EP477: Through Line Show: What the Tribe Thinks You Need to Know About Trust or It’s Gonna Be a Problem. Also, Why You Are Smart, With Stacey Richter

A couple months ago, I did my very first episode (EP467) that locked down a very clear through line, a theme tying together a bunch of RHV (Relentless Health Value) episodes from earlier this year. That earlier through line was a lack of good primary care means higher emergency room spend.

For a full transcript of this episode, click here.

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Let’s talk about another emerging (in hindsight) through line. And to be clear, just like that last show, this through line emerged because of you lot who listen every week. You all wrote great, really insightful comments and reposts that excavated underlying themes tying a bunch of the episodes together. So, this show is going to be about one of these underlying themes: the very real impact of trust or lack of trust, which may come from too little antitrust.

I’ll pause for a sec for you to appreciate that little poetic gem I copied from Mick Connors, MD, and I’ll tell you where we’re gonna finish up. Spoiler alert: It’s with me telling you, Relentless Health Value listener, this whole thing is gonna wrap up with me telling you how smart you are.

Because you’re ultimately going to be the happiest, probably the longest living, and also most successful. So, stick with me here because we’re gonna go down before we go up. I also wanna mention the bonus clip that you will find released on the exact same day as this show.

It’s from one of the first Relentless Health Value episodes from literally 10 years ago that I did with Charles Green, who is an expert on trust. Most of that original and ancient episode is kind of terribly embarrassing for me to revisit. Don’t get me wrong, Charles Green is amazing and totally carries the interview; but I listened to myself and realized that, yeah, 10 years of practice makes not perfect, for sure in my case, but at least better.

This is likely TMI, so let me move on and say that the 10-minute bonus clip of that original show covers how to earn trust and to be worthy of trust IRL and thus really apropos to this conversation. So, you will find this clip for your convenience back in the pod feed also released today.

Okay … so, trust, the impact of trust. Just two weeks ago, my guest, Peter Hayes (EP475), talked about a pervasive lack of trust that has developed among patients and also Americans scared to become patients as well as clinicians.

Enrico Cullen also called out on LinkedIn the other day. He was talking about the show with Kenny Cole, MD (EP473), and he wrote, “If a patient is not taking the statin that you prescribe them because their neighbor’s uncle developed bad muscle aches while taking it … all it means is they trust their neighbor more than they trust their doctor.” So, that was something that Kenny Cole had said during the show.

Or as Denise Wiseman, PhD, MBA, CPXP, wrote the other day (again about the Kenny Cole episode from a few weeks ago), she said, “One key message that stood out: Building trusted relationships isn’t soft or secondary—it’s a critical lever for better health outcomes and smarter system design. As Dr. Cole says, ‘It’s our job to earn their trust and go on a journey with [patients].’”

Also, along these same exact lines (ie, the impact trust can have when it exists or the problems a lack of trust creates), Julie Siemers, DNP, MSN, RN, wrote, “It’s fascinating how trust shapes patient choices. Strengthening those connections with various providers is essential for better healthcare outcomes.”

And, right? Let me paraphrase Enrico and Denise and Julie with some additional context. If trust isn’t built with patients and then if some clinical or pop health or navigator/coordinator somebody pops up on the scene and tries to close care gaps or navigate members away from a low-quality or ridiculously high-cost care setting, or tries to get a member/patient to not show up in the ER as a default …

Look, anybody trying to do any of these things without a foundation of member or patient trust will be mopping up the floor while the faucet’s still running. Listen to the show with Matt McQuide (EP468) for this point with five underlines. Listen to the show with Christine Hale, MD, MBA (EP471) on high-cost claimants.

The TLDR on that one: You cannot spreadsheet your way out of high-cost claims. You need trust. You gotta, with all of these things, start with a step one: Build trust. And if you hop over that part, yeah, good luck with pretty much anything that you’re gonna try to do, as many find out the hard way.

