Intro: The following SHSMD Podcast is a production of DoctorPodcasting.com.

Bill Klaproth (host): On this edition of the SHSMD Podcast, remember that Billy Joel song, it's A Matter of Trust? Well, it is a matter of trust. Am I dating myself with that song? I probably am. But it's a culture of trust that you need to build within the walls of your healthcare setting. It is an essential element of the healthcare process, and you're going to read about it in Future Scan 2023 as Jeff Goldsmith has written a brilliant article on this.

Host: And we're going to talk with Jeff right now about building that culture of trust and how important it is. Do you trust me on this? Well, you should. So, let's get to Jeff right now.

This is the SHSMD podcast, rapid insights for healthcare strategy professionals in planning, business development, marketing, communications, and public relations. I'm your host, Bill Klaproth. In this episode, we talk with Jeff Goldsmith. Jeff is the President of Health Futures, and one of the nation's foremost health industry analysts specializing in corporate strategy, trend analysis, health policy and emerging technologies. And you can read about the culture of trust with Jeff Goldsmith, which is featured in length in Future Scan 2023. So, trust me on this. You're going to learn about trust in this episode.

Jeff, welcome to the SHSMD podcast. As you know, we start every episode of the SHSMD podcast with rapid insights, one quick tip someone can use to make their marketing communications better today. Jeff, give us your rapid insight.

Jeff Goldsmith: We're talking about trust. Trust is something that is earned. You earn it by being who you say you are and doing what you say you're going to do. It's never granted. It's always earned.

Host: That's a great rapid insight. You always earn it. It's never granted. You always earn trust. So, you can't take that for granted. You got to earn it. That's right. Well, Jeff, I am so thrilled to talk with you and about your article in Future Scan 2023. And you've got such an interesting backstory and I think this kind of shapes the whole interview and what you talk about. So, can you tell us about your cancer diagnosis back in 2014 and how that shaped your view of how essential the element of trust is between a patient and the care system they work with?

Jeff Goldsmith: Yeah, I mean, I worked in healthcare for 45 years, so I'm obviously a big expert. But in 2014, I was a little bit worried about a lymph node on my neck, went to my ENT, and she said, "You know, why don't we do a biopsy?" And the biopsy came back malignant. And it wasn't just malignant, it was malignant, but it wasn't lymphoma, meaning that it was metastatic. So, it was out of nowhere, just a bomb went off in my life. And it was very much like looking down the barrel of a shotgun. For me, the central question wasn't what's this going to cost or what are people's star ratings or any of that, it was about who do I trust to help me manage this open-ended risk to my life. So, it really was a very high stakes transaction and I think this is something that people that come into healthcare from a marketing background miss. Healthcare is fundamentally about managing a high level of consumer risk. And, you know, the idea is it's an assault on your personal integrity. Not all of those assaults are life-threatening, but this one certainly was. It really ended up fundamentally changing how I thought about the health system and the healthcare relationship.

Host: So, it really gave you a different perspective being a patient having metastatic cancer, which means it's starting to spread, right? And like you said, it's like you're looking down a barrel of a gun at that point. That would give you a full paradigm shift, I would think.

Jeff Goldsmith: Yep. And of course, a lot of that process is kind of narrowing the uncertainty and then taking action. And it's at the point of taking action where trust comes in, is that I'm putting my life in somebody's. This isn't like I'm wandering happily down the aisles at Costco and said, "Let's have some cancer today," that isn't the way it worked at all. So, the issue of who I trusted to manage that risk was a really big deal.

Host: That's an interesting way you put it, narrowing uncertainty. Is that where trust comes in, when you're narrowing uncertainty, you're learning who to trust, which makes things more certain? I feel better about that, that uncertainty is lessened because I'm trusting this healthcare system or this doctor more. Is that right?

Jeff Goldsmith: I had a hard decision to make. I had to basically leave my community. I worked at the University of Chicago for almost 20 years. They have a spectacular head and neck cancer program. And though it was painful to say to the doc that diagnosed me, "I really would like to go home to get my care," she was really cool about it, and that's what I ended up doing. They did a really fine job, not only of finding the primary tumor, but ultimately dealing with the cancer. A six-hour, really intense surgery, no chemo or radiation needed, so the surgery cured my cancer.

