The Truth About Trust

 From the 10/2/2020 newsletter

Director's Corner

The Truth About Trust

Adina Kalet, MD, MPH

In this Director’s Corner, Dr. Kalet considers the importance and complexity of trust in medical education and encourages us to hone our judgement and have courage …

Anyone who doesn’t take truth seriously in small matters cannot be trusted with large ones either.

-Albert Einstein

The first presidential debate this week has me thinking about the consequences of not being able to trust someone on whom you depend. We rely on our elected officials, like our physicians, to listen, have empathy, engage in respectful - even if sometimes - heated disagreements, make good judgements in very complex situations, have control over intense emotions and, most importantly, consistently tell the truth. To “trust someone” implies that we have confidence in that person, and believe that the individual will be capable, adaptable, and competent now and in the future – even when faced with novel, rapidly evolving circumstances, emotional and physical stressors, and unpredictable challenges.

While always in the background, trust (“entrustment” and “trustworthiness”) has moved to the forefront in the medical education. How we make these trust judgements in medical education – and in life – is worth a hard look.

How do we measure trustworthiness in trainees?

Hodges and Lingard point out that the discourse about what makes a “good” physician – a core responsibility of our work as medical educators – has moved through a series of distinct and overlapping eras over the past seventy years. In the Psychometric Era, we valorized measurable, highly standardized knowledge tests (e.g. MCAT, USMLE Board Exams). The next phase brought great enthusiasm for demonstrable, directly observable, and behaviorally measurable core clinical skills (e.g. oral exams, mini-CEXs, OSCEs). Next, and to the frustration of many program directors, organizations introduced comprehensive, nuanced competency frameworks designed to capture and document each learner’s developmental progress via new standards and milestones.

These changes reflect our evolving grasp of “quality” in medical education. As our understanding improves, we will uncover how to develop rich portfolios of assessment data for each of our trainees. But in the end, data do not make high stakes decisions. We do. And these decisions require making trust judgements and having the courage to act on those judgements.

Trust judgement barriers and opportunities

Unfortunately, clinical faculty are not very good at assigning objective measures of competence. My colleagues and I spent years trying to get experienced clinicians to make reliable (reproducible) measurements of medical student clinical competence. Even with lots of fancy, performance dimension, frame-of- reference, and behavioral observation training, experienced professionals are eccentric and resist standardization. This, I believe, is because there is no single “truth” about clinical competence.

Trust judgments are highly context-dependent and idiosyncratic. We tend to be internally consistent and we know a trustworthy resident when we see one. An experienced professional possesses a highly-honed identity and a strong sense of what a trainee must demonstrate to be trusted to care for “our” patients. Unfortunately, we disagree with our colleagues on when individual trainees can be entrusted to “fly solo” and more independently care for patients. Gingerich has challenged us to embrace this disagreement and see it as a strength rather than a weakness.

Furthermore, experts are also context-dependent! As we collect and collate more-and-more data from larger, diverse pools of experts, we must ensure that trust judgements are appropriately interpreted to protect students from the vagaries of any individual’s bias. This is what van der Vleuten and others call a Program of Assessment for Learning. Ultimately, trained competence“judges” will be charged with making final high stakes assessments regarding decisions such as advancement and graduation. These judges will determine if, based on solid evidence, we can trust a learner to consistently “do the right thing, at the right time, for the right person, and for the right reason” in their next phase of training.

Moving from theory to action

Social and cognitive psychology researchers suggest that competency judges need to both understand the value and limits of the objective data (e.g., exam scores don’t predict clinical skills competence, but they do predict future exam scores) and should explore and develop their judgement “sense.” This sense of who to trust is highly dependent on an individual’s characteristics, experiences and biases. Knowing thyself, in particular understanding one’s biases, is crucialbecause if we are cognizant of them and have integrity, we can make adjustments – “forcing” ourselves to slow down our thinking, toggle to a more analytical rather than intuitive deliberative strategy, when we are in danger of making an error. This takes work, discipline, and practice with feedback.

There is much interesting work to be done to ensure we have trustworthy physicians. Fundamentally, most of us make our trust judgements based not on what students know or can do (we can always teach that stuff), but on who they are as people. Do they always tell the truth even when it leaves them in a “bad light?” Do they admit when they missed a physical exam finding or forgot to check a lab or failed to follow up on something? Do they take the time to listen, attend to details, interact with empathy and kindness, even when stressed emotionally? Do they strive to improve rather than rest on their laurels or test scores? Do they seek to understand the perspectives of others? How do they handle being wrong or making a mistake? Can they sincerely apologize?

We are accountable to society to make defensible promotion and graduation decisions based on each learner’s competence and trustworthiness. These are difficult-to-measure, shifting concepts. We pledge to engage in the ongoing discourses and learn how best to make difficult, discerning judgements.

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.