So, what I just said there, starting with a foundation of trust to make almost anything happen as the step two, is this a popular but just kind of rando theory based on nothing much as far as evidence goes? Oh, very much no. So much evidence.

Listen to the pod with Rebecca Etz, PhD (EP295) from a while back that covers a few of the numerous very well-run studies which find over and over again how a patient who answers a question like, My doctor and I have been through a lot together—questions that are essentially assessments of trust. If you get a good answer to a set of questions like this one, you will find a patient panel with far better biometric scores than if you use the biometric scores themselves as the quality metric.

That’s a thing that makes you go, huh? But it’s because Goodhart’s Law will get you. Listen to the show with Rishi Wadhera, MD, MPP (EP326). This is wildly counterintuitive, I grant you, that if you use as the quality metric what you want to improve, you don’t actually improve what you want to improve a lot of times.

This happens because, in short, humans—even very smart ones—tend to try to shortcut our way to a goal to be efficient and all. But then what we wind up doing is inadvertently undermining our ability to achieve the goal because we inadvertently slice out essential parts of the process actually necessary to achieve the goal. And goodbye, trusted relationships or trust or establishing trust with patients, which seems kind of optional. And then goodbye, our best shot at the goal.

So that’s a “do not,” you know, don’t cut out the part where you’re earning trusted relationships. But what’s a “do”? Lots of things. Listen to any of the episodes I have already mentioned.

But here’s also some interesting comments that I read to this end on LinkedIn. James Button wrote, and this aligns very much with Charles Green’s writings and trust formula that, again, you can hear about if you listen to the bonus add-on. But James Button wrote, “Trust often grows through proximity (like in-home care coordination) and familiarity (peers who truly get it). It’s not that I don’t trust my doctor—I do. But when it comes to decisions about my health, I tend to lean on those who have a better understanding of my day-to-day life and/or those who have been through similar experiences. If we don’t start recognizing and integrating [those] connections into care models, we’re going to keep missing opportunities to truly support people and drive meaningful behavior change. … This isn’t just about fine-tuning operations, it’s about building a system that genuinely meets people where they are.” And I’m gonna add on the end “… and that people can trust.”

Now, is earning trust simple? Well, Dr. Mick Connors wrote an article entitled “Trust Is Hard to Earn, Easy to Lose.” So, that’s the short answer.

He also wrote, “The Irony of ‘Anti-Trust’ in Healthcare: Why No One Trusts the System,” which is a very well-done headline by you, Dr. Mick Connor, as I said earlier; and I’m gonna very opportunistically use it as a segue because I’m scrappy like that.

So, speaking of antitrust, here we are asking patients to trust their doctors when many doctors and other clinicians, especially in consolidated or rolled-up organizations subject to antitrust, these clinicians do not trust their bosses, be they their admin, leadership, or their private equity ownership.

I just read a post by Olusoji Olakanpo, MD, about pediatric physician shortages; and he wrote, “The participation rate is falling. … We have many licensed pediatricians in the country, but there is a distrust/unwillingness to work for employers (corporate/hospital … systems) who employ 74% of doctors. This … causes a vacancy crisis … our workforce is working part-time, [they’re working flex, or just plain not] working at all rather than hit [this] wall of moral … injury.”

I mean, you start to get why with the lack of trust that healthcare workers have for some of their bosses. When you hear stuff like Yashaswini Singh, PhD (EP474) was saying in that episode from a few weeks ago about how some private equity–owned practices have been rumored to hang up scoreboards and give doctors bonuses based on, like, how many injections they do. I’m picturing the sign above the scoreboard: Always Be Injecting, you know, like Always Be Closing.

I was just at the MSK (Memorial Sloan Kettering) Direct Summit, and I heard Robert Sidlow, MD, MBA, comment that this country is in a state of crisis right now because never have fewer medical students selected primary care or pediatrics.

