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Trust-Based Partnerships Are Essential — and Achievable — in Health Care Service

      Abstract

      When people think about trust in the context of health care, they typically focus on whether patients trust the competence of doctors and other health professionals. But for health care to reach its full potential as a service, trust must also include the notion of partnership, whereby patients see their clinicians as reliable, caring, shared decision-makers who provide ongoing “healing” in its broadest sense. Four interrelated service-quality concepts are central to fostering trust-based partnerships in health care: empathetic creativity, discretionary effort, seamless service, and fear mitigation. Health systems and institutions that prioritize trust-based partnerships with patients have put these concepts into practice using several concrete approaches: investing in organizational culture; hiring health professionals for their values, not just their skills; promoting continuous learning; attending to the power of language in all care interactions; offering patients “go-to” sources for timely assistance; and creating systems and structures that have trust built into their very design. It is in the real-world implementation of trust-based partnership that health care can reclaim its core mission.

      Abbreviations and Acronyms:

      NM (narrative medicine)
      Trust is a precious asset of any service organization. No service depends on trust more than health care, given how uniquely important, variable, complex, and personal this service is to patients.
      • Berry L.L.
      • Jacobson J.O.
      • Stuart B.
      Managing the clues in cancer care.
      Trust — a “willingness to rely on an exchange partner with whom one has confidence”
      • Moorman C.
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      • Zaltman G.
      Relationships between providers and users of market research: the dynamics of trust within and between organizations.
      — is the bedrock of how clinicians establish genuine relationships with patients. They listen attentively; cultivate open, honest dialogue; value patients’ self-knowledge alongside their own medical expertise; and follow through on care plans they develop with patients in a climate of mutual respect.
      • Sisk B.
      A piece of my mind. Time will tell.
      • Lee M.
      Healing as a servant instead of a prophet.
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      When less is more, or acknowledging the value of tincture of time.
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      How becoming a doctor made me a worse listener.
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      Questioning a taboo. Physicians’ interruptions during interactions with patients.
      • Adwish R.L.A.
      • Berry L.L.
      Making time to really listen to your patients.
      • Berry L.L.
      • Danaher T.S.
      • Chapman R.A.
      • et al.
      Role of kindness in cancer care.
      • Churchill L.R.
      • Schenck D.
      Healing skills for medical practice.
      • Bendapudi N.M.
      • Berry L.L.
      • Frey K.A.
      • et al.
      Patients’ perspective on ideal physician behaviors.
      Some routine health services — such as getting a flu shot at a pharmacy or being seen for an ear infection at an urgent care clinic — are essentially transactional and nonrelational. Most other health services, however, benefit from a trust-based relationship, especially when patients regularly see the same clinician for primary or chronic care or when they are seriously ill. In those circumstances, transactional medicine belies health care’s true purpose, which is physical and emotional “healing” in its broadest sense, to the degree possible.
      • Awdish R.L.A.
      • Berry L.L.
      Putting healing back at the center of health care.
      In health care, the “customer” often presents with some combination of stress, anxiety, fear, or pain — needs that demand a relational approach.
      Relational medical care requires clinicians to individualize their service to each patient’s values, cultural beliefs, emotional state, family support, financial capabilities, and medical needs, as well as to the mode of service delivery. The importance of trust-based partnerships in uncertain acute-care settings was starkly evident during the first surge of the coronavirus disease 2019 (COVID-19) pandemic, when families were excluded from intensive care units where loved ones were being treated. Clinicians’ communication and empathy, so essential in providing acute care, became even more salient when the physical presence of families was not possible.
      • Awdish R.
      • Ely E.W.
      Keeping loved ones from visiting our coronavirus patients is making them sicker. The Washington Post.
      Additional challenges tied to trust are the well-documented disparities between White patients and patients of color. Stereotypes and implicit biases held by clinicians have been shown to negatively affect care for racial and ethnic minority groups and to contribute to health inequities.
      • Doescher M.P.
      • Saver B.G.
      • Franks P.
      • Fiscella K.
      Racial and ethnic disparities in perceptions of physician style and trust.
      Subsequent vaccine hesitancy in vulnerable populations is driven by many factors, including historical mistreatment of Black communities,
      • Bunch L.
      A Tale of two crises: addressing COVID-19 vaccine hesitancy as promoting racial justice.
      but is also inextricably tied to trust. In a recent study of Black patients, receiving a recommendation from a trusted clinician facilitated vaccine acceptance.
      • Momplaisir F.
      • Haynes N.
      • Nkwihoreze H.
      • Nelson M.
      • Werner R.M.
      • Jemmott J.
      Understanding drivers of COVID-19 vaccine hesitancy among blacks [published online ahead of print February 9, 2021].
      The COVID-19 pandemic quickly shifted many medical care encounters from in-person to telemedicine visits, challenging physicians to create or sustain relational trust despite physical separation. To be sure, telemedicine offers important benefits beyond protecting against virus exposure, and its use is likely to expand even as the pandemic recedes. However, telemedicine cannot replace the intimacy possible in an in-person encounter. As supportive oncology and palliative care physician Marcin Chwistek writes, “…the in-person visit…travels beyond the verbal: body language, rush of emotions, physical proximity, and touch. If it goes well, there can be a sense of peace for the patient that they are cared for, and satisfaction as meaning emerges for the clinician….the virtual visit is a fundamental alteration to the patient-physician encounter.”
      • Chwistek M.
      “Are you wearing your white coat?”: telemedicine in the time of pandemic.
      The most well-understood dimension of trust in health care is competence: Patients typically assume doctors are competent, absent evidence to the contrary.
      • Bendapudi N.M.
      • Berry L.L.
      • Frey K.A.
      • et al.
      Patients’ perspective on ideal physician behaviors.
      ,
      • Howe L.C.
      • Leibowitz K.A.
      • Crum A.J.
      When your doctor “gets it” and “gets you:” the critical role of competence and warmth in the patient-provider interaction.
      ,
      • Rothenfluh F.
      • Schulz P.J.
      Physician rating websites: what aspects are important to identify a good doctor, and are patients capable of assessing them? A mixed-methods approach including physicians’ and health care consumers’ perspectives.
      But excellent health care requires more than mere trust in clinicians’ professional ability; it centers on both competence and partnership. This multidimensional trust involves patients’ confidence that a clinician is interested in them as a person, not just as a patient; will be a reliable, caring partner in preventing, diagnosing, and treating disease; and will offer support when curative treatment is not possible.
      Grounded in our cumulative experience in service-quality research, clinical care, and organizational change in health care, we have identified four interrelated service-quality concepts that are central to fostering partnership-based trust in health care services: empathetic creativity, discretionary effort, seamless service, and fear mitigation. In this article, we explore how each concept directly informs health care delivery, and we offer guideposts for implementation — how to put the concepts into practice.

