Let Me Down Easy: Rebuilding Trust in Health Care

I attended the American Hospital Association (AHA) Leadership Summit in Denver a couple weeks ago. The last time I had attended an AHA event was 15 years ago at the Annual Meeting in San Diego. I have been racking my brain to remember the themes from that conference: population health, clinical integration and the promise of health IT in supporting more integrated care.

In 15 years, health systems have gone through a whirlwind—EHR implementation, Medicaid expansion, huge industry consolidation and mega-system-formation, experimentation with value-based care models, a major pandemic, and now AI. I recall running an analysis back then looking at top non-profit health systems by revenues—it was dominated by academic medical centers, with top revenues around the $10 billion range. The landscape is very different today, with Kaiser Permanente in the $125+ billion range, followed by major non-profit systems with now national footprints such as CommonSpirit and Advocate. The institutions patients and clinicians now navigate are vastly larger than fifteen years ago.

Despite all this change, the topics at this year’s Leadership Summit were actually fairly similar: leveraging new technologies (in this case AI) to improve access and quality, redesigning service lines (in this case primary care, geriatrics/longevity and behavioral health), scaling innovative care models (in this case team-based, virtual and hospital-at-home models), experimentation with value-based care models, and improving the patient experience.

What I remember most from 2011 though, was a mind-blowing live performance by Anna Deavere Smith previewing her “Let Me Down Easy” one-woman show. She had interviewed hundreds of people around the country—patients, doctors, a rodeo rider—and then embodied them onstage, using their exact words, pauses, and breaths, revealing the very human costs of health system and health policy failures.

Under the buzz words of “Transformation,” “Re-imagining Care Delivery” and “Leading Future-Ready Health Systems” at this year’s conference, I actually heard an undercurrent that reminded me of Anna Deavere Smith’s work—namely, how do we rebuild trust when so much has been eroded over the years between health systems and their patients, as well as between health systems and their care teams, when that trust is at risk of being eroded further with the advent of AI (There were nurses protesting outside the conference—concerned that they would be replaced by AI). One leader noted that “humans have only so much cognitive capacity for change, and we are asking our care teams for near-constant change.”

So, what I listened for was how health systems were working to rebuild trust. The best answer I heard came from a physician executive at a rural system in the upper Midwest. A man in his community had attempted suicide in his combine harvester. When the physician later asked why he hadn't come in for help, the man explained that he drove the only red pickup truck in town. Everyone would have known whose truck was parked outside the mental health clinic. The system's response was to build an anonymous virtual mental health program. As another rural leader said: Rural health care does not have to be a smaller version of urban health care.

I keep returning to that story because it required someone to ask a question and listen to an answer that contradicted what the system had assumed. That is Anna Deavere Smith's method, more or less—the discipline of taking another person's words seriously enough to be changed by them. It is also the thing AI cannot do for us. AI can extend reach, absorb documentation burden and surface patterns no human would catch, but it cannot be in space with human vulnerability.

The other approaches I heard in Denver were variations on a theme. Systems pursuing High Reliability Organization status and building cultures where errors surface rather than hide. Health system leaders building a “culture of curiosity and resilience,” making room for experimentation and failure. Leaders describing the importance of “going to the Gemba” where the work is actually done. These may sound like different philosophies, but they all rest on the foundation of creating cultures of trust—where mistakes or failures are seen as opportunities for learning and growth.

This is the premise behind a model we are currently developing. Rebuilding trust with care teams starts with pacing change to human capacity: involving clinicians in designing the tools and workflows meant to help them, being transparent about where AI will be used and creating space for experimentation with it. It means building cultures where surfacing a problem is rewarded and leaders spend time where the work actually happens. Rebuilding trust with patients requires the discipline of listening and holding their vulnerability with attention.

Health systems are entrusted by people at their most vulnerable. That has not changed in fifteen years and will not change in the next fifteen. Maintaining or rekindling trust in a world of high-churn, decreasing affordability and growing anonymity is the challenge ahead.