Trust is the Core of Medicine

A number of promising new digital health companies have surfaced in the past two years, prompted in part by the demand for telehealth visits that soared in the first wave of Covid-19. These companies have been fueled by a wave of breathless hype and tens of billions of dollars in venture and private equity investment.

Far from being a new kind of health system, as feverish boosters suggest, the plethora of virtual-first digital health offerings — in which patients’ initial entry point is with a virtual provider they do not know — are a clumsy power grab intended to detach patients from trusted relationships with established caregivers, using instant access as bait, in order to control their downstream care.

The vast majority of these efforts will likely end in costly failure because they ignore the central role of trust in health care.

The late Kenneth Arrow, a Nobel Laureate in economics, once observed that “virtually every commercial transaction has within itself an element of trust.” But the role of trust in health care is especially crucial. Arrow wrote that illness is an “assault on personal integrity.” The consequences of failure for the patient are so great that the level of trust required in a health encounter is greater than in virtually any commercial transaction. The more threatening the medical problem, the greater the level of trust required.

The health system runs on trust.

Medical services are not, in the main, retail transactions between anonymous customers and commercial suppliers. Visits to retail clinics like CVS Minute Clinics and hospital-sponsored remote clinics are estimated to be about 50 million a year, according to Nate Bronstein of the Convenient Care Association, which represents this sector, compared to roughly 900 million annual physician office visits and nearly 800 million hospital outpatient visits.

And while it is true that telehealth visits soared during the spring 2020 surge of Covid-19, the number of anonymous digital visits remained a small percentage of that total traffic. The vast majority of visits early in the Covid pandemic were with patients’ own doctors, done remotely with FaceTime or dedicated telehealth technology. Telehealth was instrumental in helping patients maintain contact with established caregivers during lockdowns and the long period of uncertainty about the safety of the health care system that followed.

As the early struggles of digital pioneers like Teladoc (founded in 2002) and American Well (founded in 2006, and now called Amwell) showed us, the demand for “talk to a stranger on the phone about your intimate medical problem right now” is limited. These firms have relied on acquiring and rolling up smaller firms for their recent growth. Teladoc’s total number of “visits” in 2021, around 14.5 million, is a vanishingly small fraction of the nearly 1.8 billion annual physician encounters or outpatient visits.

Up to one-quarter of U.S. adults do not have a physician or regular source of care. Yet many of these people may or may not be “patients” actively using health care who are future candidates for digital health. Some folks are “unattached” because they do not need medical help, or cannot afford it.

Health care architecture: circles of trust

Health enterprises can be thought of as interlocking circles of trust, radiating outward from the physician-patient relationship. The more complex the problem, the more likely a physician does not act alone, but as part of a trusted clinical team comprised of consulting physicians, nurses, pharmacists, and others. Those teams are embedded in a framework of administrative and support services that are often, but not always, in hospitals that provide them with technological and logistical support.

Physicians are increasingly part of organized groups, either independent group practices or those owned by or receiving support from hospitals or other enterprises. However large or small, physician enterprises are held together by collegial ties, shared values, and complex webs of internal referral and consultation the strength of which depend on high levels of trust. Physicians who do not trust their colleagues’ professional judgement for personal or family medical issues do not hesitate to seek care outside their employing organizations.

Management guru Peter Drucker once characterized the core clinical enterprise — the hospital — as “the most complex human organization ever devised.” It has hundreds of “products” with a bewildering range of technical complexity, delivered by teams of highly trained professionals and enmeshed in increasingly complex webs of commercial relationships with government and commercial payers. Hospitals and multi-hospital systems have brands, to be sure, but the strength of those brands is no greater than the store of trust patients and their clinicians have in the organizations that support them.

Rather than seeing digital health as a new business, I see digital modalities such as telehealth and remote patient monitoring as force multipliers that extend and strengthen the trusting relationships that remain the core of medicine. Given the level of personal risk patients bring to the care system, and the complex web of trust required to manage that risk, earning and maintaining the trust of patients should continue to be the central mission of anyone who participates in the health enterprise — either in person or digitally.

Originally published on STAT.