Trust: In Healthcare and New Media

A Twitter friend turned me on to Julien Smith and Chris Brogan's Manifesto on Trust Economies. Which got me to thinking of an early morning exchange I had with a panelist at the Health 2.0 Conference in October 2008 in San Francisco.

The panel was a second presentation of the Edelman Report on Infoentials in Healthcare which was held early the second morning of the conference after the previous day's scheduled presentation was mobbed. I found the Edelman Report quite a cause for optimism, mostly because of the observation, that on-line information coupled to expertise scored significantly higher in confidence among infoentials than did on-line information alone. "The most credible source for health information is 'my doctor or healthcare professional' (96 percent)."

This observation on value added by the trusted physician provoked me to comment to the panelist that trust is multilayered and  begins when the parties involved: practitioner (or per Edelman a website or service) and patient/consumer find one another "trustworthy". Trust evolves as the parties experience one another and grows as this experience of trusting serves those involved.

Smith and Brogan's "Manifesto" makes the point explicitly and in rather utilitarian fashion. I've also been reading Robert Solomon & Fernando Flores, building trust in business, politics, relationships, and life since Kent Bottles of the Institute for Clinical Systems Improvement told me about.

I'm further prompted in these comments by Michael Millenson's comments on the Health Affairs Blog about Jay Katz. I loved Millenson's piece because with an experienced essayist's precision, Millenson lays out Katz's skepticism for the practice of medical research and medicine as he knew it in his era with its wholesale abrogation of physician trust for the patient.

Given that Katz in The Silent World of Doctor and Patient was writing during and about an era for which I still hold remnants of a romantic fantasy and confidence in the righteousness of those physicians I idolized either personally or by reputation, Millenson's essay both calls me to finally shed that fantasy and imbued me with the energy to complete this post.

In the practice of medicine, historically trust began with patient and physician finding one another "trustworthy." The sheepskin on the wall, the neighbor's recommendation and the practitioner's physical appearance ("like me" in physiognomy; "better than me" in habitus and often wealth) gave the patient reason to find the physician "trustworthy."

During the twentieh and now twenty-first century, the physician has been explicitly trained to suspend disbelief--presume the patient trustworthy. Certainly we practitioners have also learned to look beyond the bare bones narrative for what the tale may obscure or imply as much as what the patient's recounting discloses; still, the clear theme has been and continues, "The patient tells you the diagnosis if you'll but listen."

Out of this suspension of disbelief and presumption of trust, the physician and patient sought a caring and comforting relationship which in historical terms was about "Curing sometimes, relieving often and comforting always." Or as Francis Weld Peabody put it (J Clin Invest. 1927 December; 5(1): 1.b1–6.) "One of the essential qualities of the physician is interest in humanity, for the secret of the care of the patient is in caring for the patient."

Writing here as a physician trained in the 1970's and the son of a physician who was trained in the 1940's I'd like to fantasize that I still maintain a strong connection to that ethos and the trust that may be developed through "caring for the patient."

Though I lead and teach physicians as my life's work and I engage this issue every day with a hopeful mien; at my core I despair: Few physicians of my acquaintance approach each patient interaction with a suspension of disbelief and a presumption of a trustworthy patient. No, fortunately such suspicion is not universal, but it is widespread, particularly in my own field of emergency medicine. If my reading of general medical journals and many websites and blogs is to be believed, others see it as well. Perhaps you think I'm suffering from the "availability heuristic"?

There are many possible contributors to this state of affairs, perhaps the medical negligence environment contributes, regulatory structures around advising victims of domestic violence, the well-founded and appropriate concern for finding and reporting abused children--complete with a penalty for the physician who fails to do so--all contribute and create an inherent suspicion around many injured patients regardless of the compassion of the practitioner. I'm sure some will dispute these suggested contributors and perhaps you identify a more critical factor I've overlooked. Please add your comments below.

In short, there are environmental as well practitioner (and patient/consumer) contributors to trust deficiencies in healthcare today and in the absence of maintenance, entropy takes over and trust decays.

It certainly has done that in practice and it is unlikely that primary physicians in 15 minute encounter will rapidly rebuild it. A troubling conundrum indeed.

Just Recertified--Am I competent, good, outstanding . . . or not so much? Bob Wachter wants to know.

