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.