Host: That's amazing. And for inquiring minds, I'm talking to you now, you look great. So, everything is fine now, everything is good?

Jeff Goldsmith: Yeah. I mean, it was 2014, so that's eight years.

Host: Well, we're very happy to hear that.

Jeff Goldsmith: Yeah. Something else is going to get me, not throat cancer.

Host: So, you have another great phrase called the interlocking circles of trust. Can you explain that to us?

Jeff Goldsmith: You know, healthcare organizations look really formidable. I mean, the great big buildings, thousands of employees. But really, the architecture of a healthcare organization is really interlocking circles of trust. The central circle is the relationship between a patient and his physician. Not everybody has a physician. But when you get cancer, you definitely have one. So, that's the core of the circles. That clinician rarely acts alone. In a complex medical problem, they have to rely on a supporting cast of colleagues and consultants and all the rest of it. So, that's the second level. It's inside the medical community and inside the clinical enterprise. There's a third level of trust, which is those folks can't act by themselves. They need the logistical support, that's what the hospital does. It provides them the operating suites and the labs and the beds and nursing care to support it. So, there has to be trust between those clinicians and the hospital that supports their practice.

And then finally, the hospital doesn't act alone. It frequently relies on contractors, consultants, advisors, vendors, healthcare information technology firms, you name it. There has to be a level of trust there. All of these circles of trust have to reinforce one another or the patient notices and you don't get optimal care.

Host: Right. So, you've got the patient and physician in one circle, supporting cast in another; the logistical support as you called it, the actual physical location, I would take it, of the hospital; then, the contractors, consultants, advisors. So, you need trust in all four of those areas. That is the interlocking circle of trust.

Jeff Goldsmith: The key thing is that they kind of build on one another. They're all connected to one another. the way I think about trust is it's sort of the glue that holds all of that. It. And if you don't have it, people end up doing a suboptimal job, they end up doing more than you need, they order more tests, you stay in the hospital longer. It isn't efficient for there not to be a high level of trust among all those actors.

Host: Is there a turning point for trust where you're narrowing that uncertainty, if you will, to the point where you're like, "Okay, I'm starting to trust these people"? Is there one thing that each one of these circles does to ensure that trust.

Jeff Goldsmith: I don't think that's the way it works. I mean, I think, in any relationship, you know, you're learning and testing and paying attention and feeling more confident and more relaxed as you become convinced that the people you're dealing with are who they say they are, and they're going to do what they said they're going to do. So, it's something that grows and builds in a successful relationship over time. It's not something that happens in a flash.

Host: So, like you said earlier, you earn trust. So over time, you develop that and you earn it. So, trust is an important thing and you want to go to the brightest minds, the best places. So, some people might think, you know, this is all well and good, but might be limited financially or geographically. "I can't make it to Chicago. I live in Kansas. What am I going to do?" How can a hospital executive best address the challenges of economics and even distance when it comes to trust?

Jeff Goldsmith: I think part of it is recognizing how vulnerable and frightened the patient is, because then that imposes-- there's almost a moral quality to that relationship where you have to take care that that individual understands that you understand, that they're suffering and frightened. And I think there's a level of respect and an expectation of the quality of communication with them. People don't like being surprised. They really want to feel that their circumstances, not just economic, but cultural, racial, whatever are taken into account and respected. So, I think it's an element of respect that builds and that begins the moment the person walks in the door,

Host: So, that's kind of a good roadmap recognize that people are vulnerable and frightened no matter where they are, even if you're in a rural setting. "I know you're vulnerable right now. I know you're frightened. You're scared. But I'm going to do everything I can to put you at ease and walk you through this and show you we know, like you said, who we are, that we know what we're doing." Is that right?

Jeff Goldsmith: Yeah. And, you know, you raised the financial dimension. That's actually really important because one of the things that's happened in the last 15 years is that there has been a tremendous escalation in the level of financial risk to individuals and families who are walking in that door. And I think people kind of don't recognize how much fear there is around that. It's not just that people are afraid of getting sick and what will happen to them, they're afraid about not paying the bill and about whether their family's finances will be ruined by the transaction. So, I think that imposes a special set of constraints on how you communicate with them, how transparent you are, and how understanding you are about the limitations on their ability to pay the bill.

