Trust as the Critical Component in the Complex Medical System

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Contributor / Lynda Chin

Director of REDI Platform,
Former, Associate Vice Chancellor for Health Transformation &
Chief Innovation Officer for Health Affairs
The University of Texas System / Health Management

One-on-one relationships keep things simple. But as our healthcare systems keep expanding, patients interact with an increasing number of healthcare professionals. Data management, then, becomes exceedingly complex, creating challenges in maintaining standards and the flow of communication across disparate medical teams. In her video, Chin discusses these challenges and how to deliver trustworthy data that enables physicians to make better decisions for their patients.

Transcript

My name is Lynda Chin. I am, by training, a physician who has spent time in private practice, but spent most of my career in academic research focusing on genomics, cancer genomics, and really seeing firsthand how the advances in technology and science are impacting and dramatically changing the way medicine is practiced or will be practiced.

If we look back at a century ago, the relationship between the patient and the physician is very different. It was a relationship based on trust.

You have your family doctor for generations and you trust them, and they know you.

As medicine becomes more complex, as we understand biology more and we start to understand the complexity in medicine, the field has evolved to have many, many specializations.

So there’s no longer one single doctor who takes care of health. It is more likely tens and hundreds of doctors and nurses that are involved in our care.

I think to manage this complexity in medicine today we need to have our doctors work as one team so that there is still this one-to-one relationship, you know, from a patient perspective, that the system works together to help take care of the person’s health. That means that team of doctors who are most likely not even physically in the same facility need to be able to function as a single team.

That means they have to be able to share information, and they have to be able to trust each other. If they don’t trust each other, then the team breaks down. And that trust is predicated on, I believe, transparency.

Bumper: Transparency as the Foundation for Trust

When it comes to being able to make a decision I need to be able to trust that you have made the right decision.

That means I have to know what that decision is, what the context was when you made that decision, and all of this requires being able to get access to information. And that information isn’t just any kind of data. It has to be data that we can trust. That means how the data is collected matters a whole lot. I have to be able to interpret the data because there is a standard. So if there’s no standard, I can’t really use the data to create the sense of confidence that I can build on the data and the result you have generated.

So, I think to create the transparency which translates into confidence and trust, we have to have sharing of the data, we have to have standards so that we have confidence the data are collected properly, and then we have to have a standard so that we can compare from one to the next so that we know how we can interpret the data.

Bumper: Trust and Artificial Intelligence (AI)

Medicine has gotten more complex, the amount of data and knowledge have exploded, and I would say our human brain hasn’t gotten bigger. So we need help. That’s where AI, like analytics, comes in to not just help organize the data, but help interpret some of the data so that it generates actionable information to help an individual make decisions.

I see that AI has great potential to really impact the practice of medicine. Not to replace the human decisions, really, but to help interpret data that are not black and white. You know, there’s an art to medicine. A straight rule-based analytic is not going to help the physician, and that’s where the artificial intelligent-like or machine learning, or cognitive analytics come into play that are much more probabilistic. But, that also introduces another factor into trust. How do I trust that the AI system is making the right interpretation?

I don’t have a black and white answer. As the technology advances and matures, we will learn to use artificial intelligence more and more in the most appropriate way that can really help physicians deliver better care without taking that decision-making capability out of that human-trust relationship.

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Impacting Patient Outcomes Across the Value Chain of Lab Medicine

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Contributor / Vahe Ayvazian
Vahe Ayvazian Diagnostics Institutions and Context,Broken Trust,Reputation Management,Healthcare,Communication I'm the Director of Marketing on our U.S. diagnostics business at Abbott, and before that spent 12 years at Procter & Gamble in various marketing roles from healthcare to beauty care, in U.S. based roles, global roles and customer roles.

As you think about the diagnostics industry overall, in the most simplistic sense, it's when you get a lab test done. It's a vital industry. One of the statistics that's talked about all the time within the industry is that 70 percent of clinical decisions are based upon a lab test.

So, when you think about the decisions that clinicians and physicians make every single day, ultimately the majority of those are based upon lab data. I would say that the lab industry takes enormous pride in the quality of the re sults that they provide.

