The word trust is widely used in our society. You can find it in the names of financial institutions (such as the Northern Trust bank in Chicago), ecological initiatives (Rhode Island's Southside Community Land Trust), and advertising and marketing (as in the many pitches assuring us that we can trust the entity doing the pitching). It even appears on our currency, albeit in reference to a higher authority.
Why Do We Need to Trust?
Why is trust so important? After all, most of us have to deal, to one degree or another, with people and organizations we don't trust (remember, I live in Chicago). And whether you trust someone or not, if he or she holds power over you, or is in possession of a firearm, or is blackmailing you, or is able to charm you out of your doubts, then the amount of confidence you have in that person is irrelevant.
In the end, we need trust, not because it is always deserved, but because it is the basis of most relationships. We send our children off to school, trusting that they will be safe and will get an education. We drive our cars, trusting that huge 18-wheeler to stop at the red light. We put our money in banks. We step into crosswalks. We buy stuff with credit cards. We confide in others.
This is not to say that all of these acts of trust have not, on occasion, led to betrayal, often with tragic results. It is to say, rather, that to get along day-to-day, we have to trust a lot of people and things.
And nowhere is trust more pre-eminent, or more necessary, than in the health care environment, where people often must trust strangers with their very lives, in situations that may have come on suddenly and are both mysterious and frightening. Trusting others, on these occasions, is not optional.
A Decade of Erosion
But something has happened to our capacity for trust. Perhaps it began with Enron, a firm people trusted as it transformed itself from a natural gas company to a major energy trading force and high stock market flyer. This year, as we mark (celebrate is most definitely the wrong word) the 10th anniversary of the beginning of the unraveling of Enron's web of lies and thievery, it's time to take a hard look at Americans' loss of faith in institutions, including health care, and what might be done about it.
Figuring out what has taken place isn't rocket science. In the 1920s, a Wild West-style stock market eventually self-destructed, taking the world economy and American prosperity with it. We apparently didn't learn much; 80 years later, nearly nonexistent laissez-faire oversight led to the corruption of Arthur Andersen, then considered the gold standard of auditing firms, when its accountants and consultants looked the other way as Enron went south. The energy giant's bosses continued to urge their employees to buy Enron shares even as they were dumping theirs.
In recent years, the temptation of massive profits from the sale of real estate derivatives (many based on subprime loans) led such firms as insurance behemoth AIG, which had no business being in that line of work, to take huge chances with other people's money (it's always other people's money, isn't it?). The brokers at Lehman Brothers (now defunct), Bear Stearns, Goldman Sachs and other major traders did the same, until the whole house of cards crashed.
Was it any wonder that, at the end of the first decade of the 21st century, nearly 10 years after the beginning of the end for Enron, it was revealed that Bernard Madoff, one of the darlings of the investment world, was actually a sociopathic charlatan who would cheat anyone—up to and including Holocaust survivors—to maintain his sybaritic, excessive lifestyle? My God, the man had custom-made branding irons so he could initial his steaks while he grilled them!
And for nearly a decade, financial analyst Harry Markopolos kept trying to tell anyone who would listen at the Securities and Exchange Commission (where no one was willing to do so) that Madoff was a fraud.
Add to that a raft of scandals in government, from Louisiana Congressman William Jefferson, who kept bribe money in food containers in his freezer, to Governors George Ryan and Rod Blagojevich of Illinois, who managed to violate even my state's rather modest ethics statutes. Former Congressional Majority Leader Tom "The Hammer" DeLay has been sentenced to three years in prison for election law infractions in Texas.
Nor should I fail to mention our professional sports stars, a number of whom seem to have trouble finding a willing date, and at least three of whom have been involved in murders. Rae Carruth of the Carolina Panthers is serving time for the murder of his pregnant girlfriend; Ray Lewis of the Baltimore Ravens, on the other hand, not only beat a murder rap, but was named most valuable player of the following year's Super Bowl. One bright light of a football player took a loaded gun into a New York City nightclub; fortunately, the only person he shot was himself, in the leg, accidentally. Ryan Leaf, the college football star who was a complete bust in the National Football League despite a $31.25 million contract and an $11.25 million signing bonus, was convicted of eight felony drug offenses last year, including a burglary charge for stealing an injured football player's pain medication. Then there's always O.J. Simpson. …
The End of Immunity
Being perceived as a role model ain't what it used to be. Back when President John Kennedy was seeing women outside his marriage, the press stayed mum. Richard Nixon's massive mood swings never were reported to the public. Until he became terminally ill, New York Yankees legend Mickey Mantle did not disclose his lifelong alcoholism. The press used to be polite about such things; that is, they remained silent. Not doing their job was, in the past, doing their job. Paparazzi always have been around—I grew up in Hollywood, Calif., and well remember the scandalous "movie magazines" of the time—but even then, certain topics were off-limits, such as the propensity of some Hollywood stars for sexual adventurism and, most certainly, the homosexuality of certain celebs.