      Empathetic Creativity

      Implementing strategies that increase power-sharing and understanding can enhance trust between clinicians and patients, especially for underserved populations.
      • Jones J.
      • Barry M.M.
      Factors influencing trust and mistrust in health promotion partnerships.
      Genuine empathy in health care involves viewing the clinical encounter from another’s perspective, assessing nonjudgmentally, acknowledging emotions, and responding in a caring way.
      • Wiseman T.
      A concept analysis of empathy.
      Such empathy can spark creativity that emboldens clinicians to look beyond habitual actions and normal procedures for an optimal solution. Such creativity is particularly essential as we become increasingly aware of how the structural determinants of health influence patient outcomes in nearly every disease state. Combining empathy and creativity takes patient-centered care to a higher level.
      In Detroit, the Henry Ford Health System creatively developed partnerships with local churches to host Community Conversations about the COVID-19 vaccine. These discussions between Black physicians and the community were moderated by local faith leaders, and community sites were able to administer vaccines in cooperation with the health system.
      The Shepherd Center, a Georgia hospital specializing in neuromuscular injuries and diseases, has an art therapy program enabling patients to paint as a coping strategy despite any physical limitations. Patients with limited motor function, for example, can paint with a mouth stick or with a paintbrush attached to a wrist cuff.
      • Baxter S.
      Art therapy offers outlet for creative expression.
      Pediatric cancer centers often use play to distract their anxious patients. Boston Children’s Hospital has activity rooms with child life specialists, patient entertainment centers, a Clown Care Unit, and the PawPrints Dog Visitation Program. At Australia’s Peter MacCallum Radiation Center, pediatric patients and their siblings choose superhero costumes to wear to appointments. A film crew creates a superhero movie about each child’s treatment journey, which the child receives on video after treatment.
      • Berry L.L.
      • Modi H.
      • Danaher T.
      How lessons from childhood cancer care could improve adult cancer care. 2016. The Conversation.
      North Carolina’s Novant Health Rowan Medical Center showed empathetic creativity in caring for a couple, married for 50 years, both near death from COVID-19. The intensive care unit (ICU) staff placed the couple, originally in separate rooms, in the same space with their beds side-by-side and hands clasped together. The pair passed away within minutes of each other. The staff told the couple’s son that they would have “moved mountains” to connect his parents for their final moments.
      • Potts S.
      Salisbury man grateful parents’ story has impacted many. Salisbury Post.
      In short, the health care workers turned empathy into action, in partnership with the patients’ loved one.

