specialty specific or discipline specific that were ready and in place and doing this kind of work. And they were able to then take those practice requests and actually implement them, actually—well, evaluate them. First of all, we don’t do things just because one person asks for it. We make sure that it’s not going to be another stupid something that we built. And so, but those work groups are really helpful in terms of doing the evaluation and then actually, you know, making sure that the build happens then that it gets done in a timely way and so forth. And we stay in touch with the people that make the recommendation to us as well.
Christine Sinsky: I would think there needs to be a fairly lead deep level of trust between IT and the physician leadership because they’re the ones who are probably going to feel the most judged.
Melinda Ashton: Yes.
Christine Sinsky: Or the most threatened by this. We built it this way, just live with it, or something along those lines. So how did that happen that they were not overly defensive?
Melinda Ashton: That’s actually a really interesting set of thoughts because when we were first known to be working on this, getting rid of stupid stuff, our CIO got a number of emails from friends and colleagues around the country all saying, what are you thinking? And he sort of chuckled and his response, at least internally, he was sort of saying, well I just say back to them, do you have that much stupid stuff that you’re worried about? But the real truth is that we’ve built the IT clinical relationship over years, and they are very much our partners. They really understand that their role is to help us provide really good clinical care. And I think that’s a little different than perhaps in other organizations. Now, I should say that years and years and years ago, when I first started to try to interact with it, I was told by the same CIO that he told every one of his people first answer to any question is no.
Christine Sinsky: Yes.
Melinda Ashton: And then you think about it, we changed that thinking.
Christine Sinsky: I think you’ve really hit on something there. As I was thinking about your initiative, getting rid of stupid stuff and trust, I was thinking about how as a physician, I, early on in my career, absolutely implicitly trusted my leaders to help me take good care of patients. And then the EHR was instituted and it made it really much harder for me to take care of patients in some regards, in other regards, that made it easier. But I felt like there was so much pressure and that trust was broken because I no longer trusted that the leaders were actually there to help me take better care of patients. The message became implement the EHR and don’t complain and stay quiet. And you may have started, that sounds like, with a little bit of that attitude, but that evolved and I’m guessing they’re getting rid of stupid stuff helped that, helped others trust that that had evolved.
Melinda Ashton: I think so. I think being able to go out there and say that we are gonna work on getting rid of stupid stuff, which by itself is a little bit in your face.
Christine Sinsky: Yes.
Melinda Ashton: That was helpful. And that message and actually, the article in the New England Journal of course gave it a bit more credibility as well. But I think all of that plus the fact that we were able to make the changes that were being requested. We really sincerely wanted to know what, what we had created that wasn’t helpful. And I think it is absolutely true that it’s the leadership’s role to set the environment. You know, the individual clinicians can’t change that by themselves. It’s only leadership that can, and leadership can’t do it if they don’t know what’s needed. So we need that partnership there.
Christine Sinsky: I’m curious about the name.
Melinda Ashton: Yes.
Christine Sinsky: I love the name. And I think if you just had a comment box and ask people to put in comments, you probably wouldn’t have gotten as much engagement.
Melinda Ashton: Right, right.
Christine Sinsky: But I’ve also heard a little bit of pushback about stupid.
Melinda Ashton: I agree.
Christine Sinsky: And yet I think if you didn’t have stupid, it wouldn’t have worked. That stupid just resonates with us and know that’s what spending, what’s taking up so much time.
Melinda Ashton: It does. We actually had some serious conversation at the executive team level about whether we were going to call it stupid. And at first, it was, you know, I just, when I was presenting the examples that we don’t covered, I basically throw up my hands and said, this is just plain stupid. And then we talked about we would have a program for administrative simplification, and I think the system goal actually had that terminology in it, but then we looked at each other and we said, no, we need to go out there and tell people this is, we really want to get rid of this stuff that’s totally stupid.
Christine Sinsky: In fact, I think by saying getting rid of stupid stuff, you actually engender trust because you were able to tell it like it was.
Melinda Ashton: Right.
Christine Sinsky: Right. You weren’t sugarcoating it. You weren’t saying it’s optimization. We really weren’t wrong at the beginning, you know, we’re just optimizing. No, we’re saying, you know, there’s a lot of stupid stuff here. To me, that just resonated so clearly.
Melinda Ashton: It was interesting as I went out to present this as a new program to our managers, directors’ meetings, across the system. We have four hospitals, four of those meetings Plus one at the system level. Every time I put the title up and started to talk about it, the room—there was just a ripple of kind of sheepish laughter that went through the room each time. And I had one of the people that reports to me tell me that if I hadn’t been up there standing them telling them that that’s what we were truly thinking about doing, that somehow it wouldn’t have been as trusted, I guess.
Christine Sinsky: I would say there’s a leader who understands something about my life if I heard you speaking that. I want to tell you, I had the chance to visit another organization, another academic medical center or unacademic medical center, and they had just called someone from your department and were reinstated. They were going to replay that initiative or copy that initiative and they were really enthused about it. They had gotten, I believe, 450 suggestions in the first three weeks.
Melinda Ashton: Wow. That’s great.
Christine Sinsky: Yes.
Melinda Ashton: I just love the fact that other people have decided there’s something here that they want to kind of replicate or I’d love to see it just ripple. I think it’s great.
Christine Sinsky: Yes. And I want to thank you because you’re helping us make that ripple. You’re helping us write a toolkit online at the American Medical Association on getting rid of stupid stuff so others can be inspired.
Melinda Ashton: We’re happy to talk to anybody and help anybody do this. I think it’s so exciting that others want to do it.
Christine Sinsky: I think we learn by example, and you’ve just given us a great example.
Melinda Ashton: That’s good.
Christine Sinsky: So I’m really pleased that you’ve made the trek all the way from Hawaii to come and share what you’ve learned with the larger organization, the larger group here at the forum.
Melinda Ashton: And I’m really pleased that I was invited to come in and do that. I’m absolutely excited to be part of this.
Christine Sinsky: Great. Well, thanks. I think you started a movement.
Melinda Ashton: Thank you.
Narrator: Visit buildingtrust.org to learn more.
Transparency in Health Care
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.
Teachers and Learners in Academic Medical Centers
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.
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.
Role of Storytelling
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.
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.