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Re-Engaging in Trust: The Missing Ingredient to Fixing Healthcare


Guest: Dr. Jan Berger

Narrator (00:00):
Welcome to 360 degrees of healthcare with Dr. Stan an in depth. Look at our industry from our very own chief medical officer who will talk with other medical and industry professionals on the changing and evolving landscape of the healthcare system from the inside. And now live from zero studios. Our very own infectious disease expert, Dr. Stan Schwartz.

Stan (00:29):
Good afternoon, and welcome to 360 degrees of healthcare. My name is Dr. Stan Schwartz. I’m an internal medicine physician and an infectious disease physician. My lifetime rolls from medical student to fellow, to practicing physician, to administrator, and then consultant and co-founder of a digital health enterprise zero. And as I get older as a patient have given me a 360 degree view of healthcare that I hope to share with you. If you’re listening live today, please use the Q and a feature at the bottom of your, uh, screen. And we’ll try to get to your questions. I guess today is a very special person who I’ve known for a few years and who just authored a book re-engaging trust in healthcare, the solution to fixing healthcare, the missing ingredient. Now I tortured the title of that, but Jan will give that to is Dr. Jan Berger.

Stan (01:26):
Who’s from Chicago. I read this book from cover to cover and I made a thousand notes in it. And it’s one of the most remarkable books that I’ve read, because it gave me an insight into healthcare. That it’s one of those things you think about in the back of your mind, how try us as important, but I never saw trust in the forefront of everything that we do in healthcare. And that’s what I really hope to get. Uh, you, the listeners, a better understanding of why Jan wrote this book and why this book is important to everybody who touches healthcare, whether you deliver it, you receive it, you, you intermediate it, or you arrange it. There’s something in this book for you. So with that, Dr. Jan Berger of health intelligence partners, Jan, could you introduce yourself, tell us a little bit about yourself and why did you write a book about trust,

Jan (02:21):
Stan, thank you so much for having me today. Um, I really appreciate the time to have the conversation, a little bit of background about me. Um, I am a pediatrician by training. Um, I also interestingly have a law degree. Um, and one of the things that my law degree taught me that medicine didn’t is there are many, many D different ways to look at things in medicine we’re looking, we’re kind of singularly focused. That is not necessarily true in the law. And it’s held me in very good stead because after finishing, um, my, the clinical roles that I took in healthcare, I went to the administrative and then the corporate side of healthcare, where I’ve had a number of jobs, I’ve run a consulting company that works not only in the United States, but across the world, which has also given me wonderful insights. And today I sit on boards, I do a lot of speaking.

Jan (03:25):
And over the last four years, I have focused on the issue of trust, the reason. And you asked me why trust, what got me interested. Um, I have spent much of my career like you in different aspects of healthcare, and you can either look at what the differences are, or you can look at the similarities. And for me, a lot of the work I’ve done is around human behavior. It’s about relationship building, which is by, by the way, the basis of healthcare, no matter which of all those roles you talked about is we interact and we try to achieve aligned goals. Now, the aligned goals we’ll talk about later, because I would argue it is one of the, um, opportunities we have to improve trust in the future. But this really started in 2016 when I was recognizing some fragmentation in healthcare I hadn’t seen before.

Jan (04:35):
So I, I did, um, a survey to see if I could clarify my thought in order to help the companies that I was consulting for to improve value and improve healthcare as a whole. And half of these surveys, about a thousand of them were done in the summer, late summer of 2016, the other half due to a medical episode, I had like you, as we get older, many of us take the patient role instead of the other side of the table, if you will. And, um, so about five months later, the second a thousand came out and the results were both shocking and confusing to me because they were in conflict with each other. Many of the questions I asked early on got very different que, uh, answers than later on. And so I started to do interviews to see, was it my data that was wrong? Or was there something, an underpinning of healthcare that was changed? They’re in birthed the book.