No more. Enter the Watergate scandal, investigative journalism, rewards for whistleblowers, Oprah Winfrey and confession as entertainment, the Internet and YouTube. Anything and everything that someone can find out about you is fair game, and it will be posted on the Internet and can go viral in a matter of hours. And it doesn't matter if it's true; that's beside the point. If someone believes that the earth is flat, he or she will attract fans on Facebook immediately.
Once upon a time, only celebrities were subject to such scrutiny, and if they courted the press, it sometimes came back to bite them. (I recall television talk show host Kathie Lee Gifford, who had relentlessly promoted herself as a devoted wife and mother in many media venues, suddenly asking for privacy after her husband's extramarital affair was made public) Now anyone can have his or her 15 minutes of fame, whether desired or not.
The inevitable result of constant probing, storytelling and exposés is a landscape littered with the broken remains of fallen idols.
A recent Pew poll found that only 22 percent of the public trusts the federal government; that's a bit of a drop from the 73 percent who believed in it during the Eisenhower administration. The 2010 Gallup poll of American confidence in institutions found little faith at all in Congress, big business (I'm quite sure that if oil companies were broken out, it would have been even worse for them), organized labor, television news, banks, newspapers, the criminal justice system, public schools, the U.S. Supreme Court, the president, or organized religion and churches. None of them managed to have an approval rating of even 50 percent. The winners were the military, with 76 percent of the public expressing confidence, and small businesses, at 66 percent.
Health Care Is Not Exempt
It is no surprise that, given all this, trust in the health care system is not at a level most of us would like it to be. According to the same Gallup poll, HMOs had the third worst confidence rating, at 19 percent, beaten out only by Congress and big business. The health care system overall came in at a dismal 40 percent. In a 2008 Harris poll, the U.S. health care system was ranked 10th in the world, with 33 percent of Americans saying it needed to be completely reconfigured.
The relationship between patients and their caregivers has long been a touchstone of mutual trust. What on earth happened?
The unending string of scandals I just described has not helped, but for the most part, health care brought it on itself. There have been dreadful incidents: Missouri pharmacist Robert Courtney (currently doing 30 years in prison) diluting cancer drugs (!) so he could support his over-the-top lifestyle; cardiologists in California and elsewhere implanting unnecessary stents; medical-device manufacturers concealing evidence that their products were faulty; for-profit hospital companies committing massive Medicare fraud; pharmaceutical firms peddling unsafe drugs; and on and on. We have been treated to the sagas of serial-killer nurses and physicians, and health insurance practices that would make a Mafia loan shark blush.
Furthermore, the new emphasis on improving health care quality necessarily means the outing of more dirty laundry. We still hear stories of the wrong leg being operated on, the wrong eye being removed. Patients are encouraged to write, in permanent marker, "NOT THIS LEG," when they are scheduled for surgery. Pharmacists suggest that patients check their prescriptions, just to make sure the product is what they are supposed to be getting. (How patients are supposed to know this, or know if the dosage is correct, are interesting questions.) Hospitals struggle to get personnel to engage in the most basic of patient-safety procedures: washing their hands.
Privacy of personal medical information, about which I have written before in this column ("Privacy? What Privacy? Confidentiality Who?", June 6, 2006.), remains the public's key concern about the new—and, to me, welcome—world of health information technology. In a time when every starlet's dinner choices are instantly posted on Twitter, being able to protect one's personal clinical data seems to be a forlorn hope. But we do have laws to protect this information (going all the way back to HIPAA, whose privacy provisions were and are often not enforced), and it would be nice if we honored them. The public's prurient interest in how some celebrity died does not trump that person's right to privacy in death, even if he or she did not seek it in life.
Society's general weakening of trust has spread to health care, and will only spawn erosion of the patient-provider relationship, more lawsuits and a much more complex treatment environment.
All Is Not Lost
Yet, remarkably, there is good news. In its December 2010 poll of Americans concerning which professions they trust the most, three of the top five were related to health care. For the 11th straight year, nurses came in first, with 81 percent of the public stating that they rated their honesty and ethical standards as high or very high. Pharmacists and druggists were third at 71 percent. Physicians were fifth at 66 percent. There was a steep falloff to nursing home operators at 26 percent. At the bottom were lobbyists at 7 percent—pretty ironic, given that all the top-rated health care professions have active lobbies.
