Professional accountability is balanced and well supported on a three-legged stool made up of patients, clinicians, and the health care system. All three legs must be strong, and pressure must be exerted equally and oppositely through each of them at all times. Strength and stability of the stool is enhanced by building trust in our partnerships through consistent displays of trustworthiness. The challenge for physicians, patients, and the government during periods of critical change is to create processes that allow safe displays of honesty, integrity, and reliability and acknowledge them when they occur.
KEY WORDS: accountability of physicians, trust, trustworthiness, patient-physician relationship, professionalism
Accountability is shaping the culture of medicine
Much has been written in the United States about the intricacies of accountable care, the spillover of which surely influences our thinking in Canada. Some believe that accountability drives meaningful changes in behaviour that can improve quality and performance in our health care system.1 Others think that agreements based on measurement and reporting drive change in one area but then have unforeseen consequences in another.2 Without question, though, accountability is shaping the culture of medicine.
But what is it exactly? And how do we make it palatable? In my opinion, accountability is about matching the desire to do the right thing with showing that the right thing is actually happening. It connects intent with outcomes. When viewed in that light, the concept is actually rather familiar to health care providers. It has formed the basis of our evidence-based scientific thinking for decades.
Still, an analysis of the relationships on which accountability is based may be helpful in making the concept more agreeable. Physicians maintain three professional accountable relationships: to patients, to peers, to the health care system. These interdependent relationships function like supports on a three-legged stool. Stability is certain if all three legs are strong; the forces exerted in each leg must be equal and opposite and exerted through its core. A leg can still support the stool while flexing and bowing to a degree, but ultimately each must be relatively strong for the stool to remain upright.
Recently physicians have felt unstable when perched on this stool. This is evident in statistics, such as “70% of residents are suffering from burnout.”3 It shows up in displays of intraprofessional incivility and bullying.4 Physicians may feel like they are not on a stool at all, but rather that they are trying to balance on something more like a fitness ball, where no stabilizing forces or supports exist. External pressures currently pushing health care range from political battles, to overcrowding of hospitals, to an increasingly aging and complex patient population. Without a stable stool, there is a strong likelihood that a provider will fall over. This is an uncomfortable feeling.
So how is balance restored for physicians? How can the stool be built so that there are three legs equally pushing up against the forces of professional gravity, thereby creating a safe place to sit and work? One way may be to create an environment in which a different type of conversation can be had between physicians, as well as among them, the health care system, and their patients. Open communication in troubled times, really listening to and hearing what each side is experiencing, and having authentic non-judgemental dialogue enhances stability. It does so through the creation of trust.
In health care, trust seems to have slowly eroded away over the past two decades. It has been lost as patients realize that physicians are not the sole keepers of medical knowledge.4 It has dissipated as care becomes more and more managed by administrators or others distant from the patient. It has been reduced as specialists become siloed away in sub-sub-specialties, less accessible to primary care providers, with fewer personal points of contact in the hospital corridor or cafeteria. It has been blocked by technology where voicemail and fax have become the principal methods of communications between physicians. Perhaps this is just the “new normal” and cannot be changed. Physicians should ask themselves, though, if it is acceptable for a low-trust environment to be viewed as the norm. Top
Business literature is full of commentary on the creation of trust and the benefits it confers to intraprofessional relationships. Dr. Paul Zak, at Clarement Graduate University, has spent his career researching the neuropsychology of trust. He has shown that in organizations where there is a high level of trust, compared with similar companies with low trust, employees report 74% less overall stress, 106% more energy at work, 50% higher productivity, 76% more engagement, 13% fewer sick days, and 40% less burnout.5 Surely, then, there is good reason to rebuild a culture of trust in health care.
Baroness Onora O’Neill, a highly esteemed Cambridge academic and chair of England’s Equity and Human Rights Commission recently spoke in a TedX talk on the generation of trust and how this influences our professional relationships.6 In her lecture, Baroness O’Neill posited that trust cannot simply be built; it must be earned. How, then, do physicians and their partners earn trust in accountability conversations? They do so, she says, by being trustworthy.
There is an important difference between trust and trustworthiness. Baroness O’Neill asserts that humans scan for trustworthiness constantly and that it is perceived via three qualities or traits: honesty, integrity, and reliability. Trustworthiness is naturally evaluated as well as displayed by each of us in every interaction we have and can be improved with attention. Trust is earned over time and by fairly consistent displays of the above three traits as physicians interact with each other and the system.
Offering up opportunities to trust one another exposes vulnerabilities. It requires safety. Trustworthiness is not the sole responsibility of physicians, but also of the two other partners with whom they work closely in health care. Over time, constant exposure to the principles of trustworthiness buttresses weaknesses in the integrity of the legs on our three-legged stool.
Trust between physicians and patients has changed over the past few years. There has been an implicit social contract in the doctor–patient relationship, and it is still seen as sacred. The medical social contract is explained well by Creuss and Cruess.7 In their thinking, society’s and patients’ expectations of providers in such a contract are:
In turn physicians can expect from society and their patients the privileges of:
It is easy to see where this social contract may be failing us, and likely these principles could be modernized. In the past, patients trusted doctors simply because they possessed a body of knowledge and insight that the untrained person did not. In turn, physicians would see a return of trust when advice was sought, followed, and found to be valuable. Now, patients have exposure to countless opinions and unlimited access to information on the Internet. They are much more able to make informed choices as to how they treat and care for themselves without medical expertise. There is no longer a monopoly on knowledge.