Stan (05:51):
So what are the terms that you use in the book? And this is all the way through the book is the term negative and positive trust resets. And, you know, it’s a very unique term. Can you tell me a little bit about what is a trust reset and why are some positive and some negative

Jan (06:09):
Again? Great question. One of the things that became very clear as we talked to people and, and as I then sat back and really looked at my multitude of experiences across stakeholders, is there are behaviors, either declared behaviors that we know we’re doing, or underlying behaviors that we are unaware of that can either BI build trust or that can degradate trust. Therefore, the trust resets along with these 15, which I talk about in the book, trust resets are trust tr our event resets. And I also talk about some of those in the book. And I think somewhere, I am sure during our conversation, um, today we will talk about the 800 pound elephant in the room, which is how has COVID, which we are all living through today. Be one of those event trust resets

Stan (07:20):
To talking about trust, you know, very early in the book, there was something that caught my eye and you talked about satisfaction and trust, and I had never thought of it in this way before, but you said, you know, when someone says, I’m very satisfied with that doctor, that’s not necessarily saying that you trust the doctor and trust doesn’t necessarily mean satisfaction. And you went on to say that satisfaction looks back, but trust looks forward. Expand on that, please.

Jan (07:47):
Sure. First of all, when we are satisfied with a doctor or when we trust a doctor, so it may be aligned here, it can have two basis to that statement or reaction. It can either be that somebody was competent when we are looking, whether it’s a patient and a provider, or it’s two healthcare executives. If somebody is competent, that may build, but it is very different than, um, whether somebody has been compassionate, aligned many of the empathetic, many of the emotional or interactional resets that I talk about. And, but that’s very different. And so one must understand that also the satisfaction issue for many, many years, we had hospital satisfaction surveys more recently in the business side, we’ve used net promoter score NPS, as were you satisfied, would you refer this person to, or this company to a friend or family member that’s based on what was the event or a relationship you had with them? Was that satisfactory? Did it meet your goals and your needs? It’s a look back trust is as I go into a business relationship or a personal relationship, what is my, the basis of my emotion, or will willingness to be vulnerable or to put myself out there or to interact with somebody. So that is proactive. We should not confuse the two because mostly today we measure satisfaction. We don’t measure trust.

Stan (09:53):
And, and the other profound thing in the book, you know, there were things that just come out and grab you in this book. And that was that trust allows someone to predict future behavior.

Jan (10:05):
That is, that is very, very true. How do you build that relationship consistency? One of the 15 trust sets I talk about is very important. If I’m going to risk financially, physically, myself, as in patient, or as a business woman with another organization or another person, I have to know that I’m trusting that they will have my best interest in mind that I am going to achieve the goal I am hoping to achieve. So it really is a forward looking, um, interaction.

Stan (10:53):
There, there was tremendous relevance to that particular statement in the book, when you look at COVID and one of the things that we haven’t had in, in the whole COVID saga is consistency. Mass don’t work mass do work vaccinations work. Oh, well, baby vaccinations don’t work all the time. And this lack of consistency has HOLP changed the way people like Dr. Fauci. You know, a lot of people don’t trust him cuz he’s had to change what he said based on science, but people still want that consistency.

Jan (11:27):
Absolutely. So another one of the resets I talk about is communication. So if I were having, um, a conversation with Dr. Funche, which I would love to have,

Stan (11:40):
Well, we’ll have him on for you here. So I’m sure

Jan (11:43):
There you go. Um, you know, Dr. Fauci is somebody I have followed and I’m showing my age here, um, since the eighties and the aids crisis and there’s similarities here because we were building that airplane while flying it as well. These were new diseases. We knew nothing about COVID is a new disease. We hadn’t heard of COVID 20 months ago, which is amazing. Considering there is rarely a conversation today that you have with another professionally or personally that doesn’t have that in there, but saying, we don’t know, I don’t have all the information yet, but as we know it today, acts that will minimize to a certain degree that conflictive changing behavior. But the reality is if you’re trusting somebody, um, in any kind of reaction or interaction you want to know, because you’re vulnerable, you want to know the best and where they sit in their knowledge, it isn’t bad and you don’t lose trust. And this is very important. You don’t lose trust by saying, I don’t know many people are afraid to make that statement. I don’t know because they, in their mind, it shows they’re weak or have lack of knowledge. But the true this saying, I don’t know, let’s figure it out together or let’s watch this together actually builds trust because the other person is showing vulnerability. Unfortunately, if you watch the CDC and what’s happened, um, governmental entities, Theia the CDC. Um, historically the FDA were highly trusted entities, right?