Hospital administration was not included in the survey; had it been, the results might have been fascinating.
It should be noted that the health care system as a whole, notwithstanding its 40 percent approval rating in the Gallup poll on institutions, is actually doing better than it was awhile ago. Its lowest point was in 2007, when Gallup found that 31 percent of Americans expressed high confidence in the system, whereas 30 percent had little or no faith in it. The highest point was in 2005-2006, at 44 percent approval, with only 18 to 20 percent of respondents expressing little or no confidence.
Furthermore, a 2009 Gallup poll on health reform found that people trusted physicians (73 percent), health care professors and researchers (62 percent), and hospitals (61 percent) most to make the right recommendations; the losers were pharmaceutical firms (40 percent), health insurers (35 percent) and Republicans in Congress (34 percent).
And a survey published in the March 4, 2010, New England Journal of Medicine found that despite widespread predictions that the Internet would soon trump clinical professionals in terms of where patients seek health care information, physicians are still the most trusted source. Bradford W. Hesse of the National Cancer Institute, one of the researchers who conducted the survey, explained, "As the environment gets noisier, the more you need the physician to help you decipher that noise. Part of the noise is that there's good information and there's bad information. We have a hard time understanding which is which. But doctors are credible." ("People Still Trust Their Doctors Rather Than the Internet," Medicine.net, March 3, 2010)
Despite all its failings, our health care system still is considered trustworthy by a significant minority of Americans, and certain professions are trusted by a majority of them.
But we can do better than that; we have to. After all, there is an onslaught coming. The battle in the U.S. House of Representatives over repeal of the Patient Protection and Affordable Care Act (which likely will be over by the time this is published), no matter how unproductive, is not going to spare anyone in health care who supported the law. Health insurers are using the statute as an excuse to raise premiums to ridiculous levels. Physicians, hospitals, insurance companies and others are hustling to form accountable care organizations, to which some lucky patients may be assigned without their knowledge or permission. Comparative-effectiveness research results are going to pose hard choices for professionals as to which treatment to recommend, which may conflict with patients' preferences. The parade of recalls of pharmaceuticals and medical devices likely will escalate. This is no time to be complacent.
What can providers do to not only maintain, but also strengthen, the trust patients and the public have in them? Here are a few suggestions.
Walk the walk. The easiest way to fritter away other people's trust is to have a disconnection between what you say and what you do. At least in Chicago, and probably in other places, one of our cable television companies has been running an ad campaign about how trustworthy it is—how its technicians always wear booties to protect customers' floors, how the techs arrive on time, and how customer service is always prompt, whether on the Internet or the phone. My fellow cable victims and I have had many a good laugh about that ad. Then we start exchanging cable television horror stories.
If your advertising, marketing, reports to the community and other communications contain promises, keep them. If you aren't able to do something, don't say you can. People can actually tell the difference between marketing and reality.
Don't filter information. I recently had an experience—in another country—involving a hotel. After consulting with other folks, my travel agent and I decided on a beachfront hostelry that promised a suite, a balcony and a waterfront view. When my friend and I arrived after a long, long day of travel, we were ushered into accommodations that consisted of two tiny, windowless cells with a dirty, highly suspect bathroom. The view was of laundry hanging on a line. No balcony, no ocean. We left and stayed elsewhere.
As more and more data come on line—whether you provide them voluntarily or are required to do so—it is exceedingly tempting to massage them. That gets easier as too many cooks get involved in what you are supposed to report, and what should go into the data and the reporting. There's a proverb that states, "If enough data are collected, anything can be proven by statistical methods."
But filtered, massaged or falsified data will not match up with actual performance, and using such information not only can get a provider in trouble with patients and the community, but various authorities may take a dim view of it all.
Have proper reporting procedures and use them. I find it very depressing that in this era of professed rampant enthusiasm for patient safety and quality improvement, I am still contacted regularly by health care professionals and trustees who are having problems with rogue clinicians and executives. The unacceptable behaviors range from substance abuse to sexual harassment to incompetence to outright fraud. And in almost every instance the complaining party has been frustrated, if not completely stonewalled, by reporting procedures that look just dandy on paper but are not followed properly, or are just ignored.