      Discretionary Effort

      Embedded in every service role is discretionary effort, or the difference between the amount of effort one brings to the work and the minimum amount necessary to exert to avoid adverse consequences. As patients, people need more-attentive service than they do in most other consumer settings; they require discretionary effort, which is essentially voluntary.
      • Berry L.L.
      Discovering the Soul of Service.
      Being a patient, especially a seriously ill one, heightens the vulnerability, dependency, and intensity that characterize health care as a “high-emotion” service.
      • Berry L.L.
      • Davis S.W.
      • Wilmet J.
      When the customer is stressed.
      To deliver extra-effort service in the face of physical and emotional fatigue (especially during the COVID-19 crisis), clinicians must have emotional resilience, perseverance, and a genuine devotion to their service roles. Inappropriate behavior from patients, families, and even coworkers can discourage discretionary effort, as can the hurdles of a sometimes senseless, numbing bureaucracy. In health care especially, patients are likely to notice, appreciate, and remember when they receive extra-effort service.
      A patient, “Linda,” benefited from discretionary effort during her breast cancer treatment at the Baylor Scott & White Medical Center in College Station, Texas. Linda’s doctor had scheduled her for a 16-day course of radiation treatment. Feeling confident in her treatment plan, Linda booked flights for a family vacation beginning the day after her treatment ended. When the radiation machine malfunctioned on the final treatment day, staff drove to two other Texas cities to obtain needed parts, enabling same-day repair. Linda received her final treatment at 7:30 pm. Same-day equipment repairs and after-hours treatment were not in anyone’s job description, but they occurred thanks to discretionary effort.
      • Lewis T.
      Doctors go above and beyond for local woman with cancer. KAGS.
      Houston’s Texas Children’s Hospital treated a 14-year-old girl “Susan” for a brain tumor. Now healthy and in her 20s, Susan recalls in a college term paper a meaningful service experience several hours before she underwent surgery:“When Ava, my nurse, came by before surgery, she looked me in the eye and said, ‘[Susan, I’m going to braid your hair back so that we only have to shave what we need.’ What Ava did shaped how I viewed myself every time I glanced in the mirror during recovery, and when I walked into school surrounded by “normal” girls. Ava probably doesn’t remember braiding my hair, but that moment stuck with me for the past 6 years.”
      • Berry L.L.
      • Modi H.
      • Danaher T.
      How lessons from childhood cancer care could improve adult cancer care. 2016. The Conversation.
      Ava surely had other tasks to do, but she braided Susan’s hair anyway — an act of discretionary effort. Performing such actions with intention is a way for clinicians to reconnect to purpose and mitigate against the moral distress associated with work, such as pediatric cancer care, that comes at a high emotional cost.
      • Chitwood H.
      How does an oncology nurse increase moral resilience during a pandemic?.
      During an early surge of the COVID-19 pandemic in Detroit, when patients faced extreme isolation that threatened their sense of identity, some nurse assistants in the ICU of Henry Ford Hospital helped patients to pay their routine family bills remotely using iPads supplied by the health system. One patient described a nurse assistant, Judy, as “an angel”: “She knew I still needed to be a husband to my family, even as a sick man in the ICU.”
      • Freiss S.
      • Kalter L.
      • Halpert M.
      Metro Detroit’s top doctors and the heroes who inspire them.

      Seamless Service

      Giving patients a cohesive, seamless health care experience strengthens trust. Patients appreciate when a health system coordinates moving parts of the service, aiming to achieve the least-possible disruption, duplication, and confusion. This frictionless experience is especially important for seriously ill patients who often have neither the physical fortitude nor the presence of mind to decipher and fit together the discrete elements of their care, including getting all of their clinicians to be “on the same page.”
      Seamless care demands an organizational culture of “boundarylessness,”
      • Tichy N.M.
      • Sherman S.
      Control Your Destiny or Someone Else Will.
      whereby clinicians step out of their institutional, specialized silos to secure and streamline the expertise and resources their patients need. The care is inherently collaborative, such that professionals are not afraid or unwilling to ask one another for assistance, regardless of their position. A study of Mayo Clinic revealed that its boundaryless culture not only makes it “safe” for clinicians to seek help, but also encourages this behavior.
      • Berry L.L.
      • Seltman K.D.
      Management Lessons From Mayo Clinic.
      At Lillebælt University Hospital in southern Denmark, a 38-year-old woman with disseminated terminal cancer was having increasing difficulty coping in her own home. She had symptoms from recurrent fluid (ascites) in her abdominal cavity, and sending her home after an outpatient consult seemed unwise. So, on that same day, the radiology department installed ascites drains for her, and the inpatient oncology department admitted her the next day. The oncologist then called a palliative care team and a hospice near the patient’s home, 80 miles from the hospital, and the next day the patient was transferred to that hospice in her own town. The patient didn’t have to figure out any logistics and was able to focus on herself, rather than on navigating a fragmented health system.
      A seamless service orientation must also extend beyond direct medical care, given that illness can give rise to nonmedical needs. Cancer is a leading cause of personal bankruptcy, for example, and many patients would benefit from expert financial counseling and assistance.
      • Greenup R.A.
      • Rushing C.
      • Fish L.
      • et al.
      Financial costs and burden related to decisions for breast cancer surgery.
      • Meeker C.R.
      • Geynisman D.M.
      • Egleston B.L.
      • et al.
      Relationships among financial distress, emotional distress, and overall distress in insured patients with cancer.
      • Fenn M.
      • Evans S.B.
      • McCorkle R.
      • et al.
      Impact of financial burden of cancer survivors’ quality of life.
      • Chino F.
      • Peppercorn J.M.
      • Rushing C.
      • et al.
      Out-of-pocket costs, financial distress, and underinsurance in cancer care.
      • Ramsey S.
      • Blough D.
      • Kirchoff A.
      • et al.
      Washington state cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis.
      Financial counselors at Marin Cancer Center, in Northern California, verify insurance coverage for each patient; cooperate with local hospitals, other clinicians, and insurers to obtain timely authorizations; provide patients with a written benefits summary at their first visit; and connect patients with needed services, such as transportation and home care.
      • Berry L.L.
      • Deming K.A.
      • Danaher T.S.
      Improving nonclinical and clinical-support services: lessons from oncology. 2018. Mayo Clinic Proceedings: Innovations, Quality & Outcomes.
      Care facilities can even be designed with seamlessness as a goal to foster medical teamwork and coordinated care.
      • Berry L.L.
      • Crane J.
      • Deming K.A.
      • et al.
      Using evidence to design cancer care facilities.
      • Gharaveis R.
      • Hamilton K.
      • Pati D.
      The impact of environmental design on teamwork and communications in healthcare facilities: a systematic literature review.
      • Van Houtven C.H.
      • Hastings N.S.
      • Colon-Emeric C.
      A path to high-quality team-based care for people with serious illness.
      • Mohr J.
      • Batalden P.
      • Barach P.
      Integrating patient safety into the clinical microsystem.
      Design that unnecessarily separates care team members (the “clinical microsystem”) impedes their natural collaboration, possibly depriving patients of beneficial services, such as an oncologist having a “curbside” consult with a palliative care clinician about managing a patient’s symptoms.
      • Berry L.L.
      • Crane J.
      • Deming K.A.
      • et al.
      Using evidence to design cancer care facilities.
      With a seamless service orientation, clinicians and their organizations view care from the patient’s perspective — and are flexible and proactive in coordinating with colleagues and other service providers — so that the health system truly holds up its end of the trust-based partnership that high-quality care requires.

