Economics: A Creative Paradigm for the Importance of Trust in Pediatric Care

healthy child with pediatricianWhen parents bring their child to a clinician, what is the foundation of what goes on in that visit?  Trust between parents and pediatrics is essential for optimizing children’s health outcomes. When parents trust their child’s pediatric provider, they come together as an effective team working to ensure the child’s health and well-being.

“What it comes down to is that we can’t give parents meaningful advice without having first secured their trust,” says Dipesh Navsaria, MPH, MSLIS, MD, associate professor of pediatrics at the University of Wisconsin School of Medicine and Public Health, founding medical director of Reach Out and Read Wisconsin and president of the Wisconsin Chapter of the American Academy of Pediatrics. “Families need to come into those conversations with some degree of trust that their pediatrician cares about not only their child’s health but also cares about helping them support that child’s health and well-being. Unless we establish this trust, a lot of what we say or do can get easily nullified.”

Navsaria is a faculty expert on Pediatrics Supporting Parents, a NICHQ-led national quality improvement initiative with the global aim that all children start kindergarten healthy and ready to learn.

Yet, while the importance of trust is clear, strategies for building it often remain nebulous. Recognizing this, Navsaria sought a more concrete framework for understanding trust by looking at the science of economics.

“Trust is a big component of economics. Consider that markets are ultimately built on trust: the dollar bill only has value because we trust that the dollar has value; and people need to trust each other to do business with each other—to trust that other people will deliver on a trade or deal. So, if we can grasp the basic components of how economics—an objective science—understands trust, we might gain some insight into how we, as health professionals, can think about promoting trust in our work.”

Interested in finding out what this looks like? Below, Navsaria highlights three principles on economics and trust (each shared in italics by, Rob Grunewald, economist in the community development department at the Federal Reserve Bank of Minneapolis) and describes how these principles can inform trust-building strategies in the pediatric setting.

One. Historical track record: A positive track record builds trust between market participants. For example, if your bank has consistently treated you fairly and responded to your concerns, you are more likely to keep banking with them.

The significance of a positive track record is directly applicable to parent-pediatric relationships, says Navsaria. If a pediatric health professional has done right by a family before—addressed the family’s needs, made correct diagnoses, responded to their concerns—they’ve developed a foundation of trust. Moreover, each interaction builds on the previous interaction, both directly and indirectly. First impressions matter, as do word-of-mouth recommendations and even online reviews. Until a family gets to know you, they’ll look to friends, family, and other parents to find out who they trust with their children’s care.

Importantly, the entire pediatric office or clinic is responsible for establishing a positive track record. The experience families have with front-desk staff or another clinician will help inform their overall view of the pediatric office. Remember, your clinic or hospital is only as courteous as your least-courteous staff member.

Two. Flow of information: Open channels to understandable information builds trust and gives market participants confidence to act on information. For example, if you are considering investing in a company, you’ll be more inclined to invest if the company has 1) given accurate information about its revenue and expenses, 2) provided that information in a comprehensible format, and 3) clearly explained your different investment options.

Each of these three components are important for pediatrics, explains Navsaria. First, prioritizing open channels of communication can build trust and improve care. Families should know their provider is being honest with them and feel confident their opinions are heard.

Consider a mother who is worried her daughter has a urinary tract infection, says Navsaria. If the test is negative, providers need to do more than just share the result, because one-sided, limited communication does not engender trust. Instead, it can result in confusion and leave parents concerned that their provider missed something. 

“There’s a lot more we can do to build open communication channels,” says Navsaria. “For example, I often turn my screen with the result towards parents, so they know they’re seeing exactly what I’m seeing. Then, I walk them through what they’re seeing on the screen and explain how it supports my diagnosis.”

Second, families should receive information in a format they can understand. Consider how many times families leave health encounters confused about what to do next. Maybe their child screened positive for a developmental delay and they aren’t sure what that really means, or think it implies that they did something wrong. Or perhaps their child was diagnosed with asthma and they’re not sure what that means for the child’s future. These confusions not only adversely affect the health of the child, but they erode trust between parents and pediatric providers. Bulleted lists that explain concepts clearly and simplify key steps, clear language without jargon, and time spent reviewing and asking if families have questions all go a long way toward helping families understand what they’re being asked to do.  Reassuring families about whether their own actions contributed to the situation is equally important and helps strengthen trust between families and providers.

Finally, families need to feel they can act on the information given. Even if families understand a recommendation, their social, personal and psychological circumstances may make the recommendation difficult to follow. Talking to families about potential barriers, such as transportation or taking time off work, and findings a solution that makes sense builds a trusting relationship and help families follow recommendations. Showing families that you understand the challenges they face is significant.

Three. Institutional framework: Markets work better when institutions are transparent about rules and consequences. Individual participants will often make market transactions irrespective of their trust level of other specific participants if the institutional framework is transparent and consistent. Simply put: institutional trust matters. For example, if you trust the banking system, you are more likely to put your money in a bank than keep it in a safe at home, even if you haven’t yet built a strong relationship with a particular bank.

“Building institutional trust is perhaps one of the biggest challenges we face, because there’s a long historical legacy of health care not being transparent, especially regarding underserved populations,” says Navsaria. “There’s significant mistrust among African American people, in particular, because of segregation of care and unethical clinical studies, like the Tuskegee study.  It goes beyond those long-ago instances, though, and to repeated overt and minor instances every single day. We can each help counteract this with purposeful transparency about our organizational framework—by openly sharing how decisions are made and ensuring decision-making is consistent with our organization’s mission. And this needs to go beyond mission to building structures, accountability, and internal controls to ensure it actually happens.”

Below are two examples of how to move towards purposeful transparency.

  1. Be transparent about the decision-making process: A provider tells a father that she doesn’t want to run a CT scan for his child. In response, the father worries that the provider is dismissing his concerns about his child; after all, she seems very busy… and what if there’s some financial incentive for this provider not to order tests? If instead the provider sat down with the father and explained that she never orders the test unless it’s absolutely necessary because it is very costly for families and exposes children to high levels of radiation, the father would clearly understand the decision-making process, which helps build trust in the institutional framework.
  2. Make policies transparent and consistent with institution’s mission: A family arrives ten minutes late to an appointment and is told that they have missed their appointment and must reschedule. The family didn’t know about these strict rules; and even if they had known, they couldn’t have been there on time because they’d been delayed by public transportation. The practice’s policies reflect an unjust, closed-off, unrealistic system that’s inconsistent with its intended purpose: to support the child’s best interest. A more consistent policy would recognize the many variables that affect appointment-keeping and pursue alternative solutions for late appointments (such as fitting the family in later that day or finding another practitioner who has availability).

“Transparent decision-making that consistently puts the patient’s welfare first generates trust,” says Navsaria. “The more we can do this—whether as individual practitioners or within the policies of our organizations—the more trust we’ll earn.”

Interested in learning more from Dr. Navsaria? Here, he shares strategies pediatric health professionals can use to improve early childhood referrals.