I've been hearing about this sort of thing for 35 years and it is always infuriating. In these latter days, there are a great many incentives for whistleblowers to shine a light on improper behavior; these range from moral obligation to financial reward. And if the employee or observer cannot get someone to listen within the organization, he or she has a great many other places in which to howl loudly. Harry Markopolos, who tried so hard to stop Madoff, ended up howling to Congress.
Empower the staff. Certain airlines and other organizations have flat policies that if there is a problem, any employee is empowered to fix it, if he or she can. The same should be true in health care organizations. This might go against the grain of certain guilds or traditions, but if a housekeeper sees a patient about to fall out of bed, she or he should not have to call a nurse or orderly and hang around, doing nothing, because it isn't her or his job to save the patient. An empowering organization is one whose employees are loyal to that organization, of course, but it is also one whose employees are also loyal to patients, fellow employees and the community. Empowered employees make for empowered patients and empowered personal support systems, because the health care experience becomes much less scary and uncertain—and a heck of a lot more trustworthy.
Admit when you've erred. Health care folks tend to get their knickers in a knot when a mistake has been made, because they're afraid of lawsuits (which will happen in any case), public humiliation (which will happen in any case), and/or personal embarrassment (which depends on with whom you're dealing). Covering up is the knee-jerk response, but in this day and age, it just isn't an option. If you blew it, you blew it.
I do believe, however, that a sea change is taking place, and the idea of being honest about what happened is beginning to overtake running for cover. We are engaged in an earnest debate about whether physicians should apologize to patients when mistakes have been made. The trend in the hospital field is to be open and honest about errors, whether clinical, financial or administrative. We have seen more CEOs take responsibility for what happens on their watch, even if, in some cases, it costs them their jobs. The landscape seems to be changing, but not fast enough. As my late friend David Manoogian, a health care attorney, used to say, "I would a thousand times rather defend a provider who tried to protect patients than one who tried to cover up malfeasance."
It isn't just clinical quality. The push for quality improvement is long overdue and not only will make for better care, but also better relationships between patients and those who treat and look after them. But it can't stop there. Fiduciary responsibility, competent governance, administrative accountability, stewardship of resources and community service are all part of the mix. A hospital or medical group could offer the highest possible quality of care, but if it is running roughshod over a community garden so it can erect a new building, or won't let local residents use its mostly empty parking garage at night, or is making patients and their families jump through dozens of hoops to get to the right location on the campus, the trust factor likely will be in the tank.
I am aware of provider organizations that, by all measures with which I am conversant, offer superb care. And many people who live in their communities hate them, for nonclinical reasons.
Try to treat all patients the same. Yes, I know, there are obvious exceptions. If your organization treats prison inmates, there must be special precautions. If someone presents with an obvious infectious disease, he or she must be isolated and treated in a different manner. Triage exists for a reason, and if you are waiting in the emergency department with a sore throat and someone comes in who has been shot, that patient gets your spot.
But that doesn't mean that certain people should be given extensive privileges simply by dint of being rich or famous. There are few faster ways to become distrusted than to have a regular practice of letting Mrs. Gotbucks or the latest star of a television dance show move to the head of the line simply because of social status.
A friend of mine who, at the time was the CEO of a large and respected health care system, had to take his child to the emergency department on a Saturday night after the kid suffered a sports injury. My friend did not try to pull rank, despite the fact that he was the head guy, and he and his son sat patiently along with everyone else, waiting their turn. He later told me how proud he was of how the ED staff performed, and how glad he was that they didn't know who he was.
Hey, maybe we should nominate some health care CEOs for Undercover Boss!
It's not a one-shot deal. After its highly ethical and much-praised decision to recall all Tylenol products from the market because of the 1982 poisonings (you can look it up), Johnson & Johnson soon was regarded as one of the most-admired companies in the United States—a good place to work, with products one could trust. But competition is tough and times change; late last year, J&J recalled adult Tylenol caplets because they had a noxious smell. That was the 13th recall of a J&J product in 12 months. It will take time—perhaps a good bit of time—for this vaunted firm to regain the high public trust it held for so long.
Trust is built slowly, year after year, decade after decade, on reliability, consistency, good public communication, honesty and sincerity. Trust also can be lost overnight. It cannot be regained so quickly.
Working at being trustworthy, and being seen as such, is a lifetime commitment for individuals, and a "forever" commitment for organizations. But in times like these, it is also the best quality an organization can have to help it weather the storm and remain a known and trusted friend of patient and community alike.
Copyright © 2010 by Emily Friedman. All rights reserved.
Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of the Center for Healthcare Governance's Speakers Express service.
The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.