Jan (13:45):
If you look at the data, my data, as well as others’ data, um, over the last 18 months, the roller coaster we have lived through and the inconsistencies have created a negative trust reset with governmental organizations because of more how they handled it, not what they did and did not know. Right.

Stan (14:10):
Um, the other thing you point out in the book was, you know, healthcare doctor, patient relationship used to be kind of an intimate one to relationship. And now there are carriers intervening. There are corporations, doctors have been employed. The data now is that 70% of the physicians in this country are now employed by either large groups or health systems. How has the employment of physicians? And, and you go into this typically in the HMO era, when people used to see the physician maybe acting on behalf of the health plan or the health system in the decisions that they made, but what has happened to trust and particularly how can employed physicians gain trust back when it’s lost

Jan (15:00):
Again, a great question, and this is not for people like you and Istan. This is not the first time that physicians have, um, gone into an employment relationship. If you look at the eighties and early nineties, I started my practice in a staff model HMO. So it isn’t the first time. Um, so what we do know is people trust people, they don’t trust organizations. And I gave an number of examples of that in the book. There are few places where organizational brand does breed trust, but that’s very, very rare. Um, so, and in many cases, people don’t trust in insurance companies because of their past relationship. They don’t feel that their outcomes are aligned. So if physicians are working and other providers are working for those organizations that are not trusted and quote, don’t have a heart, and I don’t mean they aren’t, but you can’t point to a person and say, that is this insurance company, or that is that hospital it’s humanized. So physicians lose some trust because patients and the caregivers and their families don’t don’t know if they are aligned or not now, are there ways to overcome that? Absolutely. And that is to be open and honest and transparent also to build the personal relationship, um, many years ago. And in the acknowledgements, in my book, I, I talk about somebody by the name of John McKendry and Dr. McKendry was, um, a primary care physician, a pediatrician practiced solo by himself, and he taught me the very important, um, piece of healthcare called social cement.

Jan (17:18):
And social cement was half of the five by seven note cards, which is how he kept his medical records. And most doctors did in the late seventies and eighties had Joey joined the soccer team, or Sally painted her bedroom blue. And the next time you saw them, you started the conversation that way, that meant you listened, you were empathetic and you built a one on one relationship. Physicians can still do that. It’s interesting. When I am in the neighborhood that I live in, which I also practiced medicine in 30 years ago, I will see somebody who was my patient 30 years ago. And I’ll say, so, do you still play tennis? I remember you joined the tennis team and they’ll look at me and say, how do you remember that? But those kind of relationships that builds trust, regardless of who your employer is and who you’re working for

Stan (18:24):
You, you just touched on, on transparency, which there’s another thing that actually reached outta your book and grabbed me. And that was the difference between honesty and transparency, which, you know, we all think of transparency as an organization, being honest, the hospitals have to be transparent about their prices. That means they’re honest, doctors have to be transparent about their information. They give you. That means they’re honest. Tell the listeners how transparency and honesty are so different.

Jan (18:56):
They’re very different. First of all, giving people, you can be transparent in a way that somebody has no idea what you just said, or you’re mandated to do it. And so you find another back door so they can be aligned, but they are not always aligned. Um, intent is part of it looking to achieve, um, the goal, think about, um, a health plan and a provider group who are negotiating financial con contracts. You can give information that is misleading or is not complete, that would lead to a certain decision or a certain assumption. That’s not necessarily honest, is it? So what you want to do is find the area of transparency, where you can reach aligned goals, where both sides, it’s not a tug of war. Healthcare has become a business tug of war, and that’s very important. So like your earlier question on satisfaction versus trust, I think we have to be clear on definitions, but more importantly intent

Stan (20:26):
If you’re listening live or if you’ve just joined us, we’re interviewing Dr. Jan Berger, the author of the recently released book, re-engaging in trust, the missing ingredient and fixing healthcare, which by the way, you can download on your Kindle from Amazon. So you can actually read it this afternoon. Um, Jan, you talked about organizations and how organizations have different challenges and engaging trust. Some of the people are gonna be listening to this webinar and to the podcast are people who belong to, or, or benefit advisors, brokers, people that help people understand or navigate healthcare. You talk about trust being a determinant of future success. Can you frame that in the context of people that advise about healthcare intermediate about healthcare?

