Trust And Relationships As The Way To Improve Health Care

By

Leonard Zwelling

Early in my fellowship on Capitol Hill, I was taught the four P’s of life in DC—policy, process, politics and personality—in ascending order of importance.

Every congressional office knew what it believed proper policy was. The policies of my Democratic heritage were not going to move the beliefs of the staffers in the office of the senior senator from Wyoming, a very conservative Republican.

The process by which things get done in DC is a combination of the Constitution, the rules of Congress, and tradition. Again, the ability to pass legislation will not depend upon anyone coming up with a new process to turn a bill into a law.

The politics are what they are and always have been, only worse now. No longer is there a Democrat right of a Republican or a Republican left of a Democrat. Things are pretty polarized in Washington. There are few in the center.

That means the entire government, the fate of the nation and the place of the United States in the world hinges on personality, or more specifically, on personalities or relationships between the members of Congress and the various personalities that constitute the executive branch of the federal government. Particularly one. The President. People matter and much of the gridlock in DC now is due to people in Congress not being able to get along with each other and no one doing much of a job establishing a working relationship with Mr. Trump.

https://www.nejm.org/doi/full/10.1056/NEJMp1905941

https://www.nejm.org/doi/full/10.1056/NEJMms1813043?query=featured_home

These two articles that bookend the July 11 issue of The New England Journal of Medicine prove the point, for it is not only in government that relationships matter. They matter in medicine. Now more than ever.

The first article discusses the problem of under vaccination, particularly the deficit in measles vaccination that has plagued the country this year worse than in any other since the advent of the MMR vaccine. Sure everyone should be vaccinated unless there is a medical reason not to do so, but that is not the case. The government theoretically has a role in remedying the situation, but how? It is clear that a whole lot of mandates and financial penalties and barring unvaccinated kids from schools or public areas has not really conquered the problem. If anything, they may have made it worse. As the author, Dr. Julie D. Cantor makes clear, it is going to take the development of relationships between governmental health agencies and the anti-vaxxers to try to overcome what has become a serious public health problem. As Dr. Cantor says, “…force, whether economic or physical, does not educate, develop trust, or protect human dignity. And it will never be an antidote to fear.”

Trust is also the topic of the second article. Drs. Richard J. Baron and Adam J. Berinsky note how so many of the dilemmas facing modern medicine come from a lack of trust between the providers of health care and the patients who depend upon them. Sure, medicine is more scientific than ever and based on much firmer “facts” than was the case even fifty years ago. But medicine has also become more corporate and depersonalized. The authors note that confidence in all institutions of American life has eroded. Medicine is no exception falling from 80% in 1975 to 37% in 2015. That translates to a lack of trust in people running medical institutions (60% in 1974 and 36% in 2016). Furthermore, fewer than half of American doctors own their own practices now. Doctors have moved from being small business owners to being workers for someone else.

Now combine that with the fact that people get their medical information from some truly dubious places now (e.g., the Internet) and there’s a real crisis of trust between doctors and patients.

That is one of the reasons this blog has urged the leadership of MD Anderson to clearly state why Asian faculty members were let go and who is responsible for what is clearly a decline in patient care surrounding the administration of blood.

If American medicine is ever going to right itself after many years of going down a series of wrong paths, it might best start by focusing like a laser on re-establishing trust with patients and communities.

It is this trust that is absent from the vaccine debate and that has led to all these new cases of measles. Well-meaning parents are making poor decisions because they don’t believe that the medical system or the government is acting in their best interests or those of their children. Patients are having doubts about what their doctors tell them. Why shouldn’t they? How many cases of self-serving pill pushers or “medical entrepreneurs” committing awful conflict of interest violations can the public be expected to tolerate and hold on to its belief in the system or in doctors?

Medicine’s brand is less than stellar. So is government’s. Both would be aided by the redevelopment of trust. Trust is based on relationships—in politics, in science, in medicine.

Leonard Zwelling