Increasing trust in health care.

Trust in American health care and in the people running medical institutions is in decline, which poses a threat to the physician-patient relationship. In response, the ABIM Foundation has established the Building Trust initiative, which includes the Trust Practices Network, advancing research in trust, leadership convening, and various communications vehicles. The Trust Practices Network includes hospitals and health systems, specialty societies, health plans, consumer organizations, employers, and others who are working to reaffirm and strengthen trust as a pillar in their own missions. Participants offer examples of how they have built trust, and their contributions have illuminated 4 dimensions of trust: competency, caring, communication, and comfort. This commentary discusses an exemplary practice for each of these dimensions and describes the "positive deviance" strategy that underlies the Trust Practices Network. It also offers an overview of the other elements of Building Trust, such as a grant program to promote trust as well as diversity, equity, and inclusion in internal medicine education, and an effort to spur additional research on trust.

Professionalism as the Bedrock of High-Value Care.

"High-value care" has become a popular mantra and a call to action among health system leaders, policymakers, and educators who are advocating widespread practice changes to reduce costs, minimize overuse, and optimize outcomes in the United States. Regrettably, current research does not demonstrate significant progress in improving high-value care. Many investigators have looked to payment models, benefit design, and policy changes as the main levers to reduce low-value care delivery; thus, the prevailing approach to ensuring high-value care has been to identify and limit low-value services. This approach has a clear limitation: The number of identified low-value services has become too high for individual physicians to track. Using professionalism as a key driver of practice change presents an important opportunity to shift from a deficit-based reactive model to one that is proactive and uses the concepts of intrinsic motivation and medical stewardship to effect high-value care. Transforming aspirational values such as professionalism into actions that engage all physician stakeholders regardless of their position or influence, and regardless of system agility or payment structure, has the potential for bringing about real change. These concepts can be integrated into medical education, introduced early in training, and modeled by educators to drive long-term sustainable change. Physicians can, and should, embrace professionalism as the motivation for redesigning care. Payment reform incentives that align with their professional values should follow and encourage these efforts; that is, payment reform should not be the impetus for redesigning care.

A Trust Initiative in Health Care: Why and Why Now?

The authors describe the importance of trust in health care, while noting with concern the documented decline in Americans' trust in the medical system, its leaders, and to a lesser degree, physicians themselves. They examine a number of reasons for this decline, including both larger societal trends and elements that are specific to health care. They then link trust to medical professionalism, explaining why the ABIM Foundation has decided to champion trust as an issue in the coming years. Finally, they offer thoughts on the specific actions the ABIM Foundation may take, including the launch of a Trust Practice Challenge designed to uncover practices that are currently working to build trust in a variety of practice settings and health care relationships, and the exploration of potential avenues to combat medical misinformation.

A narrow view of Choosing Wisely.

This letter argues that an editorial published in the August 2018 issue provides an unduly limited perspective of the impact of Choosing Wisely.

Organisational strategies to cultivate professional values and behaviours.

BACKGROUND: In recent years, there has been increased focus on the importance of professionalism among medical students, residents and practising physicians, as well as the interaction between individual behaviours and the practice environment. METHODS: Recognising the need to better understand how organisations advance professional behaviours, the authors undertook an exploratory, qualitative study. This study consisted of screening interviews with 30 organisations. Staff and an expert advisory committee developed criteria to select 10 organisations for further study. The authors then conducted in-depth interviews with two leaders from each of the 10 organisations. RESULTS AND DISCUSSION: Qualitative analysis revealed several key findings, including diversity in the language that organisations used regarding professionalism, and the professional behaviours that they chose to promote. Despite this diversity, all organisations shared a common strategy of clearly articulating their values and reinforcing these values. This reinforcement occurred through the provision of aligned organisational systems and structures, and the cultivation of strong interpersonal relationships. To better illustrate these findings, the authors provide several examples that demonstrate how organisational leaders use values to cultivate professional behaviour in their organisations.

Systematic review of the literature on assessment, feedback and physicians' clinical performance: BEME Guide No. 7.

BACKGROUND AND CONTEXT: There is a basis for the assumption that feedback can be used to enhance physicians' performance. Nevertheless, the findings of empirical studies of the impact of feedback on clinical performance have been equivocal. OBJECTIVES: To summarize evidence related to the impact of assessment and feedback on physicians' clinical performance. SEARCH STRATEGY: The authors searched the literature from 1966 to 2003 using MEDLINE, HealthSTAR, the Science Citation Index and eight other electronic databases. A total of 3702 citations were identified. INCLUSION AND EXCLUSION CRITERIA: Empirical studies were selected involving the baseline measurement of physicians' performance and follow-up measurement after they received summaries of their performance. DATA EXTRACTION: Data were extracted on research design, sample, dependent and independent variables using a written protocol. DATA SYNTHESIS: A group of 220 studies involving primary data collection was identified. However, only 41 met all selection criteria and evaluated the independent effect of feedback on physician performance. Of these, 32 (74%) demonstrated a positive impact. Feedback was more likely to be effective when provided by an authoritative source over an extended period of time. Another subset of 132 studies examined the effect of feedback combined with other interventions such as educational programmes, practice guidelines and reminders. Of these, 106 studies (77%) demonstrated a positive impact. Two additional subsets of 29 feedback studies involving resident physicians in training and 18 studies examining proxy measures of physician performance across clinical sites or groups of patients were reviewed. The majority of these two subsets also reported that feedback had positive effects on performance. HEADLINE RESULTS: Feedback can change physicians' clinical performance when provided systematically over multiple years by an authoritative, credible source. CONCLUSIONS: The effects of formal assessment and feedback on physician performance are influenced by the source and duration of feedback. Other factors, such as physicians' active involvement in the process, the amount of information reported, the timing and amount of feedback, and other concurrent interventions, such as education, guidelines, reminder systems and incentives, also appear to be important. However, the independent contributions of these interventions have not been well documented in controlled studies. It is recommended that the designers of future theoretical as well as practical studies of feedback separate the effects of feedback from other concurrent interventions.