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