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Book Review:
The Trust Crisis in Healthcare: Causes, Consequences, and Cures
By David A. Shore, PhD.,
209 pp, $39.95New York, NY, Oxford University Press, 2007ISBN-13 978-0-19-517636-0
http://www.amazon.com/Trust-Crisis-Healthcare-David-Shore/dp/0195176367/ref=pd_bbs_sr_1/103-7734731-2939809?ie=UTF8&s=books&qid=1180924161&sr=8-1http://www.amazon.com/Trust-Crisis-Healthcare-David-Shore/dp/0195176367/ref=pd_bbs_sr_1/103-7734731-2939809?ie=UTF8&s=books&qid=1180924161&sr=
My quandary is how to present this book to colleagues and friends, in light of its important content, its vacillating delivery, and its [obscure] intent. Either laser-point scrutiny will sear such surface-level solutions to healthcare’s trust crisis, or The Trust Crisis will simply perpetuate the current delusion. This book is a symptom of dishonesty’s insidiousness. For despite its distinguished pedigree, it is not a scholarly work, but rather the descendant of a more complete prior work under the same aegis and similar name, and an excellent entrée into the world of expensive, sought-after corporate speakers.
Most practicing physicians and many in the public will recognize a majority of the information in what appears to be a barely edited assemblage of lectures and would be just as well served by a bullet list of its main points followed by some discussion. Undoubtedly, this compilation showcases a cast of smart, highly specialized men and women diligently presenting their expertise. The Harvard School of Public Health “Trust Initiative” will continue to prosper under the tutelage of these sharp marketing-branding experts with various clinicians tucked into the curriculum to give it scientific patina and street credibility. The executives for whom these lectures are programmed may benefit from learning how to make their competitive companies—and for a few of us, our practices—appear trustworthy. But of what benefit is the appearance of trustworthiness, if we are not completely honest? For example, replacing the MD with a “midlevel practitioner” is cheating. We do a fantastic job of watering down our services in the guise of process and accessibility, but at what cost?
It is both reasonable and responsible to ask: why should I trust the people behind this book? Had it not been for the editor’s specialization in strategic marketing, would this book have found its way into my hands? Yet how can the reader be sure that this book’s purpose is not about positioning a particular, limited view or agenda The bottom line is: we can’t be sure of any of these—but if it is our intention to be honest, we will see through any latent deceit and benefit from The Trust Crisis raising more questions than it answers.
My first question in response to this work is: How does the concept of “trust” mesh with our current form of healthcare: intrinsically addictive, codependent and enabling? Creating the appearance of trust is not in itself, a priori, a trustworthy or estimable act. What happens to sincerity when we are all “trained” to be sincere? The “professionalization” of such ideology results in sclerosis of those same ideas—of the thought-generation process itself, even as data and product appear to evolve. This leaves the introspective professional to grapple with the question: is it better to fail at what will ultimately succeed or to succeed at what will ultimately fail?
Until we come to societal consensus and convention on what constitutes reasonable and necessary care (read : “rationing”) we will never find satisfactory solutions to issues of access or price. Furthermore, we sure can’t believe everything patients tell us. Is it still — was it really ever — in the patients’ best interest to be treated as we would want to be treated? How did our standards evolve? When did we learn to adequately measure quality, not just “process”? Why did the evolution of a third-party payment system coincide with the evolution of waste, fraud, and abuse? Do I want to be a “brand”? (Is that a good thing?) As scientists, humanists, therapists and sociologists, are we really getting to the heart of matters, the core, or is this just too scary? How many will have the courage to discover, by way of their own experience and not some well-positioned textbook reading, the answer to “what is true compassion?”
I am grateful for having attended a fine school that taught me to think for myself, whether they realized it or not. From the beginning of my clinical medical training, it was obvious that a co-dependent relationship exists between many doctors and most patients. We take away their pain with drugs and call it compassion. We give them unnecessary antibiotics and tests in the name of peace. We miss opportunities to teach about seeking that peaceful strength of completeness that lies within , simple elementary self-care measures, and about what really requires a physician, then rationalize that “they wouldn’t listen anyway.” We learned to rely on technology instead of our senses and our true compassionate hearts, despite minimal evidence of efficacy and demonstrably adverse cost/benefit/risk profiles. I’ve lost my taste for calling this “healthcare.” I’m “crisis-ed” out.
Despite what polished prêt-a-porter spinmeisters weave into speeches and treatise, our society has not made the definitive resolution to make good, equal, reasonable healthcare available to all. I heard clearly, several times along the decades-long learning path, that my “purpose as a physician was to make [my]self unnecessary! ” and I did my best until the managed care company plans made their false promises. I kept my word and did my job too well for their taste. Is sentencing a patient to chronic medication in most settings something to be proud of? Or does it represent a failure of our best opportunities?
The contributors to this good-looking but frequently derivative hardcover tome would have done well to include and review in context a neutral glossary of some fundamental vocabulary and historical terms, for example: truth, academic, arrogance, attraction versus promotion, conscience, corruption, doctor (from the Indo-Eurasian “dek”), faith, health, integrity, morals (eternal) versus ethics (temporal), political expediency, psychosocioeconomic investment, and sincerity. If one studies the connotations of these concepts, what they will gain from this book is markedly expanded—for these humanistic virtues lead to better understanding of how to treat our fellow man more than statistics, simplistic diagrams, or technical training.
As much for its omissions and defects as for its insights, The Trust Crisis is a actually a valuable study in human nature, containing a few points of brilliant light in a dreary sky of pathos. It led me to take an inventory of my personal character , use my trusted, nurtured, intuitive feelings as an altimeter and see where I am willing and able to correct my own behavior. And that’s when I realized the solution to the trust crisis will not be mined from this book. To find the resolution, each must go within — or go without.
8-1
Mark Antony LaPorta, MD, FACP
Independent Professor of Medicine
Medical Advocacy and Internal Medicine North Miami, FL
Financial Disclosures; None reported
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