Rebuilding Trust in Healthcare

A Doctor's Prescription for a Post-Pandemic America

Paul Pender

• Publisher: Early Arrival Press
• Year: 2020
• ISBN:
  9781087918044
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Rebuilding Trust in Healthcare: A Doctor's Prescription for a Post-Pandemic America centers on the patient-physician relationship as the fundamental building block of any proposal for healthcare reform. Paul Pender MD, a passionate advocate for patients and physicians, describes how trust develops between doctors and their patients and how that trust has been eroded by internal and external factors. The coronavirus pandemic has underscored a lack of trust in the healthcare system that was present long before the onset of COVID-19. Dr. Pender explains that the most critical element in regaining trust begins in the physician's office.

The narrative with case presentations illustrate the myriad problems confronting our healthcare system in clear language for patients, healthcare providers and policy makers.

Dr. Pender practiced clinical ophthalmology for 38 years, specializing in the medical and surgical treatment of eye diseases. He completed his residency at the world-renowned Wills Eye Hospital. Honors include a lecture series in his name by the New England Ophthalmological Society and the Secretariat Award from the American Academy of Ophthalmology for his work on webinars for clinicians.

Dr. Pender blogs regularly on timely medical issues on his website www.PaulPenderMD.com and popular social media platforms. He serves as an advisor to Vxtra Health, a company committed to collaborating with physicians to earn trust and manage healthcare costs.

Chapter 1

Chief Complaint

WHAT HAPPENED TO OUR TRUST IN HEALTHCARE? You may have asked yourself that question a lot lately. The coronavirus pandemic has placed our healthcare vulnerabilities front and center. Distrust about the origin and virulence of coronavirus and the supply chain charged with meeting its challenge has underscored concerns that have been smoldering for some time. We have felt overwhelmed by a wave of uncertainty hitting our healthcare system like a tsunami. We ask ourselves, what sources propagated that wave in the first place? Distrust in our healthcare has impacted both those receiving it and those providing it.

Our dependence on a viable healthcare system and its providers has come to occupy an uncomfortable place in our minds, especially in a time of crisis. This book will examine sources for distrust in healthcare and recommend a path toward rebuilding that trust. While the fundamental building block for restoring confidence in our system of healthcare arises first from the relationship forged between patients and their doctors, our leaders in multiple areas— insurance, pharmaceuticals, government, public health— must share in the mission with skill, compassion and integrity. That’s a lot to ask, but as Americans, we have the power to shape our future.

Before I launch into my story, first a word about our calling as doctors and fellow healthcare workers. We don’t practice in a digital vacuum, yet we are charged with more frequent and more detailed documentation of our encounters with patients. Lately, it hasn’t been a pretty picture.

Recapturing Our Humanity as Doctors¹

So much of what I read from the futurists is the stuff of science fiction without the humanity. We now have cellphones with facial recognition for identification (and to create effective and personal emojis). Artificial intelligence is being developed to gauge the emotional state associated with facial expressions, something physicians have developed over years of clinical practice. Unfortunately, that ability to look a patient in the eye, to discern if the entire story is being shared or only a synopsis of the problem, is compromised by the doctor turning to check boxes on the computer.

If there is a universal complaint I have heard from patients who see harried primary care physicians (PCPs), it is the feeling of being disconnected from their care provider. There may be multiple causes for this assessment, but the one most often cited by patients and by doctors alike is the documentation requirement imposed upon the medical profession. There is little face-to-face time allotted for the visit, and often the patient’s face is pointed toward the physician’s back. Hospitalists are charged with treating sick individuals they may have never seen before, sometimes managing data without doing a thorough physical exam. Since the vast majority of primary care practices are now owned by hospitals or large clinics, financial pressures require that outpatient care be the exclusive domain of the primary care physician while unscheduled urgent conditions be shunted to hospital-affiliated urgent care centers. The PCP, the physician best equipped to know the emotional and physical needs of the inpatient, is not only discouraged from making hospital rounds but is barred from writing orders or performing procedures that are part of a PCP’s skill set. Humanity and pride of purpose for physicians are sacrificed for efficiency and the demands of payers.