Trust from the social contract is now based on a shared relationship. The insights physicians can offer are in the interpretation of information through the lens of experience and previous exposure to similar patients and problems, as well as a deep longitudinal knowledge of the patient. As doctors show trustworthiness and adapt to this new reality, if they adapt to it, accountability changes. It becomes more equal. This leg of the stool is the easiest to keep strong as it is tested and reinforced dozens of times each day in patient care. Top
The second leg of accountability is that of peer to peer. Doctors have had trust and assessments of trustworthiness built into their learning from their very first days in medical school. They take advice from colleagues on how best to care for some of their most challenging medical dilemmas. For the most part, this trust is based on strong relationships between them. There can be variability in trust based on experience and individual interactions with specific colleagues, which allows choice, as trustworthiness builds over time. One may choose to wait longer to have a patient see Dr. Jones because one trusts her judgement more, even when a more accessible doctor may have the same level of competence but is not seen as having the same degree of reliability or integrity.
Trust in the community of physicians as a whole may have diminished as well. Reasons may include system barriers to maintaining a strong medical community of practice (increasing degrees of sub-specialization, siloed locations of practice where hospital and community physicians rarely mix, fewer personal connections with peers), some could be related to demands on time, and some may be related to a changing professional mix in the work environment.
With effort, though, trustworthiness between peers can be enhanced in this difficult time. Trusted relationships can be nurtured through dialogue, direct and honest communication, and by working side by side on challenging health care issues. Again, to build better connections and trust, clinicians need to increase their trustworthiness. Colleagues should be seen as partners rather than adversaries, supporting a diversity of ideas and multiple opinions on how to solve any collective problem. This will strengthen the second leg of the stool. In using and nurturing trust, physicians are being accountable.
Accountability to the system
A very important third leg of accountability comes from physicians’ intersection with the larger health care system. This includes the structures that surround their work (hospitals, regions, community agencies) and the government that funds most of it. There has been a huge erosion of the strength of this stool leg recently. Some would even go so far as to say that, in some provinces, it has rotted completely. If we agree that the integrity of the wood itself is poor, then it behooves us to find ways to build in strength and resilience from the outside, like a cast on a broken limb.
Trustworthiness is hard to assess when you fear that at any time the three tenets of honesty, integrity, and reliability are missing. Bracing and bridge-building will allow trustworthiness to accumulate on both sides of the relationship. Both providers and system planners must strive for ways to show that each is being honest, acting with integrity, and exhibiting reliable competency. This will be hard work, especially when agendas are not the same. And it will not happen all at once. Top
Trustworthiness can be built with constant acknowledgement of work done in good faith. It will require transparency, patience, careful observation, examination of failures, and celebration of success. The relationship does not need to be perfect for trustworthiness to be shown, but the approach does need to be consistent. To succeed at earning trust, physicians and the health care system must view each other with open minds and watch for examples of cooperation that enable change so that these are not missed.
In positions of vulnerability, both doctors and health system leaders should be careful not to make assumptions about the motivations and intentions of the other. With care and repair, a broken, unstable stool leg can be replaced with a stronger one made of new hardwood. This wood will not be without its knots, but knots don’t necessarily weaken the core of the leg. It can be strong despite its imperfections and is much more interesting to look at. With this earned trust, bilateral accountability is easier to understand and maintain. Top
Achieving balance, finding strength
Professional accountability is balanced and well supported on a three-legged stool, made up of patients, clinicians, and the health care system. All three legs of the stool must be kept intact and strong, and pressure must be exerted equally and oppositely through each of them at all times. Strength and stability of the stool is enhanced by bracing weakened legs and by building trust in our partnerships through consistent displays of trustworthiness. The challenge for physicians, patients, and the government during periods of critical change is to create processes that allow safe displays of honesty, integrity, and reliability and acknowledge them when they occur. Over time, less and less effort will be required to find balance, and eventually there will be comfort felt in just sitting, knowing that we won’t fall over.
1.Phipps-Taylor M, Shortell SM. More than money: motivating physician behavior change in accountable care organizations. Milbank Q 2016;94(4):832-61. doi:10.1111/1468-0009.12230
2.Mannion R, Braithwaite J. Unintended consequences of performance measurement in healthcare: 20 salutary lessons from the English National Health Service. Intern Med J 2012;42(5):569-74. doi:10.1111/j.1445-5994.2012.02766.x
3.Holmes EG, Connolly A, Putnam KT, Penaskovic KM, Denniston CR, Clark LH, et al. Taking care of our own: a multispecialty study of resident and program director perspectives on contributors to burnout and potential interventions. Acad Psychiatry 2017;41(2):159-66.
4.Boyle T. Ontario doctors ‘distressed’ over wave of bullying, infighting. Toronto Star 2017;Feb 27.
5.Zak PJ. The neuroscience of trust. Harv Bus Rev 2017;Jan/Feb:85-90.
6.O’Neil O. What we don’t understand about trust. TEDxHousesOfParliament; 2013. Available: https://tinyurl.com/ybrgvv7s (accessed 15 Oct. 2017).
7.Cruess SR, Cruess RL. Professionalism and medicine’s social contract with society. Virtual Mentor 2004;6(4). Available:
Darren Larsen, MD, is a lecturer in the Department of Family and Community Medicine and adjunct lecturer at the Institute for Health Policy Management and Evaluation, University of Toronto. He practices at Women’s College Hospital.
This article has been peer reviewed. Top