      Fear Mitigation

      Illness is at best inconvenient and unpleasant. Serious illness turns one’s life upside down, often intensifying emotions such as insecurity, anxiety, and especially fear. Clinicians earn patients’ trust when they help manage fear without resorting to false narratives or unnecessary treatment.
      Identifying what a patient fears most requires close listening with minimal interruptions and asking the right questions (eg, “What concerns you most about your illness?”) in the right way (eg, “What questions do you have for me?” rather than “Do you have any questions?”).
      • Moriates C.
      A few good words.
      A clinician’s verbal and body language can also elevate or moderate fear. For instance, answering a patient’s question about prognosis with “Let’s not worry about that now” is likely to heighten rather than lessen fear,
      • Berry L.L.
      • Jacobson J.O.
      • Stuart B.
      Managing the clues in cancer care.
      as is a lack of eye contact.
      • Gorawara-Bhat R.
      • Cook M.A.
      Eye contact in patient-centered communication.
      • Hardavella G.
      • Aamli-Gaagnat A.
      • Frille A.
      • et al.
      Top tips to deal with challenging situations: doctor-patient interactions.
      • Hillen M.A.
      • de Haes H.C.J.M.
      • van Tienhoven G.
      • et al.
      All eyes on the patient: the influence of oncologists' nonverbal communication on breast cancer patients' trust.
      As one patient explained, “I can tell when the [doctors] ... pay attention to what I’ve told them. There are some who only look at the computer.”
      IHI Multimedia Team
      Your patient can tell when you’re not listening. IHI 2020.
      Timely care can moderate fear. Waiting for appointments, the start of treatment, or important test results can be excruciating for anxious patients as they envision worst-case scenarios.
      • Berry L.L.
      • Davis S.W.
      • Wilmet J.
      When the customer is stressed.
      ,
      • Paul C.
      • Carey M.
      • Anderson A.
      • et al.
      Cancer patients’ concerns regarding access to cancer care: perceived impact of waiting times along the diagnosis and treatment journey.
      ,
      • Attai D.J.
      • Hampton R.
      • Staley A.C.
      • et al.
      What do patients prefer? Understanding patient perspectives on receiving a new breast cancer diagnosis.
      Empathetic creativity, discretionary effort, and seamless service all can contribute to timeliness of care. Consider this cancer patient’s story:In post-treatment, I was experiencing more fear than with the initial diagnosis. I had positive outcomes from chemo and surgery but was really frightened on follow-up visits that something would show up. Lying on the [computed tomography] table, I thought, “Boy, they sure are taking a lot of pictures.” Before one follow-up exam, I was especially upset. About 5:30 in the evening before seeing the doctor, he emailed me and said, “All the images looked fine.” It was a huge relief.
      • Berry L.L.
      • Danaher T.S.
      • Chapman R.A.
      • et al.
      Role of kindness in cancer care.
      It’s usually not possible to pre-empt the fear of seriously ill patients, but their fear may be minimized by preparing them for interventions. For example, laboratory staff at Denmark’s Lillebælt Hospital mitigated children’s fears of needles and blood tests by developing an app that lets them role-play taking blood samples from animated characters. Some cancer centers give radiation patients and their families a tour of the treatment space before the first treatment. “Patients will fear the machine less if you show it to them,” explains a radiation services manager.
      • Berry L.L.
      • Davis S.W.
      • Wilmet J.
      When the customer is stressed.
      A reality of health care services is the patient’s loss of control.
      • Mishark K.J.
      • Greyer H.
      • Ubel P.A.
      How hospital stays resemble enhanced interrogation.
      In non–health-care settings, consumers are typically in charge (“Do I buy or not?” “Do I use company X or Y?”). As patients, however, they relinquish power to doctors and health systems. That loss of control can induce fear, and finding ways to empower patients can help reduce fear.
      Restoring some control to patients is a valuable benefit of well-executed shared decision-making — which occurs when patients, at their discretion and to the extent possible, collaborate with their clinicians about diagnostics, treatment, care, and follow-up. Shared decision-making means giving patients evidence-based information on treatment and non-treatment options, advantages, disadvantages, and uncertainties, as well as advice and support as they explore their own values and preferences.
      • Barry M.J.
      • Edgman-Levitan A.
      Shared decision making — the pinnacle of patient-centered care.