Well, I think healthcare organizations are really vulnerable right now because if they're treating this as just a normal commercial transaction, they're missing a huge amount of potential risk in the relationship and that risk isn't just to individuals. It's political risk. It's risk to the community mission of the organization. If people are afraid to walk in the door because they don't believe you understand that this is a significant financial problem for them, then you're going to start in the hole and you're not going to get to where you want to go.

Host: You know, we use this term, people operate better when they feel heard, like employees, the staff. My boss, I feel like I'm not heard. I'm very unhappy here." But when you have a boss that nurtures you and makes you feel heard... That's what it sounds like here, Jeff, when you walk in, no matter where it is, and I'm worried about finances, I'm worried about dying and worried about who's going to take care of my family, the hospital, the healthcare system has to take all of that into account and make sure that you're hearing that patient and that fear in their voice, the anxieties that they're coming to you with. Is that right?

Jeff Goldsmith: Right. But also responding substantively to it. Part of the problem is that 70 million Americans have high deductible plans where they may have $3,000, $5,000, $8,000, $10,000 of front-end cost exposure to that significant patient encounter and don't have the $3,000, $5,000, $7,000, $10,000. So if you don't approach that problem from a point of understanding of realizing that you're going to need to accommodate them, the idea that it's okay that they're bankrupted by the transaction isn't okay at all.

Host: Point of understanding, I like that. So, really what I got out of that is you must recognize that people are vulnerable, people are frightened, worried about more than just their health, of course, they are. But financially, is this going to ruin me? And you have to come at this with a point of understanding and all of that is building that culture of trust. So through the pandemic, telehealth of course shot way up, right? It really accelerated our use of telemedicine. How does that play into the role in the culture of trust?

Jeff Goldsmith: I think there are a lot of misconceptions about the growth in telehealth during the pandemic. It was very sudden in the spring of 2020. You had this multi-thousand percent explosion in the number of of telehealth. But it wasn't visits with strangers, it wasn't anonymous interactions. Health systems were responsible for that explosion by standing up ways of patients and families connecting with their physicians, even though they couldn't come in person because of the lockdowns. So, this idea that we had, this explosion in completely anonymous transactions was simply nonsense. Ninety percent plus of the interactions were with people with physicians or other caregivers that patients already knew. And then as the lockdowns faded, the number of telehealth visits dropped off right smartly. I don't think there is a tremendous demand for talk to a stranger on your cell phone about your medical problem right now. I don't think that's the market.

Host: So, does telehealth inhibit the culture of trust? Is there a, you know, it doesn't help build that culture of trust, telehealth doesn't, in-person builds it?

Jeff Goldsmith: Quite the reverse, Bill. I mean, if your doctor's saying to you, I'm here for you 24/7, and you don't have to make a 20-minute or a two-hour, you know, divot in your day to talk to me, I think that is absolutely enhancing trust, not reducing it. So, I viewed digital medicine and telehealth in general as a force multiplier for those trusting relationships, not as something that was a completely new business.

Host: Okay. So, telehealth can enhance the culture of trust, is what you're saying.

Jeff Goldsmith: Absolutely. The idea that I care enough about you to be with you right now. When I had cancer, I mean, I could communicate with my physicians by text. It was really cool. So, I didn't feel like I was isolated. I wasn't, you know, sweating, "Oh my God, I'm not going to see them for 36 hours." If something went wrong, I and my family could be in touch with them virtually. And it made a huge amount of difference. And that was, what, nine years ago almost.

Host: That's interesting. Okay. So, good to know. I'm glad that I asked and that, telemedicine can certainly enhance the culture of trust or help a person earn it or build it, if you will.

Jeff Goldsmith: Absolutely.

Host: So, I want to ask you about this. I'm putting my marketing hat on right now. We always have this conversation on our marketing communications. Do we refer to people as consumers or should we refer to them as patients? More recently, it's like consumers, but then I hear patients. And I know you have thoughts on this. What is your point of view of this?