If artificial means are designed to recognize patterns to predict illness and guide our care of patients, physicians must ensure that our patients trust us to perform properly as healers, not merely as mechanics working on a complex machine. That trust can be eroded by dependence on technology to give us answers, when in fact we need more as human beings. Physicians are taught, first, to do no harm to our patients. But understanding patients’ emotional needs is also critical. Skill without compassion is not a formula for success, nor is it what patients deserve.

Working with a scribe for the last five years of my medical career allowed me to engage with my patients without having to endlessly toil over a computer. Scribes should be discreet during patient encounters so that patients can freely discuss personal details in confidence, face to face, while the medical record is documented in the background. I dictated findings to my scribe, and then translated the jargon “into plain English” for the patient after the exam was completed. I asked if there were any questions, and made sure to answer them before I left the room. The patient then checked out with printed instructions and a recommendation for a return appointment in hand. Letters to referring doctors and primary care physicians were created on the spot. I may have glanced at the visit note before I signed off to ensure that the diagnostic and procedure codes were accurate, but I didn’t take work home to complete documentation, as some physicians do. Working with a scribe allowed me to practice ophthalmology the way I was trained. Reading body language is part of that skill set for me, something I would not replace with a machine.

Having good rapport with patients is critical for determining underlying causes that adversely affect their health. Showing that we care as physicians is essential to establishing that rapport. After all, patients are checking out our body language as well.

This book will tell a complex story of what is needed for trust to develop and how it became compromised. It will describe where we are now, in the middle of a pandemic, trying to assess the physical and psychological damage to our healthcare workers, as well as the economic damage to facilities and practices. And finally, I will assess the problems diagnosed and will suggest possible treatment plans that may positively impact the future of healthcare and how it is delivered. Rebuilding trust won’t be easy, but it’s vital to our responsibilities for the health of all Americans.

Chapter 2

History of Present Illness

A PATIENT DEVELOPS TRUST from a perception that doctors care, even as medical students with few skills. In the course of medical training, some doctors responsible for teaching medical students consider them merely as observers to the process of interacting with patients. “These can be important student–doctor learning experiences, but they do not qualify as authentic, engaged health care roles because students are ‘educational bystanders’ in care delivery processes.”² Such comments invite criticism of the arrogance of the speaker. Even as students, we can help patients to alleviate their fear of the unknown. An example of gaining trust from a desperate patient occurred during my first clinical rotation on internal medicine as a third-year student.

1001 Arabian Nights

A late admission arrived on the ward where I was assigned. Many beds were lined up against the walls with only curtains to draw for privacy. There were no sinks at the bedside for hand washing. The conditions for both doctors and patients were primitive in many ways back in the 1970s.

I was directed to a middle-aged woman sitting on the edge of her bed, jaundiced, confused and anxious. Wearing only a hospital johnny, she appeared very sick to me. I observed the Chief Resident as he conducted a mental status exam on the patient, trying to assess her level of orientation to person, place and time. Person was OK, time was irrelevant, and place was a non-starter.

“Ms. Adams, can you please name three states in the United States?” the Chief Resident asked.

“Alaska, Nebraska...” the patient paused, trying to think of another answer.

“What state are you in now?”

“A state of confusion!” Ms. Adams yelled with a Brooklyn accent, and we couldn’t help but laugh. She had no history of drug or alcohol abuse, no history of liver or gall-bladder disease. Her only surgical history was a breast tumor with extension to regional lymph nodes treated by lumpectomy several years ago. The residents in charge of her care viewed Ms. Adams as a diagnostic mystery, one they were determined to solve. To help minimize her anxiety, I was assigned to hold her hand during the many tests that she underwent. We became friends in the process, so much so that she made the analogy of our pre-test banter to that of Scheherazade of 1001 Arabian Nights. I did my best to entertain her while she waited for the liver scan that would shed light on the cause of her jaundice and depressed mental status. Metastatic breast cancer that targeted her liver and the bile duct was the root of her symptoms. Her mental status gradually improved with treatment, and she was discharged after a course of chemotherapy to the care of her local oncologist.