      Shared decision-making is especially important in preference-sensitive situations and situations with high degrees of uncertainty, when the relative value a patient places on various options matters most. For example, patients with terminal cancer may have different views on whether the potential, often short, life-prolonging effect of palliative chemotherapy is worth the risk of serious side effects from the treatment.
      Clinicians may themselves have discomfort with uncertainty, and may not have spent time cultivating skill in navigating emotion-laden, complex conversations. To do this work effectively and compassionately, many organizations provide professional development to physicians in the form of communication training. A variety of models — including the University of Pittsburgh’s VitalTalk programming, Cleveland Clinic’s R.E.D.E. to Communicate, and Henry Ford’s CLEAR Communications training — share the goal of getting to the essence of a patient’s story before co-creating with that patient a plan of care that aligns with his or her values. Ready access to a communication skillset for conflict is invaluable when intrafamily dynamics, or intercare team disagreements create discord that could adversely affect the patient-clinician relationship.
      The availability of assistance helps patients maintain control and manage their fears. Toward that end, some health systems operate off-hours call centers where experienced nurses can consult patients’ electronic health records and, with pertinent information in hand, counsel patients, make clinical appointments and, in some centers, set up immediate telemedicine or in-person home visits with a member of the patient’s care team.
      • O'Malley A.S.
      • Samuel D.
      • Bond A.M.
      • et al.
      After-hours care and its coordination with primary care in the US.
      • Blankenship A.
      • Carr P.
      Integrating call center and clinical communication technology to improve patient access and experience.
      • Kappa S.F.
      • McClain C.
      • Wallace K.
      • et al.
      Implementation of a centralized, cost-effective call center in a large urology community practice.
      Kaiser Permanente places its infusion pharmacies in the chemotherapy treatment space. The proximity encourages infusion pharmacists to visit their patients for educational, feedback-related, and relationship-creating purposes during treatment sessions. Patients and family members also have the direct phone number for the infusion pharmacy. Facilitating a relationship between the pharmacist(s) who prepare toxic medication that may save one’s life can mitigate fear and build trust.
      Just as a clinician’s language strengthens or weakens trust, so does the design of medical facilities and equipment. For example, medical machines are often designed without regard for the end-user’s emotional needs. Magnetic resonance imaging machines and computed tomography scanners are scary, especially for children, given the equipment’s large size, noise, and daunting warning notices. For certain scans, children are commonly sedated or placed under general anesthesia.
      • Wachtel R.E.
      • Dexter F.
      • Dow A.J.
      Growth rates in pediatric dagnostic imaging and sedation.
      GE Healthcare designer Doug Dietz and his team designed less-intimidating scanners by tapping into children’s play orientation. They created scanners such as “Pirate Island,” at the University of Pittsburgh Children’s Hospital. In the “adventure room,” each part of the magnetic resonance imaging machine is decorated to look like a pirate ship. Children walk into the room on a “dock” with “water” painted on a floor. A shipwreck and sandcastles are depicted in the corner of the room, and kids even “walk the plank” to enter the scanner. This innovation has nearly eliminated the need for pre-scan sedation or general anesthesia. Merging empathy with creative design yielded a scanner that has greatly reduced young patients’ fears.
      • Vagal A.
      • Wahab S.A.
      • Butcher B.
      • et al.
      Human-centered design thinking in radiology.

      Partnership-Based Trust in Practice

      Every health care interaction is an experience that may or may not strengthen patients’ trust in the clinicians and organization providing the service, and evidence consistently demonstrates that patient satisfaction is driven by patient-clinician relationships.
      • Lee T.H.
      • McGlynn E.A.
      • Safran D.G.
      A framework for increasing trust between patients and the organizations that care for them.
      The four service concepts discussed above offer a different lens for viewing service quality in health care and, collectively, are crucial in moving trust from a focus only on competence to one that also encompasses partnership. Medical practices and health systems can use multiple approaches to achieve broader, stronger trust-based relationships with patients.