Jeff Goldsmith: Well, it's controversial. I mean, I was one of the really founders of the marketing movement in this field. I wrote a book 40 years ago titled "Can Hospitals Survive?" That was about how hospitals needed to change their orientation towards their patients, and to come to them, and make it easier for them to get what they needed. But I can tell you that the cancer experience had a revolutionary effect on my view of that term. I found it insulting and demeaning. It wasn't my choice to have cancer. It wasn't like I was going, "Oh my God, I think I'll have a spot of cancer today," and I'll shop around for the people that were best able to help me.

You know what? It's funny, my wife Karen is a florist, she works in retail. And when I was talking to her about this, she said, "Talking about the patient as if they were consumer is really cheesy." And I thought that was a remarkable-- we don't talk about my work very much, but I thought that was a very interesting reaction to someone that lives in the retail space. She thought it was cheesy, and so do I.

Host: So, you're saying you don't like consumer. You don't like it when we refer in marketing the consumers.

Jeff Goldsmith: I think it is a crude metaphor for the relationship. Healthcare is fundamentally about managing a high level of risk. And to me, the consequences of failure for the so-called consumer are so great that the level of trust that's required far exceeds that of virtually any other commercial transaction. The other part that I would say is I don't think most healthcare use is voluntary. I don't think it's discretionary. I don't think people are like, "Oh, I'm going to go out and use some healthcare today," I don't think that's the way it works. Most people don't want to use healthcare. They want to be healthy, they want their lives back, whatever, they want to be respected, but to call them consumers, I think is really frankly demeaning.

Host: Okay. I'm glad I asked and thank you for sharing your thoughts. I really appreciate that. And what you say certainly makes sense and you have a point of view coming at this from certainly your experience, which many of us have never had to go through what you went through. So, again, thank you for sharing that. So, does trust lead to better health outcomes? It sounds like It does. And it leads to a better patient experience then too, right?

Jeff Goldsmith: I think it is an indispensable ingredient and a successful healthcare relationship, is trust. What that trust does is reduces the level of anxiety that people feel and comforts them. Healthcare is ultimately about caring, and it's kind of hard to think about being cared for, relaxing, surrendering. It is somewhat of a passive role without the trust. It's like falling backwards and, you know, someone catches you.

Host: Yeah. So, I'm thinking about health grades and ratings and reputation management, building that culture of trust only reinforces that, which ultimately helps your healthcare organization's bottom line in the care that you provide.

Jeff Goldsmith: I mean, let's be blunt about it. If I don't feel like I trusted the care team that took care of me, I'm going to nail them on my HCAHPS questionnaire. And they're going to have a lower net promoter score because of me. So to be perfectly blunt about it, the absence of that trust damages the standing and reputation image of the care system or caregiver that's providing it. I think it's an essential ingredient of being an effective care organization.

Host: Extremely well said. Well, Jeff, this has been fascinating. It's been a pleasure talking with you about the culture of trust. I think it's so important in a conversation we should be ultimately having a lot more often. So as we wrap up, what additional thoughts do you have? What can you leave us when it comes to thinking about the culture of trust and building that in our healthcare organization?

Jeff Goldsmith: Well, to me, it's fundamentally a leadership challenge, that it really has to come from the top. It has to be the message that a CEO or president of the healthcare organization or the person that's the head of a practice has to diffuse through their organization, that's what we expect of you, and that's what we expect of our patient relationships. And we're going to hold you accountable for them. We need to be who we say we are or our brand doesn't mean anything.

Host: How true is that? We need to be who we say we are, for sure. And as you said, it starts from the top. This is a leadership challenge. So, thank you so much. It's been a pleasure talking with you. We really appreciate it. Thanks again.

Jeff Goldsmith: Bill, it's great to speak with you. Good luck.

Host: And once again, that is Jeff Goldsmith. And you can read the Culture of Trust, Jeff's article, featured in length in Future Scan 2023. To purchase your copy, just visit shsmd.org, that's S-H-S-M-D.org/futurescan. And if you found this podcast helpful and, of course, how could you not, please share it on all of your social channels. And please hit the subscribe or follow button to get every episode. This has been a production of DoctorPodcasting. I'm Bill Klaproth. See ya!