Dan Pomerantz, MD, MPH, MACP, said that the primary care crisis has many causes, such as all the things aforementioned. Two main contributors are government neglect and the ordinary business practices of commercial payers. It’s corrosive, the level of distrust we’ve got going on here. We have a situation where future PCPs or future peds aren’t thinking they’re gonna be able to count on margin, for sure; but they also distrust that they’re going to be enabled to fulfill any sort of mission.

I mean, we got medical students are rational actors, and they see and have heard about this hornet’s nest. They do not trust the system enough to spend however many years of their lives and accrue however much medical school debt. They can’t count on mission. They can’t count on margin.

Listen to the show with Komal Bajaj, MD (EP458) with a whole lot of stats on the lack of trust amongst clinicians for their bosses at hospitals or elsewhere. They don’t trust their admin teams to have their backs or to do right by patients.

And look, let’s be clear, not talking about all hospitals, not talking about all administrators. There are some excellent ones, but as a bell curve, this all is very striking.

Alright, now I was gonna go off on a little diatribe about how distrusted insurance carriers are, but I’m not gonna bother except to say, yeah, December 4, 2024. Sadly, that about sums it all up.

But keep in mind plan sponsors. If a patient goes in for, like, a free mole check or a mammogram or preventative something or other and then winds up in some kind of diagnostic code zone and gets a $600 bill, that’s benefit design. And the huge distrust in the system that results from that? Sorry, gang … it’s on the plan sponsor who let that happen.

Alright, just one more little trust/distrust context setting before I turn this ship around and we talk about why you, listening right now, you who are in the Relentless Health Value tribe, who listens every week, you are uniquely positioned for good amongst all this murk.

But just one more example of earned distrust before I move on to really inspiring pastures, so stick with me. I just wanna mention now healthcare vendors or tech and collaborations between them and others right now, which, by the way, are essential if anyone wants to defragment a patient journey or do pretty much anything seamlessly.

I was talking to a friend the other day who works at a pretty innovative healthcare company. And she was telling me a whole story about how a major player in the industry told them they wanted to collaborate on a big bid. They took all the information from my friend’s company, incorporated it into their own bid, and then submitted the bid by themselves. Is that trustworthy? It’s a hornet’s nest, right?

It makes me admire even more the physicians and other clinicians and administrators who do their level best to try to get a bead on what’s going on around them and attempt to protect their patients from getting sucked into it.

But okay, now let me do a complete 180 and say something directly to you who are listening here, and I’m saying this and I really, really want you to hear it because it’s rough out there, and maybe this is a dose of optimism and inspiration.

Two points I wanna make. The first one is this: business success. Charles Darwin is reputed to have said in the long history of humankind (and animal-kind, too), those who learned to collaborate and improvise most effectively have prevailed.

And the best collaborators, the ones with the highest collaborative IQ, yeah, these folks are trustworthy. I mean, think about it. No one is going to collaborate with someone or share data with someone if they get a reputation for sucking up someone else’s IP and then submitting the bid themselves or putting profits over patients or members or clinicians or just being untrustworthy in any number of other ways.

Whoever rolls like this will likely win a few in the short term. That’s undeniable. But if they are in any given business long enough that their reputation catches up with them … yeah. Not saying that regulatory capture or “too big to fail” nature of some of these organizations won’t protect any individual who’s doing stuff like this for a while at the organizational level.

But at the personal level? Ha! Admit it. You’re thinking the same thing I’m thinking. When someone who used to be part of a team who did everyone dirty comes looking around for a job or a favor …

To that end, there’s this book. It’s called Give and Take by Adam Grant, PhD, where he breaks people into three categories: givers, takers, and matchers. Givers can be trusted to give even if they know they won’t get anything in return. Takers can be distrusted to take even when the boundary where they know someone else is gonna be hurt by their taking.

And matchers can be trusted to keep score. Like, a matcher thinks, “Oh, you did me a favor, so now I owe you one.” But also, matchers keep score for others. Like, if they see a taker taking advantage, then they also shun the taker; and they will inform others as to what the taker has done.