      Invest in the Culture

      “Organizational culture” refers to how employees behave in their day-to-day work.
      • Berry L.L.
      • Parish J.T.
      • Dikec A.
      Creating value through quality service.
      The extra effort that allowed Linda to receive her last radiation treatment before her family’s vacation derived from organizational culture. Investing in a high-trust culture requires (1) management’s commitment to identifying and overcoming the obstacles to health care professionals’ daily work, with initiatives such as leadership “listening rounds,” staff focus groups, “town hall” sessions, and anonymous surveys; (2) use of a “balanced scorecard” of clinician performance that includes not only conventional productivity measures but also professional development, patients’ perceptions of clinicians’ performance, transparency of physician performance and their external financial relationships,
      • Montgomery T.
      • Berns J.S.
      • Braddock 3rd, C.H.
      Transparency as a trust-building practice in physician relationships with patients.
      timeliness of care, and team-building; and (3) presentations of patient stories of care-delivery success and failure at staff meetings.

      Hire for Values, Not Just Skills — and Continuously Reinforce the Values

      The first rule of execution in service organizations is hiring the right people. In health care, this means looking beyond (the obviously important) skills assessment to a candidate’s communication abilities, teamwork orientation, emotional capacity and resilience, work ethic, compassion, and kindness.
      • Lewis T.
      Doctors go above and beyond for local woman with cancer. KAGS.
      Résumés do not identify those personal qualities. Smarter hiring includes psychometric, personality, and aptitude testing; the involvement of multiple staff in interviewing finalist candidates; and use of “behavioral” interview questions designed to reveal one’s values (eg, “What would you do if you witnessed another staff member being rude to a patient?” or “Recount how you dealt with a specific disagreeable patient.”).
      • Wirtz J.
      Winning in service markets. Success Through People, Technology and Strategy.
      ,
      • Weinberg D.B.
      • Avgar A.C.
      • Sugrue N.M.
      • et al.
      The importance of a high-performance work environment in hospitals.
      The work environment must also reinforce the values for which people were hired. That means viewing the practice of medicine, as described by Ariely and Lanier,
      • Ariely D.
      • Lanier W.L.
      Disturbing trends in physician burnout and satisfaction with work-life balance: dealing with malady among the nation's healers.
      not as a production function, but a research and development practice. Clinicians need time to think, reflect, and build trusting relationships. Organizations that take a short-term view and have a “production line” mindset deprive physicians and patients of the wellness that comes from trusting relationships. Indeed, efforts to reduce health disparities and promote the health and well-being of whole populations depend on transforming the culture of medicine away from what Heen and Montori
      • Heen A.F.
      • Montori V.M.
      Achieving care: promoting alternatives to industrial healthcare.
      described as “industrialization,” the end result of systems overly focused on decontextualized data and profit extraction. As Montori
      • Montori V.
      Why We Revolt.
      writes, such practices classify each patient as “an economic opportunity” and work against a culture of caring.

      Promote Continuous Learning

      Employees must continuously develop their skills and knowledge. Health systems enhance their trustworthiness by investing in the ongoing personal growth of staff members whose behavior strengthens or weakens patient trust. Evidence-based approaches to the patient encounter have identified five core practices: preparing with intention, listening completely, agreeing on what matters most, connecting with the patient's story, and exploring emotional cues.
      • Zulman D.M.
      • Haverfield M.C.
      • Shaw J.G.
      • et al.
      Practices to foster physician presence and connection with patients in the clinical encounter.
      The essential nature of story and complete listening have led some academic medical centers and health systems to invest in Narrative Medicine (NM) training for faculty. Pioneered by Rita Charon at Columbia University, NM trains clinicians in a deep form of active listening that enables clinicians to develop what Charon calls “narrative competence” — the ability to acknowledge, absorb, interpret, and act on the stories and plights of others. Informed by a biopsychosocial model of medicine, NM focuses on looking more broadly at patients in the context of their life stories. Narrative Medicine practice can be positioned within institutions to add meaning to the work of individual physicians and reconnect them to their ideals.
      • Charon R.
      The patient-physician relationship. Narrative medicine — a model for empathy, reflection, profession, and trust.
      This kind of personal development is energizing and builds self-confidence, which in turn promotes discretionary effort. Service providers who appear unwilling to expend such extra effort often simply don’t know what to do.

      Attend to Language

      Effectively and clearly communicating with sensitivity, empathy, and honesty is especially important (and difficult) in providing medical care.
      • Sisk B.
      A piece of my mind. Time will tell.
      ,
      • Berry L.L.
      • Danaher T.S.
      • Chapman R.A.
      • et al.
      Role of kindness in cancer care.
      ,
      • Bendapudi N.M.
      • Berry L.L.
      • Frey K.A.
      • et al.
      Patients’ perspective on ideal physician behaviors.
      ,
      • Moriates C.
      A few good words.
      ,
      • Morgan D.J.
      • Scherer L.D.
      • Korenstein D.
      Improving physician communication about treatment decisions — reconsideration of “risks vs benefits”.
      ,
      • Marron J.M.
      • Dizon D.S.
      • Symington B.
      • et al.
      Waging war on war metaphors in cancer and COVID-19.
      Given the intimate and consequential nature of health care services, patients are highly alert to their doctors’ verbal and nonverbal cues. As one cancer patient said in an interview conducted by author [LB], “Patients are ultrasensitive to a doctor’s words as clues to whether they will live or die.” Tailoring language to the patient, listening without needless interruption, using nontechnical terminology, allowing for silence after delivering bad news to convey “I am here with you; we are in this together,” sitting with patients at eye level during conversation, offering a gentle touch — all convey empathy and lessen fear.
      • Berry L.L.
      • Danaher T.S.
      • Chapman R.A.
      • et al.
      Role of kindness in cancer care.
      ,
      • Stuart B.
      • Danaher T.
      • Awdish R.A.
      • Berry L.L.
      Finding hope and healing when a cure is not possible.
      • Verghese A.
      The important of being.
      • Martin D.B.
      “Write it down like you told me”: transparent records and my oncology practice.
      • Lakin J.R.
      • Tulsky J.A.
      • Bernacki R.E.
      Time out before talking: communication as a medical procedure.
      One beneficial exercise is to periodically ask clinicians to identify commonly used language that needlessly offends, frightens, or confuses patients, with the goal of banishing their use.
      • Berry L.L.
      • Jacobson J.O.
      • Stuart B.
      Managing the clues in cancer care.