In a year-old post on The Health 2.0 Blog Bob Wachter points to the activities of commercial ventures including Healthgrades, Zagat and Google to begin rating doctors right along with your favorite city magazine. As is typical for his straightforward style, Dr. Wachter puts himself in the position of seeking information for his own care and concludes that he wants all the differentiating information he can get--including Board Certification ranking of some sort. He would prefer a doctor who scored at the 87th percentile to a doctor who scored at the 5th percentile. That sounds like it makes sense--doesn't it? Seems pretty sensible--a lot of face validity in that opinion--don't you think so, too?

Not so fast; I'm not so sure it works out so well for all doctors.

In the post Dr. Wachter discusses a presentation by Dr. Kevin Weiss, the president of the American Board of Medical Specialties made to the American Board of Internal Medicine (ABIM). Bob Wachter also reveals that he serves on the ABIM and Google's Healthcare Advisory Board; I served for nine years on the American Board of Emergency Medicine (ABEM) and I still read the periodic newsletters from the Executive Director there--I have some idea of what's going on in my own specialty certifying process. I also took and passed my recertification exam this year.

Our board, ABEM, uses criterion referenced examinations rather than norm referenced examinations. I'm not certain our specialty is still alone in that distinction, but at one time we were. While I'm not a psychometrician and I don't play one on TV, either, I've come to understand that our exam is pretty good at distinguishing a doctor who know 74% of the tested material from a doctor who knows 75% of the tested material. The latter will pass; the former will not. As I understand the nature of the exam and the scoring, while it is fair to say that the doctor who knows 100% of the tested material certainly knows more than the doctor who knows 75% of the test material, it's not at all clear that one knows a third more than the other or that the test can tell that the doctor at 100% knows more than a doctor scoring at 90%; it becomes even less certain as the differences become smaller; consequently, the American Board of Emergency Medicine probably can't put its diplomates on a percentile scale as Dr. Wachter suggests may be appropriate, at least probably not based on the testing approach in use today. Not to say that the testing couldn't be changed at some future time.

So Dr. Wachter's smell test notwithstanding and the people's desire for physician ratings very much still in evidence, it's not at all clear to me that the route to the goal is as direct as Dr. Wachter suggests.

Greater transparency in support of better decision-making for patients is a desirable, laudable goal. Reliable physician ratings is probably not coming soon, though city magazines, HealthGrades, Zagat and Google are either already or shortly to begin publishing their own ratings--user beware.

Primary Care Backlash Unfortunately begins with an Emergency Physician

I'm saddened to learn of Jonathan Glauser's column in the December 2008 Emergency Medicine News from KevinMD. He notes, "With the primary care shortage starting to gain traction within the mainstream media narrative, it's inevitable that some will lash back against generalists. (via Bob Doherty)"

Jonathan's a very smart guy and I don't doubt the experience that underlies the conclusions he's drawn and the recommendations he's making in his column, yet, he's missing the bigger picture and as Bob Doherty's blog and associated comments demonstrate the data support investment in primary care--not disinvestment. I regret that I can't support your view, Jon.

Daschle: What Can We Expect Of The Health Czar In Waiting?

Jeff Goldsmith in this Health Affairs blog entry summarizes what we might look forward to in the New Year. I found his pointer to the McKinsey study useful since I've been uneasy for years in my support of PNHP's view of the source of savings in single payer healthcare. Goldsmith's three key ingredients for a health policy book by a Democrat seems on point:

1--Personal interest horror stories;
2--Debunking of Himmelstein/Woolhandler/PNHP assertion on 31% of health costs due to "administration". (See the McKinsey Global Institute’s 2007 “Accounting for the Cost of Healthcare in the United States” for a more rigorous analysis);
3--Mention of the WHO study ranking the USA 37th in the world in health care.

The piece goes on to discuss the Federal Health Board and why it might work and what political barriers to implementation it could face. I've been fascinated for years by the hesitancy to adopt a technocratic approach to the underlying issues of coverage and benefit--the diseases and technology to treat them are arcane. Perhaps at this moment the body politic suffers from sufficient fear of the complexity and of the financial abyss confronting employer paid healthcare so that rationalization whose goal might be improving upon "the failure of the intermediation system to provide sufficient incentives to patients and consumers to be value-conscious in their demand decisions, and establish the necessary incentives or mandates to promote rational supply by provider and other suppliers." (McKinsey Report cited above).

