Why It Matters
Providers cannot undo the history of racism and other inequities in health care, but there are ways to earn or rebuild trust with patients.
As soon as Amanda Mohammed-Strait, MD, Board Certified Family Medicine Physician at Oak Street Health (Dallas, Texas, USA), walked into her long-time patient’s home, she knew Mrs. Wright (not the patient’s real name) needed immediate medical attention.
After observing that Mrs. Wright looked unwell and physically decompensated, Dr. Mohammed-Strait told the patient (who had recently been discharged from the hospital) that she would call emergency services and request a hospital transfer. The patient admitted that she had suspected for almost a month that her condition had worsened enough to go back to the hospital. “She did not want to reach out to emergency medical services (EMS),” Dr. Mohammed-Strait told the Institute for Healthcare Improvement (IHI) in a recent interview, “because she had been let down before.” Mrs. Wright reported waiting hours or even days for help to arrive after previous calls to EMS.
Multiple studies have demonstrated equity gaps in EMS care when considering factors including income, race, and ethnicity, including delays in EMS response time. As a Black woman living in an underserved part of Dallas, Mrs. Wright had learned from experience to distrust the health care system and doubted she would get the care she needed. She was, however, encouraged by Dr. Mohammed-Strait’s presence and her status as a physician. “She literally told me, ‘Because you're here, they will listen,’” Dr. Mohammed-Strait recounted. “She said, ‘If I called on my own or my family members called [EMS], I wouldn't be taken seriously.’"
Unfortunately, even Dr. Mohammed-Strait’s advocacy was not enough to ensure a respectful interaction with EMS. When the crew arrived, they questioned her clinical expertise despite identifying herself as the patient’s physician and noting the patient’s recent hospitalization. “[The crew member] said, ‘Is this really an emergency? You called us for this?’” Dr. Mohammed-Strait was taken aback. She had to both convince the EMS provider of the urgency of the patient’s situation and assure the patient that she needed a hospital evaluation.
In the end, EMS transported the patient to the hospital where she received the care she needed. Mrs. Wright’s health has since been stable, but the experience of seeing how difficult it was to get her the care she needed has stayed with Dr. Mohammed-Strait. It has compelled her to consider the sometimes harsh realities of providing safe and high-quality health care in challenging conditions. She shares below some of the lessons she has learned about trust:
- Know and celebrate your patients as individuals. Mohammed-Strait knew her patient so well that she noticed that she had not seen her since her hospital discharge and scheduled a home visit. “It's very important that we learn [our patients’] names, know details about them” and otherwise treat them as individuals, she said. For example, Mohammed-Strait likes to note her patients’ favorite places to sit in the Oak Street Health community room and asks if they want some water when she sees them. “Little things are huge when it comes to patients defining trust in their care team and their clinician,” she explained. Oak Street Health also celebrates health journey milestones (including graduation from their diabetes management program) and birthdays of their older adult patients. "We have integrated birthday reminders in our electronic medical record," said Dr. Mohammed-Strait. "If a patient is in our center, staff members sing, present a signed card, and hold up a birthday banner in the patient’s honor.”
- Remember that trust can be earned despite current and historical inequities. Despite Dr. Mohammed-Strait’s efforts, her patient still suffered from poor EMS care. Providers cannot undo the history of racism and other inequities in health care, nor can they always prevent inequities, so it may feel that the deck is stacked against building trust. However, providers and organizations can strive for understanding, demonstrate empathy, and persist in other trust-building behaviors. Despite the “recurrent episodes of mistrust” her patient experienced, “I believe because of who I am and who [Oak Street Health is] as an organization, the patient did feel like she could trust us, which is very powerful,” Dr. Mohammed-Strait said.
- Representation matters. As Dr. Mohammed-Strait noted, “I'm an African American female physician, and I am unique. I wish I weren't unique, but it's the reality of our health care system.” As a Black woman, Dr. Mohammed-Strait is familiar with the racism her patients face, despite her medical degree and years of practice. “It is important that there's mending of these gaps and addressing health inequities,” she said, “but it also helps so much when there are individuals that look like the people they serve.”
- Community involvement makes a difference. For Dr. Mohammed-Strait, commitment to building trust and providing quality care extends outside the bounds of her clinic: “Part of the mission that I have as a clinician is to ensure that we're serving the needs of our community effectively,” she said. “The only way to do that is to literally be in the community.” She has seen patients “instantly light up” when they see her out in the neighborhood. “Learning from those that have lived in the area for decades and going to community centers, churches, food pantries, shelters, and so much more has been transformative in my approach,” Dr. Mohammed-Strait noted. She believes it helps her team more effectively treat their patients in a more holistic manner to see them beyond their clinical encounters.
Editor’s note: IHI thanks faculty member Dawn H. Johnson, MSN, RN, for conducting the interview with Dr. Mohammed-Strait. Oak Street Health was one of six organizations that participated in IHI’s Trustworthiness in Health Care Prototyping Network, funded by the ABIM Foundation.
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How Can You Make Trust Stronger If You Don’t Have It?
It’s Not You, It’s Us: Earning Trust to Build Community Connections