      Offer “Go-To” Sources for Assistance

      The need for health-related assistance is often urgent, and sometimes it is perceived by patients as urgent even when it is not. Clinicians and health systems can help build trust by giving patients timely options for obtaining assistance, including those that are high-tech (eg, mobile apps with personalized, real-time information and alerts to clinical staff when patients need intervention); high-touch (eg, off-hours specialty urgent-care clinics, as for oncology patients who have adverse treatment side effects); and hybrid (eg, a tiered system that begins with a nursing-staffed call center and escalates to an in-person or vertical clinical intervention, as needed). Some health systems assign nurse “care coordinators” to their sickest patients who may be receiving suboptimal care because of inadequate communication and coordination among their multiple doctors.
      • Montori V.M.
      • Hargraves I.
      • McNellis R.J.
      • et al.
      The care and learn model: a practice and research model for improving healthcare quality and outcomes.
      • Williams M.D.
      • Asiedu G.B.
      • Finnie D.
      • et al.
      Sustainable care coordination: a qualitative study of primary care provider, administrator, and insurer perspectives.
      • Berry L.L.
      • Rock B.L.
      • Houskamp B.S.
      • et al.
      Care coordination for patients with complex health profiles in inpatient and outpatient settings.
      The care coordinators get to know their patients, work with the doctors to prevent needless test duplication and dangerous drug interactions, answer patients’ questions, and monitor for potential declines in functional status, nonadherence to treatment plans, and other issues. Care coordinators become a “go-to resource” and, in well-executed programs, can help reduce the risks and costs of emergency room visits and hospitalizations while strengthening trust.
      • Berry L.L.
      • Rock B.L.
      • Houskamp B.S.
      • et al.
      Care coordination for patients with complex health profiles in inpatient and outpatient settings.
      • Friedman A.
      • Howard J.
      • Shaw E.K.
      • et al.
      Facilitators and barriers to care coordination in patient-centered medical homes (PCMHs) from coordinators' perspectives.
      • White B.
      • Carney P.A.
      • Flynn J.
      • et al.
      Reducing hospital readmissions through primary care practice transformation.

      Design for Trust

      Health care cannot be disentangled from the facilities and equipment patients use. Empathetic creativity, coupled with empirical evidence of benefit, should drive design for patients and families — and for staff, who use the facilities the most. Trust-strengthening design is as much about attitude and values as about architectural skill. Why not, for instance, redesign examination rooms so that the physician faces the patient while working on the computer?
      • Schwieterman T.
      It’s time to rethink technology in your exam room. Physicians Practice. 2019.
      The discipline of evidence-based design has grown rapidly since Ulrich first documented that patients in hospital rooms with views to nature experienced less anxiety and pain, and faster discharge, than patients who looked out at an adjacent building.
      • Ulrich R.S.
      View through a window may influence recovery from surgery.
      Evidence-based design features have had concrete benefits such as reducing patient infections with single-patient rooms and improved air quality; noise with sound-absorbing materials; patient falls with wider bathroom doors and slip-resistant flooring; medication errors with better lighting; and stress and anxiety with art, music, and comfortable spaces for families. Such features improve the overall experience of all users of the facilities, bolster safety and efficiency, and reduce waste — while cutting operational costs, especially for hospitals.
      • Riisbol M.J.
      • Timmerman C.
      User consultation and the design of healing architecture in a cardiology department — ways to improve care for and well-being of patients and their relatives.
      • Sadler B.L.
      • Berry L.L.
      • Guenther R.
      • et al.
      Fable hospital 2.0: the business care for building better health care facilities.
      • Ulrich R.S.
      • Berry L.L.
      • Quan X.
      • et al.
      A conceptual framework for the domain of evidence-based design.
      • Gharaveis R.
      • Kazem-Zadeh M.
      The role of environmental design in cancer prevention, diagnosis, treatment, and survivorship: a systematic literature review.
      • Guenther R.
      • Vittori G.
      Sustainable Healthcare Architecture.
      • Cama R.
      Evidence-Based Healthcare Design.
      • Hamilton D.K.
      • Watkins D.H.
      Evidence-Based Design for Multiple Building Types.
      Princess Margaret Cancer Centre in Toronto, for example, has created serene, calming spaces for hospitalized palliative care patients and their families by using evidence-based design–informed selections of color and wood for interior spaces, as well as carefully designed outdoor and indoor meditation gardens, which stand in stark contrast with the hectic atmosphere of many in-patient facilities.
      • Hannon B.
      • Swami N.
      • Pope A.
      • et al.
      The oncology palliative care clinic at the Princess Margaret Cancer Centre: an early intervention model for patients with advnced cancer.
      Designing for trust takes this kind of creative approach, one that conceives of clinical care in its fullest context.

