Got Trust? We Are Ignoring A Vital Predictor Of Engagement In Care

Trust is foundational to engagement in care, yet it is largely ignored in our conversations about health care transformation.

A few years ago, after multiple attempts to convince a patient to keep his clinic appointments, I decided to meet him at a cafe of his choosing. We established a patient-provider bond that led to his continued engagement in care. I asked why he initially refused to come to clinic. He said he was afraid he’d run into someone he knew but primarily he didn’t trust the health care system. This reaction, especially among the undeserved, is much more common than we care to admit. Trust is foundational to engagement in care, yet it is largely ignored in our conversations about health care transformation.

That’s why a recent presentation at an NCQA conference is so refreshing. Dr. Toyin Ajayi, co-founder of Cityblock Health, discusses trust as an essential but undervalued currency in health care. For 14 minutes, she captivates listeners as she reflects on lessons learned from a patient she calls Charlene. Charlene, a woman from a poor neighborhood, died of cancer but Ajayi says a retrospective analysis of her care journey clearly revealed “the catastrophe lurking in her cries for help”. These were cries no one heard because the subtleties were overlooked by health care teams who instead labeled her non-compliant for not engaging in follow-up care. Ajayi uses this heartbreaking case to ultimately pose the question, ‘Would Charlene’s experience have been different if she received health care in a system she trusted?’ The answer is likely yes. But how do we build a trusted health care system, particularly for underserved patients like Charlene? Attention to few observations can help move us forward.

Building trust starts outside four walls. The commonly espoused approach “meeting people where they are” has little sustainable impact if community members never see representatives from local health institutions in their environment. Getting proximal and being seen in the community sends a message of sincerity and builds bridges. A few years ago, an advisory board at NIH solicited suggestions about how to increase enrollment of diverse populations in clinical trials. My suggestion was to send researchers into the community to educate, listen and use the information to establish a non-academic trial site in the neighborhood. The suggestion was never implemented. The historical distrust and community suspicion associated with research remains prevalent and these perceptions influence engagement in routine health care. Showing up in the community is a great first step.

Also, we need to talk less and listen more. When patients enter care, the initial clinical interview – the history- can be overwhelming and feel like an interrogation. If tailored appropriately, the history can be transformed into an empathic exchange that builds trust. What if we re-imagine the clinical history and instead of starting with questions about the nature and duration of the medical complaint, the first question is about the patients’ deepest fears and skepticisms about seeking care or about past experiences that influence their perceptions about care? What if we started with probes like, “I understand it may have been tough for you to come here. Thank you for making the effort. First tell me your biggest concern about being here.” or “What matters most to you about your health?”. These prompts can help establish trust and assist in allaying fear, which is among the biggest barriers to engagement in care.


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