Why It Matters
The patient had been in the hospital for almost a week. At the time, I was an internal medicine hospitalist at New York Presbyterian Hospital, and I had just come onto the service.
For several days, the patient had been waiting for an MRI. When I first spoke to him on the day we met, I was the latest person to tell him he could go home once we got more information to guide his treatment plan.
I imagine the patient had no problem with this plan the first few times he heard it. It made sense to get the diagnosis right and make sure the treatment was working before he was discharged.
By the time I saw him a few hours later, though, to tell him that we still were not sure when he would get his MRI, his patience had evaporated. He exploded. He and his wife directed their days of accumulated frustration at me. The intern and the resident had warned me that the patient and his wife were upset, but I was not prepared for the level of vitriol they unleashed.
It would have been easy to get defensive. After all, the situation was not my fault. And, in fact, I had experienced frustrations earlier in the week with the radiology scheduling for other patients.
I could have simply walked out. I did not have to take that kind of abuse, right? And it was not hard to imagine things getting uglier. But the part of me that wanted to help won over my impulse to flee a very difficult situation.
When the patient and his wife paused to take a breath, I sat down in the chair near the patient’s bedside. I asked what they wanted the most at that moment. The patient said, “I want this MRI done. I’ve been waiting for it forever.”
I told him I also wanted the very same thing because there was little I could do for him without the MRI. He could leave, of course, but it would have to be against my clinical advice, and that would not be the best thing for him. But then I had an idea: I decided to pay a visit to radiology and bring his wife with me. After all, we were on the same side. “You can’t leave your room, but your wife can,” I told him.
That was not what the patient and his wife were expecting. And it was not what I anticipated doing before I walked into the room. Looking back, though, it is an example of how to build strong, and more trusting, relationships with patients. Sit, listen, ask questions with genuine and respectful curiosity, and then co-produce the next step based on what you learn.
Trust in Health Care
Paul Batalden, one of the founders of the Institute for Healthcare Improvement (IHI), has often talked about how health care is a service that is co-produced primarily between a clinician and a patient. That service is a set of activities meant to make someone healthier, and what makes those activities result in healing is a strong therapeutic relationship.
The oil in the gears of that relationship is trust. Without trust, it is very difficult to create a therapeutic relationship. Without trust, it is hard for patients to take the necessary actions that would result in better health for the individual, family, or, indeed, a whole community. Trust is vital to drive meaningful improvements to quality in health care. It is, therefore, troubling to see erosions in public trust in health care.
For many years, Gallup has done surveys of public confidence in a range of institutions in the US, including health care. For many major institutions, there has been a documented atrophy of trust. Many people trust large, centralized institutions less and less, year on year.
There are many reasons for this. The media is full of stories every day that give us reasons not to trust institutions or their leaders. We hear about leaders or institutions who have taken advantage of the trust that many have given them. In Gallup’s most recent survey, institutions that include newspapers, the criminal justice system, big business, organized religion, the medical system, and technology companies have all seen declines in public confidence.
Notably, Gallup found that public confidence in the US medical system has dropped from 51 percent expressing “a great deal” or “quite a lot” of confidence in 2020 to 44 percent in 2021. The ups and downs of the COVID-19 pandemic and the recent challenges around vaccinations have likely contributed to declining confidence and trust in many of our most important institutions, including health care.
The Essential Drivers of Trust
Recently, I have developed an appreciation for the work of Frances X. Frei, Professor of Technology and Operations Management at Harvard Business School. Frei focuses her work on helping leaders and organizations to develop empowerment cultures in which people can fully realize their own capacity and power. To build an empowerment culture, it is essential for leaders to build trust.
According to Frei, trust is driven by three key components: authenticity, logic, and empathy. As Frei and Anne Morriss have written, “People tend to trust you when they believe they are interacting with the real you (authenticity), when they have faith in your judgment and competence (logic), and when they feel that you care about them (empathy).”
As I understand Frei, authenticity is important for trust because we are not going to be good at anything other than being our true selves, and authenticity matters when building strong relationships with others. Logic is important in building trust because people need to have confidence in the strength of your ideas or your ability to carry them out, and you need to communicate clearly about the rational strategies you are pursuing.
Empathy is crucial when building trust, but maybe not in the way we typically think of it. The usual thinking around empathy is that we have to walk a mile in the other person’s shoes to have it. Frei’s conception of empathy is about centering another’s experience. In health care, we learn — and build trust — by focusing on the experience of an individual, a population, or a community. Consistently putting our own interests first makes it difficult for individuals to believe we care about them. As Frei and Morriss write, “If people think you care more about yourself than about others, they won’t trust you enough to lead them.” Even if we can’t walk a mile in someone else’s shoes, we can build trust by demonstrating our willingness to place the experience of that individual in the center of our thinking and designing a system around it.
With the patient and his wife who were waiting days for an MRI, instead of focusing on myself and getting defensive, I offered them a reason to trust me by making clear that I shared their frustration, wanted the same thing they did, and was willing to partner with them to co-produce a solution. I did not realize it at the time, but in retrospect, I had chosen to sit with them in empathy and that changed everything.
The patient’s wife came with me to radiology and the MRI happened later that afternoon. The next day, when we were sending the patient home, the whole dynamic of our relationship felt different. I do not know for sure what they thought of the entire interaction, but I believe they went from seeing me as an adversary to a trusted ally.
Can Trust in Health Care Be Rebuilt?
One of the most hopeful things Frei says about trust is that it is possible to rebuild it. According to her, when trust is broken — or never fully developed — it is almost always due to a breakdown in authenticity, logic, or empathy.
Frei calls these breakdowns a “wobble” to indicate that trust can be shaken and put off balance, but it is not necessarily permanently damaged. Trust can be repaired when you acknowledge the break and take intentional action to address the drivers of trust. Or, as Frei and Morriss, put it, “When you take responsibility for a wobble, you reveal your humanity (authenticity) and analytic chops (logic) while communicating your commitment to the relationship (empathy).”
My experience as IHI’s CEO bears this out. I can think of countless examples in which we have wobbled, and I have learned that earning and regaining trust is an ongoing endeavor. It requires thoughtfulness over time and consistency about how to listen with humility and empathy, and then how to transfer power in co-produced relationships. It takes time — and many repetitions of these actions — but I am convinced that building trust is essential to improving human health, and building trust in the world requires us to build trust within our organizations. At IHI, this means better feedback loops, more informed decision-making, stronger engagement from all parties, and clearer expectations on all sides as to how we should do the work of improving health and health care worldwide.
Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, social justice, leadership, and improving health and health care worldwide.
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