And likewise for givers, like, if a matcher sees a giver doing someone a solid, it certainly works both ways; and they will make sure there’s enough compliments to go around.

And this is why whenever the game is a long game, givers will ultimately prevail. The most successful people in history are, in fact, givers. We all know how truly wonderful it is to work with people you can trust to help you when you need help, and we gravitate toward these folks.

Now it’s important as a giver to set boundaries and all that. But yeah, I’d strongly suggest that most Relentless Health Value tribe members are probably somewhere on the giver or giver/matcher continuum. And maybe this is the place to state for the record how smart you are to be who you are, not for being here precisely but for thinking the way that you obviously think to have made it here to begin with.

Because what this show is all about, every single episode, every single week, is how we can make sure that we give patients or members the best that we can manage to give them. How do we show up and work together to create a new healthcare system that just does better? I hear over and over again instances where someone who listens to the show reaches out to a guest or someone else who they see commenting on LinkedIn (so they know also listens), and how something great happened as a result.

The collaborative IQ of this tribe is big, big, and this matters because here’s a second reason why you’re smart to be here as a giver or the giving kind of matcher.

You know who is the happiest in life? You know who lives the longest? Right … people who have friends, a community who have purpose they are dedicated to fulfill.

We are social beings, after all; and giving and helping others in our community actually confers much more happiness than selfishly taking. I read that book The Purpose of Life by Viktor Frankl many years ago, and it sticks with me. Viktor Frankl was in a concentration camp. It was clear to him that those who survived were not the ones who were physically the strongest.

It was the ones who had purpose in their lives. And that’s a common finding in all those longevity studies, too, like the blue zones and all that. Finding meaning and also investing in relationships, which means being trustworthy, helps combat loneliness; and all of this is particularly important as people age.

But lastly, this is healthcare we’re talking about, and I’d strongly suggest being a taker is kind of antithetical to the whole practice of medicine.

I mean, think about it. You want an organization providing healthcare to sick people solely focused on how they can manage to take or get their clinicians to take? As a culture that just feels very, very off. And the danger there, as they say, is culture eats strategy for breakfast, lunch, and dinner.

So, thanks for being trustworthy. Thanks for being a giver. Thanks for being here. It really matters.

Also mentioned in this episode are Mick Connors, MD; Charles Green; Peter Hayes; Enrico Cullen; Kenny Cole, MD; Denise Wiseman, PhD, MBA, CPXP; Julie Siemers, DNP, MSN, RN; Matt McQuide; Christine Hale, MD, MBA; Rebecca Etz, PhD; Rishi Wadhera, MD, MPP; James Button; Olusoji Olakanpo, MD; Yashaswini Singh, PhD; Robert Sidlow, MD, MBA; Dan Pomerantz, MD, MPH, MACP; Komal Bajaj, MD; Cora Opsahl; Adam Grant, PhD; and Tom Nash. 

For more information, go to aventriahealth.com. 

Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry.

In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.

00:47 What is the new, emerging through line becoming apparent in healthcare?

01:54 Bonus Episode with Charles Green.

02:52 What is the impact of trust in healthcare?

02:55 EP475 with Peter Hayes.

03:11 EP473 with Kenny Cole, MD.

05:31 EP295 with Rebecca Etz, PhD.

06:07 EP326 with Rishi Wadhera, MD, MPP.

07:06 Why does trust grow through proximity, and why do providers need to integrate this into care models?

07:59 Why antitrust is so prevalent in healthcare.

10:00 What are two main contributors to the lack of primary care doctors?

13:27 Why collaboration builds trust.

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Ann Lewandowski, Peter Hayes, Yashaswini Singh, Dr Kenny Cole, Dr Eric Bricker, Dr Christine Hale, Nikki King, James Gelfand (Part 2), James Gelfand (Part 1), Matt McQuide, Stacey Richter (EP467)