Jan (21:22):
Absolutely. First of all, I will tell you that, um, trust needs to be part of every organization’s sustainability metrics. And it’s not only externally focused as we’ve talked about, but think about your organization and the interactions you have day to day with your peers in the company you work for. If you don’t have trust, the ability to sustain success is, is really challenged. Um, we do know that externally focused, if somebody is willing to use your services to trust your services in order to be successful, because they’re asking to use your services to address a challenge, a problem that they have, all right, that means you have to have aligned goals. You have to have the knowledge and you have to put yourself out there and look in their best interest. So we know that success and trust externally between two organizations is very important. But I have to tell you how many organizations that I talk to when I ask what is the trust within the organization? Because they can’t, um, look, look outwardly if they can’t look inwardly. And we know right now, we at a time where, what are they calling it? The era of the great resignation,

Jan (23:09):
Um, people don’t generally resign from a company they trust there is a, a relationship, an emotional relationship there that very often is stronger than the other issues. So it becomes a very important issue. And it’s one don’t use satisfaction. Again, just like we talk about enough motor score saying I’m gonna do an employee engagement survey or employee satisfaction survey the word trust, connotes that people are vulnerable and willing to have somebody else support them, help them educate them or direct them

Stan (23:58):
In the second part of your book you go into and, and you define the different areas of trust. You define the ’em and then you redefine them. And, and maybe the better term is you put, you talk about the dimensions of trust, you know, like there’s communication and so forth. One such explanation that you have in the book is that trust allows us to interact without fear. Can you tell us about some of these various different faces of trust and for each one of them, you talk about what an individual, what an organization can do. How about a few examples?

Jan (24:35):
I’d be happy to do that. Um, communication is one of them and whether it is a provider and a patient or a provider and an insurance company, a hospital, or two service organizations, we all have our own lingo. We learn a set of words that it’s kind of like going and learning French or Spanish. We have our own words interestingly, and we use those words and somebody does not understand them.

Jan (25:15):
It’s a negative trust reset. So understanding, and it’s interesting, we’ve over the last few years, we’ve talked about health literacy and speaking in a way that, um, a non healthcare professional understands, but it’s not just in the patient and the provider world. It is also on the business side of healthcare. Um, respect comes along with that. And it’s kind of a challenge because, um, if you’re not speaking some of the, in two healthcare professionals, then maybe they don’t respect. We know titles create, um, can create either a trust set, reset in a positive way or a trust reset in a nugget way. Um, operationally, it was fascinating to me that when we made some descriptions, as we were doing our interviews, and we would say, what are the things when you first walk into a provider’s office that make you trust them or distrust them.

Jan (26:29):
And we heard things like dirty, you know, uh, dirty floors or one of my favorite magazines that are 2, 3, 4 years old, dirty bathrooms. And that, that created a negative reset, um, on the business side, when one professional sat on one side of the table and the other sat on another, so there was almost a power play there that was a negative trust reset. We consistently heard a round table or something where there were two people who interacted without a physical thing in the middle, actually created a positive trust reset. So things such as that, how you are organized very, very important.

Stan (27:23):
I remember you and I talked recently about hints from helloe and she used to say, yes, never trust a doctor that can’t keep a plant alive.

Jan (27:33):
It’s true though. Isn’t it funny that we make light of that, but the attribution of one action to another really does impact trust.

Stan (27:48):
You also mentioned something really interesting that I thought about technology, and this probably goes back to electronic medical records. And you said that if technology does not support the building of relationships and trust it is hurting both of them other than electronic medical records, can you give us examples of that?