Ah, "incentives or mandates . . . ". Physician, heal thyself.

Hospital Marketing in the Web 2.0 World

So what does this book have to do with hospitals--aside from the title of this post?

I learned of this book because I read Robert Scoble through the RSS feed of his blog and just recently, Scoble interviewed Kawasaki in an 18 minute video. Guy Kawasaki argues the reality of marketing in the era of social media. He makes the audacious assertion that, "Twitter is the most powerful branding mechanism since television." yet this assertion receives independent affirmation in the unrelated efforts of Paul Levy, CEO of Beth Israel Deaconess Medical Center (BIDMC) Boston who in his activity on twitter @paulflevy and in his blog is successfully marketing his hospital through the social web. My hospital's medical director regularly reads this blog.

Most hospital administrations look at their local market--primary and secondary geographic market areas, usually defined by zip codes. To most administrators Boston wouldn't be relevant to our hospital's market in Brooklyn--today they're right--it's not. Marketing hospitals today is mostly not far removed from how I learned it in my MBA program in 1988. Yet I believe Kawasaki would argue that the social media Web 2.0 tools are awaiting deployment in Brooklyn. Ten postings on Yelp review my hospital, Maimonides Medical Center and nearby NY Methodist's ED was discussed on a community bulletin board.

Kawasaki tells us that if we don't get out there and brand ourselves--others, typically our most vociferous and perhaps disgruntled patient-customers will and are doing it for us.

In Brooklyn we're not competing with Paul Levy and BIDMC which is why we can learn so much from what he's doing; we're competing with our communities to own our brand and to define ourselves in the marketplace. The Web 2.0 social media tools are the way to go and Twitter is a great way to start; Facebook is not just for your college student. Define yourself, don't leave it to others to do it for your. See you on the social web. @sjdmd

Engage with Grace

Engage with Grace is a project I learned about a month ago at the Health 2.0 Conference. Alexandra Drane presented the very personal story of her sister-in-law's death, at home and in direct opposition to the recommendations of her physicians. About 1000 people in the room and you could hear a pin drop--except for occasional sobs--mine included.

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Several dozen bloggers in the health care field and beyond are engaged in a blog rally* this weekend, simultaneously posting the one slide and Alexandra Drane's post to
encourage conversation about a topic that's often avoided but every family ought be discussing: How we want to die.
Please try it, using the slide above as a discussion guide. It's not
that hard to have the conversation with your loved ones once you get
started.

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We make choices throughout our lives - where
we want to live, what types of activities will fill our days, with whom
we spend our time. These choices are often a balance between our
desires and our means, but at the end of the day, they are decisions
made with intent. But when it comes to how we want to be treated at the
end our lives, often we don't express our intent or tell our loved ones
about it. This has real consequences. 73% of Americans would
prefer to die at home, but up to 50% die in hospital. More than 80% of
Californians say their loved ones “know exactly” or have a “good idea”
of what their wishes would be if they were in a persistent coma, but
only 50% say they've talked to them about their preferences.But
our end of life experiences are about a lot more than statistics.
They’re about all of us. So the first thing we need to do is start
talking. Engage With Grace: The One Slide Project
was designed with one simple goal: to help get the conversation about
end of life experience started. The idea is simple: Create a tool to
help get people talking. One Slide, with just five questions on it.
Five questions designed to help get us talking with each other, with
our loved ones, about our preferences. And we’re asking people to share
this One Slide – wherever and whenever they can…at a presentation, at
dinner, at their book club. Just One Slide, just five questions. Lets start a global discussion that, until now, most of us haven’t had.Here is what we are asking you: Download The One Slide
(that's it above) and share it at any opportunity – with colleagues,
family, friends. Think of the slide as currency and donate just two
minutes whenever you can. Commit to being able to answer these five
questions about end of life experience for yourself, and for your loved
ones. Then commit to helping others do the same. Get this conversation
started. Let's start a viral movement driven by the change we
as individuals can effect...and the incredibly positive impact we could
have collectively. Help ensure that all of us - and the people we care
for - can end our lives in the same purposeful way we live them. Just One Slide, just one goal. Think of the enormous difference we can make together.
(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team.)