A month later, I was summoned to the ward clerk’s station to see a visitor. Ms. Adams returned to thank me for my kindness and support during her hospitalization. She wore bright red lipstick and a big smile as she presented me with the orchestral version of Rimsky-Korsakov’s 1001 Arabian Nights. I was touched that she would present me with a gift. I didn’t solve her medical mystery, far from it. But I did help her, emotionally and psychologically, get through a tough patch while in the hospital, and she was grateful. I later learned, within a month of her unannounced visit to see me, she had succumbed to the cancer.

Ms. Adams first presented with confusion, a symptom associated with the toxic effects of high bilirubin in her bloodstream. The bilirubin was also causing the jaundice, including a yellowing of the whites of her eyes. She had several medical issues, but the biggest factor I had to deal with as a student was her fear. She had no local family or friends. Her thinking was clouded, and she was alone in the hospital, in unfamiliar surroundings. She expressed her fear openly, and the doctors assigned to her care were less committed to dealing with her emotional state than to determining the cause of her physical symptoms. By talking her off the ledge, I connected with her in a very human way, helping to ease her fear of the unknown. I have put that principle to work in my practice of ophthalmology, the specialty of medical and surgical care of patients with problems relating to their eyes.

Often, the body language and facial expression of a patient tell a great deal about the fear associated with a condition that can potentially compromise one of our most important senses—our ability to see. By explaining the nature of the problem using a large desktop plastic model of the eye, I put into simple language what the patient needs to know about the condition and what I propose to do about it.

A woman recently returned to see me about cataracts I’d diagnosed a month earlier. At her prior visit, she expressed fear that, after the surgery, she wouldn’t be able to lift her 150-pound brother with Down syndrome, for whom she was the primary caregiver. She assumed that there would be restrictions for lifting in the immediate post-op period. Her primary objection to going ahead with the procedure was not about the surgery itself but about the aftercare. She put off the decision, knowing that she needed to see better (intellectually) but unable to accept the notion of her eyeball being cut (emotionally). She categorized the two components of decision-making, intellectual and emotional, as equally necessary, and I concurred. She asked to discuss with me the risks and benefits of cataract surgery, the options for the type of intraocular lens that would be inserted, and the needed post-op care, including any medication and other concerns such as restrictions on lifting. Thankfully, she didn’t require 1001 nights to reach her decision, and her surgery went well.

I present these examples of gaining trust through empathy to demonstrate patients’ needs for support in the face of the unknown. Fear of the unknown, whether from loss of sight or from the threat of COVID-19, creates anxiety. Physicians are not simply body mechanics working to solve a puzzle or replace a part. They can and should offer hope and comfort as they apply knowledge to find a solution. But most of all, patients should have a reason to trust physicians to care for their needs. Patients need to know that physicians are in their corner for whatever the fight may be.

Medical education has vastly improved since I graduated from medical school in the mid-1970s. Currently, there are more opportunities to engage patients early in the educational process during the basic science years of study. For medical students who don’t want to become clinicians, numerous opportunities are available for research. Lab work has proved vitally important in the study of the coronavirus, and medical researchers have brought their studies to public view that may have lived only in obscure medical journals before the pandemic. We are grateful for the signals coming from private companies and from publicly funded laboratories about potential treatments, especially those that act to temper the exaggerated immune response of the host³ and those that attempt to kill the virus.⁴ A recent poll⁵ of over a thousand US adults asked the question:

“Regardless of how often you get information from these sources, how much do you trust information provided about the coronavirus outbreak by each of the following?”

Not surprisingly, two-thirds of respondents trusted the Centers for Disease Control and healthcare providers a great deal or quite a bit, 25% a moderate amount, and single digits for little trust or none at all. Contrast that level of public trust in social media at 11% as quite a bit, 26% a moderate amount, and 63% little or none at all. I will have more to say in a section on the impact of social media on the public’s trust in healthcare. But for now, let’s stick with the subject of doctors of medicine and osteopathy, MDs and DOs.