Jan (28:08):
Surely let’s talk about telehealth today. That’s a very hot conversation. The reality is telehealth works well under two conditions for the most part. One is if it is a short, acute, but not serious interaction that you need to have now, and it brings convenience. People can check the box, they get their need met. All right. The second is if you have a relationship with a provider prior to telehealth, it can build a relationship. It is not a tion of trust. I can look at you. In some cases, it’s actually really increases trust. Cuz there aren’t phones ringing and all kinds of things. I can look at you. I can look at your facial expression and we can continue to build that relationship. Those are really good things with the exception of mental health today, building a brand new relationship through, um, telehealth and virtual care is going to be a trust challenge. And nobody’s talking of about it. Yes, it improves access, but it shown that your long term emotional feelings about the other party are not strengthened by this. And that’s even, I sit on a number of boards as I was stating. We’ve done the business of the boards during, but some of my boards have new board members. I’ve never met face to face.

Stan (30:09):

Jan (30:10):
That doesn’t build trust in them. That means I did my job for the moment. I don’t have that trusting relationship. So when we talk about technology, if used under the right conditions, it can actually build trust, but don’t assume that it will build. I really do have some concerns about virtual first or virtual only relationships in healthcare. In the go forward

Stan (30:46):
In the book, you talked about one of roles, the, the trusting role for a person’s primary care provider is to, and I’m quoting here address the feeling of being untethered in healthcare. Can you expound on that? Untethered in healthcare,

Jan (31:05):
Stan, I’m so glad you bring that up because that was one of my biggest aha moments. When the gentleman I interviewed used that term and talked about, uh, space flight and being untethered. Um, healthcare is confusing. It’s hard, it’s emotional and all of us want somebody who’s on our side and can help translate it for us. Um, historically for any of you who are listening or watching right now, if you are old or if you have had more life experiences like Stan and I, you remember a gentleman by the name of Dr. Marcus Wellbe and many of us wanted to be Dr. Marcus Wellbe because whether it was an emotional issue or it was a physical issue, he and Juanita his nurse, um, were, and Steven Kylie, his partner helped you through every thing that was hard, whether it was physical, whether it was emotional, take healthcare was much simpler. Then take it today.

Jan (32:25):
It’s much more confusing. Who’s paying, who’s saying yes. And who’s saying, no, I have multiple silos in my care. Who’s gonna to help me whether it’s tethering me, whether it’s taking my hand and has my best interest and can lead me through the confusion. I will tell you, as recently as last week, I had to spend 15 hours dealing with a number of issues on what from one visit. I unfortunately lost my primary care physician. Two years ago. I would’ve looked to her to help me through. She retired. I don’t have a relationship with this new primary care physician. And she really was very honest and said, this isn’t what I’m supposed to do. The billing problem, the question of coverage or not coverage, you need to having, um, the next visit. You need to go to somebody else. I will tell you 35 years in just about every stakeholder role in health care. And I was untethered

Stan (33:46):
Interesting. You know, you just, by the way, I just, for those people listening in the audience, you always hear about Marcus Wellbe. I encourage anybody to go to YouTube and look at a couple of episodes of Marcus Wellbe. Cause although he was a great patient advocate, he was not part of what we call shared decision making anymore. And I don’t think he would be in practice in the 50 years that have ensued since Marcus Wellbe was a popular item. You just mentioned your doctor, she, which brings up another question. It, one section of your book mentions that women show a higher level of distrust in the healthcare system, healthcare system than men. But yet in another area you mentioned that women trust their providers more than men. How does that reconcile and how does gender discordance make a difference in the trust relationship? A man seeing a female doctor, a female, seeing a male, all doctor and all the changes that we’ve had. For example, almost all obstetricians and gynecologists coming out today are female, too many questions at one time.