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* In case you are wondering, "blog rally" is a term invented this past weekend.
A blog rally is the simultaneous presentation of identical or similar
material on numerous blogs, for the purpose of engaging large numbers
of readers and/or persuading them to adopt a certain position or take a
certain action. The simultaneous natu re of a blog rally creates the
ironic result of joining the efforts of otherwise independent bloggers
for an agreed-upon purpose. As far as we can tell, this is the first
recorded use of a blog rally -- occurring from November 26 through
November 30, 2008, in support of a viral movement called 'Engage with
Grace: The One Slide Project' -- organized to encourage families to
discuss end-of-life care issues while gathered together for the
Thanksgiving holiday weekend. This particular blog rally also has a
parallel component on Facebook, where many people are donating their
status to bring attention to Engage with Grace.

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I must credit Paul Levy, President and CEO of Beth Israel Deaconess Medical Center in Boston whose blog, Running a Hospital is where I learned of the weekend "blog rally". Levy is also on Twitter as PaulFLevy.

Employment Arrangements for Emergency Physicians

I meet once a month for breakfast with our EM residents. I learned this from my mentor, David Wagner, who started it well after I was no longer his resident and was serving on his faculty. I know the residents loved having his ear for an hour and there was a lot of give and take. I've been doing this now for five years and our sessions have never had much give and take. The ground rules for the hour are that I have to be able to act on information that I hear, but that nothing I hear will be attributed to the individual. Sometimes more is said than other times, but last year it finally occurred to me that some structure might be useful, particularly if focused around content not usually part of the core residency educational program. While all residents get some exposure to administrative topics, it seemed logical to focus more on these areas.

So as with many things, "Breakfast with the Chair" at my shop in 2008 has become more structured than what I fantasize Dave's were, back in the day. I'm using these sessions to talk to the residents about "life, the Universe and everything." Or at least to discuss some of the basics of selecting life, disability, travel and other sorts of insurance and what's on every senior resident's mind at this time of year: getting a job.

Tomorrow morning I'll discuss the various models of employment offering complete descriptions and trying to avoid judgments, though commenting on the strengths and pitfalls of each as I understand these. On the list will be the following:

• Hospital Employed



• Corporation Employed including single owners, small and large ownership groups, publicly traded corporations



• Independent Contractor models with and without your own Professional Corporation



• Locum Tenens



• Democratic Group grant/earn-in/buy-in models

I'm going to point them to this page with the suggestion that they pose their comments and questions here, too.

Farad Johnmar Discusses Health 2.0: Fad or Fundamental?

Fard Johnmar at HealthcareVOX nicely summarizes and explores some of the concerns I've been feeling as I've vacillated over attending the Health 2.0 Conference next month in San Francisco. I do think the fundamental concept is valuable, I'm concerned by the sound of hype inherent in the term: language does create its own reality. Nonetheless, I'm headed for San Francisco for the conference on my way to Chicago (I'm starting from Brooklyn, NY) for the annual ACEP Scientific Assembly.

I'd like to suggest that consistent with his theme, he could sharpen both his diagram of the four "clogged arteries" and his explanation of its content. First the diagram itself could benefit from the third dimension, I envision a cone the base covering the entire diagram and drawing to a point at a figure/avatar representing the user-consumer-patient-community of users.

I suggest this blanketing user-consumer-patient-community of users input not to hold this central aspect (We used to call it "patient-centered" and "family-centered" care.) outside or orthagonal to the concept embedded into the diagram, but rather to respect the underlying thoughts while refining the concept. For I see in all four of the "clogged arteries" components of purely professional endeavor and components of professional interaction with user-consumer-community of users.

Medical Decisions seems especially fraught. Perhaps that's just me, a physician-educator-executive, responding to the term in this context when my efforts over the past 30+ years in this realm are best crystallized by Jerome Groopman in How Doctors Think where the focus is really on how doctors make medical decisions. The user-consumer-patient-community of users certainly does as well, differently and at many different levels. Johnmar in conflating physician prescription practice with managing end-of-life care cost rather crosses many more boundaries than I can comfortably traverse within the core concept--at least so long as I'm devoting the attention I am to young physicians learning the practice of making medical decisions.