From the physical specimen and how it's processed all the way down to the report generation that goes in there, you could argue within the entire healthcare system there is nothing that is more efficient today and more accurate from a repeatable standpoint than the laboratory testing.

Bumper: The Role of Trust in the Lab Medicine Value Chain

As we think about trust in the industry for diagnostics, it really has been deemed as a manufacturing site. So, when I would ask physicians, when I asked people in the lab, even hospital executives what can the lab do better, and what I hear consistently is increasing the turnaround time of the result and reducing costs.

For me the light bulb really went off that the lab truly is seen as a manufacturing site, and it takes great pride in that, and it should. From that operational efficiency that it can provide. For me, it's a cultural piece within healthcare institutions, and it's a cultural piece within society, as to how much do we really think about it and even care what our laboratories are doing everyday.

They've just been so good at such a small part of their job that there is just enormous trust to say that: yes I'm ordering a test and that result will be accurate. But, again it becomes the question of what did the laboratory, and what did that head of pathology, do to actually ensure that, that physician was interpreting those results correctly or even ordering those right tests.

That is a conversation that in most institutions today isn't happening. The lab is trusted to provide accurate results, but they're not trusted, or quite frankly enabled, to have that conversation where they can provide value in a much deeper way across the value chain of lab medicine and ultimately impact the patient outcomes.

Ultimately, when you think about some of the news of negative results right now, where the assumption was from some companies doing lab testing that the results were accurate when they actually weren't.

People's lives were truly put in danger because the wrong clinical decision was being made based upon the diagnosis from the lab tests. I would flip it to say how do we turn that into a positive thing, and how can we begin to have a conversation as a society, and across our healthcare system where we begin to talk about the importance of, and the pride that should be taken in, the high quality testing that's being done, and the right test being done at the right time.

We want to shift the lab from being a manufacturing site to being a clinical decision support center, and that in many ways is the broader vision that we're trying to drive. Abbott can play a part within that vision, but ultimately we're just a small piece of the larger vision that we're trying to drive for the lab and also for the broader health system.
Trust in healthcare is especially critical when a child's health and well-being is at stake.

Trust and Vulnerability: A Pediatrician's Perspective

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Kelly Michelson Pediatrics Definitions,Distrust,Government,Healthcare,Institutions and Context,Regulation,Reputation Management,Vulnerability Trust is really about relationships. And it can be relationships between people; it can be relationships between a person and an organization; or it can even be between people and events.

People actually have different definitions for trust, and I think it’s important to think about, what do we mean by trust? Some would call it an “action based on expectations of how others will behave in relation to yourself in the future.”

Another definition of trust that applies well in the healthcare setting is the following: “the optimistic acceptance of a vulnerable situation in which the trustor believes the trustee will care [in the] trustor’s interest.”

There are some parts of that definition worth emphasizing — in particular, this notion of “vulnerability,” that there has to be some sense of vulnerability in a trusting relationship, whether it starts from that place or develops into a vulnerable place.

So, you can imagine having a relationship with someone, and once you’re very trusting of that person, that actually can make you more vulnerable.

More commonly in the healthcare setting, though, we see a patient who because of their illness, has some inherent vulnerability, and that helps to set up a situation where trust can build.

Another important piece of this definition is this concept of motivation — the idea that, in a trusting relationship, one person is doing something caring for another person or something in another person’s best interest.

And finally, embedded within this definition is the notion that trust is a forward-looking concept. While it may be influenced by past events, it really describes how a person or organization behaves moving forward.

BUMPER: Trust and Distrust


In talking about what trust means, we also have to consider what’s meant by “distrust.” And while the jury’s kind of out about a clear definition, I think there’s some important things to talk about.

Some people would talk about distrust as the absence of trust, the lack of familiarity, sort of not having a feeling one way or another.

Another way to look at distrust is that it’s the opposite of trust, that it’s a situation where a person is pessimistic or concerned about another person’s motivations.

And finally, one can think about distrust as a substitute for trust, not necessarily the opposite of trust. So, at some level, you can have distrust and trust at the same time.

For example, maybe I get sent to an emergency room, and I feel confident about the situation because I know it’s a good emergency room. But something happens, and I sort of feel like, “Well, I’m going to hold out and reserve judgment.”