Jan (34:54):
Well, let me take it and take it up a layer just for a moment. First of all, I know there’s a certain level of generalization here. Each of our life experie are different, but what has been shown is the empathy and the, um, ability to have a more vulnerable conversation is taught more for women than men. And if you look at the specialties that women early on, um, either were pointed to or chose pediatrics, OB GYN, those were things where the relationship and the conversational part of healthcare was much greater than the doing the cutting, the sewing, the fixing in the other ways. And it was less respected, but consistently we have found that on empathy scores and vulnerability scores and trust scores, women providers get higher scores. Hmm. Now the issue of discordance actually has a great deal of basis in, um, cultural, ethnicity and race.

Jan (36:18):
So there’s a great deal of data out there that in the Latino community, men, um, trust men more and the provider side, um, than they do women in just about all other cultures, actually the discordance between male and female men trust women providers more because in many cases, women are the CEOs of family healthcare. So they rely on women and they trust women to take care of their health. If I were in a room with, uh, your listeners, I would ask how many of the men in the room have mothers, girlfriends, wives, whatever, who make sure that their healthcare is taken care of. And my guess is it’s probably 80% or greater. So if you use the great healthcare, 80% rule CEOs of the healthcare are more commonly women. Um, so it is gender does make a difference on both sides. Um, but there are ethnic racial and cultural differences as well.

Stan (37:46):
We have time for one more point, if you would, the last point, uh, toward the end of your book, you said, and I, again, I’m quoting one cannot assume that if you are trusted today, you will be trusted in the future. Is trust sort of like a vegetable garden that you have to keep tending and to be sure that it bears fruit and vegetables.

Jan (38:08):
Well, as I am spending a lot of my time when I’m not working these days tending my fruit and my vegetables. Um, that’s a great analogy I think, um, to end and think about the 800 pound gorilla that I spoke about COVID is a great example of the issue of having to tend the trust garden, if you will. So often when people have historically thought about trust, it’s been conceptual. It hasn’t been very concrete. The reality is trust is a very concrete action. It is the only action I would argue that can have the impact across all stakeholders. So let’s take one moment and talk about COVID pre COVID. I talked about governmental entities like the CDC and the NIH were very trusted and actually early on in COVID they were because it was someone talking to them. But because of a number of things we talked about in the inconsistencies and some of the communication issues and some of the other issues that came into play, um, with government, um, they lost their trust and they were highly trusted before the most highly trusted individuals pre COVID were healthcare providers.

Jan (39:44):
They had the highest decrease in trust during COVID because they were unavailable. Their offices were closed, they didn’t have answers. So they didn’t answer. They became invisible in many cases to, in some cases, through no fault of their owns. In other cases, I would argue they missed a chance to continue to grow that trust garden. The, these were the most trusted people. If you look at the American board of medicine, recent work in trust, they know there was some mistakes made during COVID and they are working and looking to see what are the lessons learned? The pharmaceutical industry, who was not trusted before COVID because of vaccines and because of medications had the highest increase in trust through COVID, it’ll be interesting to see, do they maintain that the other highly trusted group to finish up was employers. And there’s a huge message here. Employers were the communication in conduits. Um, they were the ones who were talking to their employees, if you will, during COVID and they gained a great deal of respect, a great deal of trust. So the reality is in every interaction we have, we are either doing a positive, negative trust reset, and it’s very much as you stated a impact that has great opportunity, but it is like a garden. And if you ignore some things or do it wrong, you could have a very negative impact.

Stan (41:47):
Well, we’ve interviewed, uh, Dr. Jan Berger today, the author of re-engaging in trust, the mixing ingredient in fixing healthcare. And I strongly encourage everybody to read this book. It’s got really something for everyone in it. I hope you’ve enjoyed our conversation today. Jan, thank you very much for joining us. Uh, we’d like you to stay, take care and stay healthy if you’ve taken the COVID vaccine. Thank you. If you have haven’t time to sit down with your doctor and have that conversation, there’ll probably be new information about COVID tomorrow expect that things will change and there will be inconsistency as Dr. Berger has told us again. Thanks very much. And we hope to see you back here next month, take care.

Narrator (42:32):
We hope you’ve enjoyed the time with our very own doctor Stan for 360 degrees of healthcare with Dr. Stan Schwartz, a part of zero studios tune in subscribe and review our podcast to keep current with the ins and outs of the medical and healthcare industry from the inside out.

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