The implications of Molly Coye's (HealthTech) observation that hospital expenditures are shifting away from labor expenditures and towards capital, both facility and technological, seems fundamental to this transition time as well. I don't know if any hospital has asked its community if the user-consumer-patient-community of users would prefer a new MRI machine or a patient navigator program. Both is too glib an answer, which while not unrealistic today in many environments, may soon become so.

The exposure to these various constructs is provocative and mind-expanding. I'm looking forward to meeting some of the progenitors of the Health 2.0 concepts and the entrepreneurs who are seeking to bring it to fruition. There has to be a pony in there somewhere.

Certifying Commission for Health Information Technology (CCHIT) and the Personal Health Record (PHR)

Yesterday I received notice of the CCHIT's next steps in certifying PHRs. The message was broadly addressed, I'm sure the entire CCHIT mailing list received it. Note the request for help in spreading the word. It's somewhat ironic that this organization--with which I participate as an ED Workgroup member--whose mission is "to accelerate the adoption of health information technology by creating an efficient, credible and sustainable certification program" seeks to speak to consumers through its marketing director.

I guess this calls for redoubling my own efforts from the inside.

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Today we are launching a program to increase the consumer participation in our personal health record (PHR) certification program development. And we could really use your help in spreading the word. If your organization has a communication channel to consumers, we would really appreciate it if you could carry the included information to them. I have attached a Word and PDF version of our invitation for your use (editor note: Same content as this post.) I would be happy to expand on this if you need more or customize it for your use if that would help.

We have several new activities in which consumers can participate:

·         The Commission has completed its first step, the creation of draft criteria for testing PHRs. Beginning Monday, Sept. 29, the criteria will be posted to http://cchit.org/participate/public-comment/  and available for a 30-day public comment period.

·         A new Web site and blog dedicated to furthering the conversation about PHRs, www.phrdecisions.com, will launch on that same date.  A consumer’s guide to certification of PHRs will also be available there. 

·         On Friday, Oct. 10, the Certification Commission will host a special free Town Call teleconference that will allow consumers and consumer representatives to gain a better understanding of PHR certification and how they can play a role in the process. The Town Call will include a presentation by Dr. Mark Leavitt, chair of the Commission, and Dr. Jodi Pettit, the staff leader of the PHR Work Group. It can be downloaded by Oct. 9 at www.phrdecisions.com.

Participants in the Town Call can ask questions during the call or online at www.phrdecisions.com. The questions and answers will be posted online following the teleconference.

The dial-in information for the Town Call is:
4:00 pm ET/ 3:00 pm CT/ 2:00 pm MT/ 1:00 pm PT

Participant Dial-In Number: 1 (877) 313-5342
Conference ID Number: 65204557

C Sue Reber

Marketing Director, CCHIT

Certification Commission for Healthcare Information Technology

503.288.5876 office | 503.703.0813 cell | 503.287.4613 fax

sreber@cchit.org

Is it time to drag private physicians out of the paper age?

Editorial

Our Pen-and-Paper Doctors 

Published: June 24, 2008 

If this country does not accelerate the conversion from paper to electronic health records, many health care reform promises will become irrelevant. 

Yes. So? 

American physicians are still paid on piece-work; productivity matters to them and their families. Seeing patients pays the mortgage and feeds the family. 

I've successfully implemented an electronic medical record that has served more than one-half million patients since 2002, yet I know that we've accomplished this only by sacrificing physician productivity even as we've improved overall productivity in our emergency department. Optimizing an entire system often requires that components of the system operate at less than optimum in some fashion. 

We can do this at my hospital because our physician staff is only partially compensated by piece-work and the alternative subsidies could be adjusted. 

The NY Times got it wrong this time. Private physicians behave as they do in response to the totally distorted payment system--even the term "reimbursement" so common in this context is evidence of this distortion. 

My Dad, an internist, used to say that the head-bone is connected to the foot-bone. He practiced internal medicine and gastroenterology and empirically experienced connectedness of the head-bone and the gut long before we had the science proving it. 

It's not the private physicians who must be dragged out of the paper age. It's the payment system and the financing of healthcare in 21st century America. 

The NY Times should castigate our policymakers, not our practitioners.