So, you can kind of share a sense of trust and distrust simultaneously — this notion about trusting, but “let me make sure that’s really the case.”

BUMPER: Trust in Individuals and Systems

When we talk about trust in health care, I think it’s important to consider it in relationship to different groups: you can have individuals, and you can have systems.

Even in this individual group, you can identify differences. So, you can have a particular one individual — a doctor or a nurse. Or you can have kind of an institution that’s an individual institution within a larger group — so, maybe one hospital within a whole healthcare system.

And then you can also look at it from a more systems perspective. And even in that context, there are more individuals and then more institutional things.

For example, maybe the group or system of how emergency doctors function or how surgeons tend to function is maybe a more systems approach — or you have how a particular institution (how hospitals work) can also be a more systems-based perspective.

The other thing to keep in mind is that relationships can be personal and they can be impersonal in the healthcare system. So, again, I use the individual doctor with their patient as a very personal relationship.

And even a patient may have a personal relationship with a hospital. You can imagine having a feeling of trust for a particular hospital and, in that way, kind of personalizing that relationship.

You may have someone who doesn’t believe in western medicine. So, even this concept of western versus non-western — this system of western medicine versus non-western medicine — is important for some patients.
Trust building begins by showing you care and are willing to comfort and support another.

Building Trust by Learning to Listen

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Contributor / Kelly Michelson
Kelly Michelson Pediatrics Healthcare,Reciprocity,Regulation The pediatric intensive care unit can be a very complicated place with a lot of players — there’s doctors, nurses, social workers, chaplains; there’s a lot of people just in the PICU itself.

And then for a particular patient, there may be even more physicians — subspecialists, other providers, just a lot of people running around all the time and people changing over.

I think each component of this VALUE mnemonic is important: we want to value what the family is saying; we want to acknowledge whatever emotions the family is going through; we want to listen; we want to understand where the family is coming from; and we want to elicit questions from the family so that we know that they understand as well.

If I had to focus in on one or two things, I would highlight two. And the first is the L for listen.

When we’re having these conversations, one of the ways that we can help support families is to stop talking and hear what they have to say, even if it means silence, because sometimes it’s in the periods of silence that families realize what they can or feel like they need to say.

And then, the other piece of it that I think is really important and sometimes doesn’t get as much attention is the piece about getting to know the patient or the family or what their issues are — asking them sometimes personal questions about why they feel a certain way, why they’re making a particular choice, and even personal questions about what their situation is like, whether it’s unrelated to the actual decision or discussion that’s going on.

I think it’s really helpful to know that the patient likes to swing on the swing.

And that kind of conversation fosters a lot of trust and support from both sides. So, now the mother knows that I care about her child, or the father knows that we care about their child.

And the healthcare provider also has a personal investment in this particular patient because now I can see what this patient looks like swinging on the swing, and I have a whole different perspective after that kind of information.

BUMPER: Learning to Trust Your Patients

In pediatrics, it’s rarely the patient who decides — sometimes, but rarely — it’s often the parent.

In an ideal world, we’re all making decisions that are important for this patient; we’re not even making decisions necessarily about ourselves. So, when you feel like you don’t have trust for a parent who’s making a decision about a patient, it can be very challenging.

And I think that one of the things that can help mitigate some of those challenges and help smooth things over is to really focus on understanding why the parent is doing or saying what they’re doing, where their behavior comes from.

And I can give you an example. There’s a parent in the intensive care unit whose child has a cancer that’s metastasized and who will likely die — their child will likely die.

And this parent has very difficult interactions with the healthcare team and is often questioning things and doing things in a way that you can’t imagine how that’s helping their child.

But I think that if we understand what the perspective of that particular parent is and why he or she feels that way, and if we look back and we realize that maybe it took this particular parent two months to get their child into the hospital and they feel guilty about that and that they impacted the outcome and that a lot of those emotions influence how they behave, I think it can help unpack the situation.

Really trying to understand the perspective of the parent can be useful when there’s a sense of distrust about what the parent is doing and why.

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Pages in The Trust Project at Northwestern University