Harvard Public Health Review
Crisis of Confidence
If HSPH's crash course can help rebuild trust in the health care industry, the results could be as powerful as any medicine available today
Across the United States, trust in institutions that guard the public's health and provide care has fallen to an all-time low. Patients mistrust insurers and pharmaceutical companies, and lack complete confidence in their doctors; physicians, in turn, are skeptical of clinic and hospital leaders. Citizens doubt government's ability to protect them from epidemics and bioterrorism, deriding each new "orange" or "yellow" warning as an empty scare.
That's the assessment of representatives of the Harvard School of Public Health led by David A. Shore, executive director of the Center for Continuing Professional Education and an expert on health care branding and marketing. Backing up theseperceptions, they say, is a growing body of research and polling data.
Why does trust matter? Eroding trust jeopardizes preparedness and takes a toll on people's health and well being, they say. It makes the public skeptical of expert advice concerning smallpox and flu vaccines alike. It drives patients to take their care into their own hands, self- medicating or relying on unproven remedies. It breeds costly regulation--and litigation.
To help health professionals understand the roots of mistrust and craft strategies to restore it, Shore launched the HSPH Trust Initiative. Since 2002, the program has drawn public health and health care administrators, pharmaceutical company directors, physicians, nurses, and representatives of the Department of Health and Human Services (HHS) and Centers for Disease Control and Prevention (CDC). Shore also takes the program on the road, addressing National Institutes of Health leaders last spring as well as an invitational conference in Tuskegee, Alabama, on health disparities. Due in 2005 are two books on the trust issue, and a new program on the expanding role of key intangibles--trust, branding, and reputation--on health care's future.
"This symposium's topic and agenda are absolutely the most important issue in America's current health care delivery system," wrote Michael Fletcher, MD, of Lee Memorial Health System in southwest Florida, in his evaluation of HSPH's program. The lack of trust in doctors, health care systems, government, and third-party payers damages the practice of medicine, continued Fletcher, a director on Lee Memorial's board, and only total openness and transparency can salvage it.
The Roots of Mistrust
In the 2002 movie John Q, a HMO-style insurer refuses to cover life-saving surgery for a small boy. Desperate, the boy's father takes an emergency room hostage and forces a doctor to operate. "The film struck a chord with American audiences," Shore says, "because of a widely held belief that insurers put financial interests above patients' health."
That attitude marks a precipitous fall for U.S. health care from its trusted position 50 years ago, in the heyday of antibiotics and X rays. The image of physicians as benevolent Marcus Welbys began to wither in the 1960s, however, as Medicare and Medicaid bureaucracies encumbered the doctor-patient relationship. With the 1980s and '90s came managed care, for-profit hospitals and insurers, shorter patient-doctor visits, and that blunt, all-business question, "Do you have health insurance?"
Since then, Shore notes, service has declined while premiums have risen. News headlines have fueled public suspicion by spotlighting both tragic medical errors (Boston Globe reporter succumbs to cancer chemotherapy overdose) and fraudulent practices (a hospital scam to bilk Medicare of $2.6 million). Meanwhile, government has been unable to resolve two problems Americans consider urgent: rising health care costs and the growing ranks of the uninsured.
Racial and ethnic disparities also taint doctor-patient interactions. Shore points to the fresh wave of revelations in 1997 about the U.S. Public Health Study at Tuskegee, Alabama from 1932 to 1972, in which doctors withheld treatment from black syphilis patients without their knowledge or consent. Minority groups believe they are treated unequally, according to the Institute of Medicine. Indeed, Shore notes, news accounts of the 2001 anthrax attacks alleged that racism was to blame in the death of one man among largely African-American postal workers who were not offered the antibiotic Cipro, unlike Senate employees.
Confusion, dismay, and "alarm fatigue" have intensified, Shore says, in the wake of reversals in research findings (e.g., hormone replacement therapy) and contradictory health advisories (eat fish; avoid fish tainted with mercury). People shrug: "I'll just do what I want. There'll be a new study next week anyway."
As the divide between Americans and their health system widens, people postpone doctor visits and don't follow treatments reliably, Shore says. Patients insist on antibiotics for viral infections, and ignore advice to exercise more and eat less. They try unproven alternative medicines, and withhold vital information about their medical history or behavior. And they decline participation in clinical trials.