      Reclaiming Health Care’s Core Mission

      As the examples in this article show, trust-based partnership is an achievable goal in health care delivery. Empathetic and compassionate partnerships manifest in concrete ways: in the self-aware behavior of clinicians and other health professionals; in smartly and seamlessly designed systems, processes, facilities, and equipment; and in thoughtful approaches to mitigating the fear patients feel as they anticipate and receive care. Specific institutions and their clinicians are putting such initiatives into practice every day. Other organizations can follow suit, tailoring efforts to their own communities of patients and health care professionals. In the end, trust in health care needs to be viewed not merely through the lens of professional competence, but also as a dynamic, relational goal that informs every aspect of the patient experience. That is how trust-based partnerships can become the centerpiece of clinical care and health services more broadly.
      The path we propose is riddled with complexity, deeply embedded tradition, competing financial interests, and (too often) a loss of commitment to health care’s moral and sacred healing mission. An essential service delivered by very smart people, health care wastes too much, harms too much, and drains the joy of serving too much. The dominant fee-for-service payment system in the United States encourages a service mindset of seeing more patients in less time and ordering more tests and procedures; it doesn’t encourage listening, reflective thought and dialogue, and the pooling of clinicians’ medical knowledge, and experience with patients’ self-knowledge.
      • Berry L.L.
      Service innovation is urgent in healthcare.
      Health care is unquestionably one of the most challenging, stressful of services to deliver. Service staff members outside of health care do not have to inform a patient of a life-limiting diagnosis or that the chemotherapy is not working and it is time to stop curative treatments. Medical care is one of the few service roles where an error can physically harm the customer, or even cause death. These pressures — combined with heavy workloads, inefficient processes abetted by organizational and governmental bureaucracy, and burdensome documentation of the clinical visit — can transform what has long been assumed to be a dream job (being a doctor) into work that is emotionally and physically draining. The cumulative effect of these and other work realities have contributed to the current epidemic of clinician burnout that adversely affects clinical care and work-life quality while impeding that trust-based relational care that excellent health care requires.
      • Berry L.L.
      Service innovation is urgent in healthcare.
      • Downing L.N.
      • Bates D.W.
      • Longhurst C.A.
      Physician burnout in the electronic health record era: are we ignoring the real cause?.
      • O’Shea J.
      Patient-centered, value-based health care is incompatible with the current climate of excessive regulation. Health Aff Blog.
      • Shanefelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general U.S. working population between 2011 and 2014.
      • Shanefelt T.D.
      • Dyrbye L.N.
      • West C.P.
      Addressing physician burnout: the way forward.
      As Swensen
      • Swensen S.J.
      Esprit de corps and quality: making the case for eradicating burnout.
      concludes, serving customers who are sick requires passion, idealism, energy, and purpose for the work — all casualties of work-related burnout.
      We can systematically dismantle these negative forces that inhibit the level and quality of trust, thereby strengthening the care that most physicians want to provide and most patients need. This effort will require commitment from inspired health care organization leaders who seek a positive financial margin for the primary purposes of keeping the doors open and investing in innovation and improvement, rather than placing financial performance above all other aims. It will also require government regulators to promote genuine patient-centered care and reduce needless inefficiency and waste. With health system and governmental leaders reclaiming health care’s core mission of healing
      • Awdish R.L.A.
      • Berry L.L.
      Putting healing back at the center of health care.
      — and clinicians insisting on practicing medicine the right way despite the obstacles — trust-based physician-patient partnerships can prevail. The examples and stories presented in this article show what is possible. We close with one more of them.
      Stefani, an 8-year-old girl from Michigan, was headed into surgery for heart transplantation at Mayo Clinic in Rochester, Minnesota. She asked one of her doctors, Mike Ackerman, if she was going to live. Dr Ackerman replied, “Of course you are going to live, and I am going to dance with you at your high school prom.” Ten years later, in 2009, with the consent of Stefani’s parents, but unknown to her, Dr Ackerman flew to Michigan to surprise Stefani at her prom. This story of a “prom promise kept” captures the beauty of health care at its best — a force for true healing for patients and for the clinicians who care for them.
      • Klein T.
      A Prom Promise Kept. Mayo Clinic Website.

      Supplemental Online Material

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      • In the Limelight: July 2021
        Mayo Clinic ProceedingsVol. 96Issue 7
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          This month’s feature highlights three articles that appear in the current issue of Mayo Clinic Proceedings. These articles are also featured on the Mayo Clinic Proceedings’ YouTube Channel ( https://youtu.be/MT3ZFDAOKYU ).
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