The study of medicine assumes that you will become a life-long learner. Doctors in New Hampshire, and in most every state in the US, are required to maintain their license to practice by taking 100 hours of credits of continuing medical education (CME) every two years that meet the high standards for current study established by the Accreditation Council for Continuing Medical Education. Educating physicians already licensed has become a thriving business. The specialty boards now require maintenance of certification in most specialties of medicine, a controversial topic to say the least. Once board certified in a specialty, physicians must not only maintain their license through CME courses, but also must study for another exam and pay thousands of dollars for the privilege of being board certified once again (for a period of several years, and then the process must be repeated). The maintenance of certification designation has been used to determine renewal of hospital privileges, so the pressure never really goes away to take study courses and to pass exams. Doctors ask, “Where is the trust that was conferred upon successful completion of my original board certification? Are my 100 hours of CME credit every two years meaningless for the specialty board?” The argument for supporting the recertification process stems mainly from a perceived need for policing of doctors, by doctors. The argument goes, “if we don’t take responsibility for ensuring the competence of our peers, someone else will do it for us.” I would expect that in the immediate future, the issue will not be resolved to the satisfaction of all clinicians, and the resentment for lack of trust from the medical establishment will persist.

Some institutions of higher learning have developed programs for medical professionals who are managers in healthcare, serving as administrators and chiefs of medical services in large clinics and hospitals. These programs are not cheap. The following course description is taken from the registration form for a 6-day conference put on by the Harvard Macy Institute⁶:

“The Harvard Macy Institute’s A Systems Approach to Assessment in Health Professions Education is designed to encourage participants to apply systems thinking in designing assessment programs to support the continuous quality improvement of students/trainees, faculty, and curricula at their academic health science institutions. The program incorporates multiple pedagogical methods, including interactive presentations, case discussions, small group journal clubs, institutional planning groups, electives (focused mini-sessions/workshops on assessment tools and approaches), and consultations with faculty experts. During this intensive 6-day program, educators and administrators from diverse health science disciplines will be introduced to key concepts from system theory, best practices in educational assessment, and mini-workshops focused on specific assessment approaches. Throughout the program, participants will also have an opportunity to apply systems principles in case discussions depicting problematic assessment situations and to plan an assessment/evaluation design to implement at their home institution.”

The fee of $4500 does not include hotel stay and meals, and it does not count the lost revenue from clinical practice over the 6 days of the course. Admittedly, it is expensive. The question is whether or not the course is well designed for its target audience. I question the “systems” approach and the catch phrases about “continuous quality improvement.” They remind me of what factory managers must deal with on a production line. If there are gaps in our healthcare delivery system, we should begin improvements by focusing on the trust we are attempting to create with our patients, and then design a system around those elements. There is much more to come on this subject in later sections, so please remain patient.

When we think about the trust patients put in physicians, there are certain assumptions to be made. The first and foremost assumption is that physicians are looking out for the best interests of their patients, regardless of their source of income. Fee-for-service medicine, representing the exchange of money for the service rendered between two parties, is rapidly becoming extinct. Third parties (commercial insurance companies, the federal government and others) determine what can be covered and what can be reimbursed as “medically necessary.” Second, the healthcare system that employs physicians is an important consideration for some patients, that is, whether the physician works on salary for a large hospital system or clinic. The assumption here is that physicians have no incentive to order more tests or to pad their bill for unnecessary services, because those measures don’t add to the physician’s personal bottom line. I’ll probe deeper into the topic of economic incentives in later sections, but on the surface, the idea seems legitimate. Let’s look at some notions of trust derived from popular journalism and from scholarly articles.

Some reporters in the media have referred to countries as “low-trust” (America) and “high-trust” (European model) depending on their level of nationalized healthcare.⁷ The response to the coronavirus epidemic shows a dichotomy between two forms of healthcare delivery. According to these models, a high-trust country has a broader safety net for the less fortunate and a population more willing to follow orders. Sweden, a high-trust country, has urged its populace to use reasonable measures like social distancing and to protect its most vulnerable groups but has not applied draconian measures to shut down its economy. In contrast, New York City, as...