The consumer health movement, patient's bill of rights, the health information privacy act, hospital rankings, concierge medicine, and the overuse of services ("defensive medicine") are all what Shore calls "fallouts of mistrust." Isolated medical scandals cast long shadows: a doctor's dramatic error in Pennsylvania weakens trust in a health center in Oregon.
As these negative effects mount, public health practitioners have come to appreciate the importance of trust in their line of duty. Asked in Congress in 2003 if the nation's public health system could handle a SARS outbreak or bioterrorism attack, Shore notes, CDC Director Julie Gerberding replied, "You can manage people if they trust you."
Shore knew he had hit a raw nerve while concluding a 1998 Wall Street Journal keynote address on health care branding. "I invite you to think of something you'd rather be known as than a trusted provider of health care," he said, a remark that elicited more discussion than any other point. Similar remarks at other forums had the same catalytic effect.
"What struck me was the universal nature of the trust issue, from Wall Street to Main Street to the developing world," Shore recalls. At HSPH, he says, deans and faculty were likewise intrigued: "They thought we'd identified an important area and come up with something fresh and new."
To define trust, Shore and faculty co-director Marc Roberts, professor of political economy in the Department of Health Policy and Management, turned to Roberts' mentor, Nobel Prize-winning economist Kenneth Arrow. Arrow outlined two pillars of trust: competence (faith in another person's expertise) and conscience (faith in that person's integrity, values, and honesty).
Roberts suggested that the Trust Initiative probe two questions: What must health care providers and institutions do to be perceived as trustworthy? What must they do to be worthy of trust?" The initiative presents these trust-building tools, whose common threads are consistency, communication, and caring:
Embrace Trust as a Mission
Articulate the importance of trust in your every endeavor. Think of trust as a brand, in the way safety is Volvo's brand. A clinic serving poor, uninsured patients should no more offer cosmetic surgery than Volvo should sponsor extreme sporting events.
Protect the Trust Mission
Organizations must ensure the trustworthiness and consistency of their every action. A simple rule of thumb asks: Does an act inspire trust? Not inspire? Or breed mistrust?
"All caregivers and employees of a health provider, all government and public health officials are ambassadors of trust," Shore says.
The public cannot separate untrustworthy individuals from their institutions, comments Trust Initiative participant Rueben Warren, who encounters this problem in his work for the CDC. This rule acquires added importance in corporations and government agencies, Warren notes, where the actions of one branch can undermine trust in another.
Appoint Trustworthy Messengers, and
Check their Effectiveness
The public needs information and advice from experts explicitly entrusted with protecting their health, such as the U.S. surgeon general, not politicians, law-enforcement officials, and the like.
"During the 2001 anthrax attacks, we heard confusing messages from the FBI, Homeland Security, and HHS," laments Trust Initiative speaker Robert Blendon, HSPH professor of health policy and management. It pays to ask people what they understand about a health issue so that misperceptions can be corrected, says Blendon, who designs public opinion surveys, including CDC polls. As an example, he points to a 1980s survey that showed adults thought they could catch AIDS in the same way people caught the common cold.
Why do patients tend to trust their personal physician, but not their health system generally? "People trust doctors who talk with them, care about them, remember them," notes Shore. Establishing trust is hard when patients don't see the same physicians consistently. Many managed care organizations strive to provide consistency, he says, but the problem is intractable for the uninsured.
Doctors need to be good communicators. "The three most important things I say to patients are 'I'm sorry,' 'I don't know,' and 'Let's find out together and decide what you should do,'" volunteered Trust Initiative participant Terrance Hammer, a family doctor from California.
Will building trust make a measurable difference for public health? The science of linking trust-building measures to specific improvements is in its infancy, but HSPH's Trust Initiative lays groundwork: Participants are asked to define strategies to put trust higher on their agenda, then measure the results
"For years, I felt that health care organizations were not selling health care services, but something less tangible and far more important," says Tom Schultz, former senior vice president of strategy for Baptist Health Systems in Alabama, who has attended three HSPH trust programs. "These programs help me understand problems with trust in a very objective, research-based manner."
"Trust is an important lubricant of the social system," wrote Kenneth Arrow. "It is extremely efficient; it saves a lot of trouble to have a fair degree of reliance on other people's word it [is] essential in the running of society."
Trust also lubricates public health. Without it, the gears of the nation's health system will continue grinding down.
Cathryn Delude, who is based in Andover, Mass., writes about health and science for the Howard Hughes Medical Institute Bulletin, The Scientist, the Boston Globe, and other publications.
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