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Patients know when you are not really present with them, and trust is built or broken in the first few minutes. Jess Bunin, an intensivist, and George Mount, a rheumatologist, co-founders of All Levels Leadership, argue that trust in clinical teams is a practiced skill built from three concrete components: empathy, logic, and authenticity. This episode is based on their article “The secret sauce of leadership trust in health care teams,” published on KevinMD. You will hear why a critical care fellow was required to say “I don’t know” once on rounds even when he knew, what a three-time cancer survivor noticed about the physicians she actually trusted, and how to communicate through genuine uncertainty without losing your team. You will also learn why George Mount spends the first few minutes of a patient encounter on trust before he asks about the chief complaint. Listen for a grounded framework for repairing trust when it wobbles.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Jess Bunin and George Mount. Jess is an intensivist, George is a rheumatologist, and together they are co-founders of All Levels Leadership. Today’s KevinMD article is “The secret sauce of leadership: Trust in health care teams.” Jess and George, welcome to the show.
Jess Bunin: Thanks so much for having us, Kevin.
George Mount: Great to be here. Thanks, Kevin.
Kevin Pho: Perfect. So, All Levels Leadership of course has been on multiple times on the show. I certainly appreciate your time and articles and perspective. So this latest article, Jess, for those who get a chance to read it, what’s it about?
Jess Bunin: It is about the importance of trust in all of our environments, in our leadership environments, in our clinical environments. And we think a lot about this. And we’ve seen a lot of breaches, whether that is in a clinical environment, whether that’s between students and teachers, whether that’s between our government and ourselves.
And we wanted to spend a lot of time reflecting on what we can do about this. And we kept coming back to Frances Frei’s model of trust, and she talks about three factors that come together. The first is empathy. So being able to see the perspective of someone else and approach it, thinking about their success.
The next one is logic. Logic has two components. Number one, do you know what you’re talking about? And number two, how well can you communicate what you know? And then the third is authenticity. I believe that our patients know when we are not bringing our authentic selves to the patient’s room or to the patient’s bedside or to our clinic room.
I also think our learners know that and our peers know that. So this model really resonates with us, and in the article we give you a few ways to think about and work on each of those in case you have a wobble in one of those areas.
Kevin Pho: So Jess, how did you and George, and All Levels Leadership for that matter, settle on trust being such a critical part of leadership out of all the elements and facets that comprise a good leader? Why did you settle on trust specifically?
Jess Bunin: It factors into everything we do. If our patients don’t feel like they’re heard, they don’t feel like we’re reliable sources of information. They can’t believe what we say and we can’t move forward together. I think communication overall depends on having a trusting relationship, and that starts the minute we meet someone. And we have some trust built around our titles and our education and who we are, but having that trust over the long term and having that built in how we look someone in the eye.
How we approach them, how we examine them. Every step along the way builds that. And it affects our longitudinal relationships and it affects every way that we communicate. And when we can make eye contact and connect, well, it makes a huge difference.
George Mount: I’ll add on to that. Thanks, Jess. You know, I was always struck when you’re on a team and things seem to be humming really well and you’re like, what is that, that makes that work? And when I started thinking about it, or we started thinking about it together, was, you know, maybe there is something there. And trust came to the surface over and over again.
And then from there we decided, well, is there any kind of literature or science behind this? And we dug a little bit deeper, and that’s when we found a couple different models. But the one that resonated most with us was Frances Frei’s model. And then some additional things that we learned was, you know, there’s some neuroscience behind this. Trust enhancing the release of hormones like oxytocin and making folks feel more comfortable with each other. Empathy goes up.
And in fact, people just feel better and are healthier when there’s trust in it. So it’s not just that sense of, yeah, things are really working together on a team. There’s actually some neuroscience behind it too. And so we started unpeeling that onion and saw all these different things and realized this is something we could take and share with other people.
Kevin Pho: George, it sounds intuitive, right? Great health care leaders need the trust of the organization or else they wouldn’t be effective leaders. So today, why do you see trust in health care, especially among some health care leaders, being so fragile? What are some ways that trust is being chipped away at, George?
George Mount: Sure, thanks. And I think it’s really important, as Jess had mentioned, is thinking about the wobbles and why they happen now. Certainly some of those are individual, but a lot of these also come from the systems we’re in and how stresses on the system really put a lot of stress on that leader and the team specifically. And if there’s a wobble within the trust, it just gets heightened and magnified, essentially, when trust is wobbling there.
So, you know, I think we all understand the different stresses that the health care environment brings. It’s a high-stakes environment to begin with. We’re making critical decisions that impact patients and patients’ families. But then there’s the social stressors that come within the current environment. Stressors to kind of hit the bottom line that really go against some of these things like empathy. You know, how do we slow down and care about folks when we’re thinking about metrics and some of those other things that are really being pushed towards us as physicians and clinicians?
So I think you’re right on. This is really important to think about now and moving forward, because I don’t think those stressors are going to lessen over time.
Jess Bunin: Yeah. I would just add on top of that, the biggest problem and the biggest breach of trust I think right now is uncertainty. Leaders want to communicate that they know and that they’re certain and that they have a path forward, and a lot of times we don’t know. We often didn’t know what we were talking about during COVID-19.
One recent example that really highlighted this to me was the government shutdown. And our leaders didn’t have information about who needed to be at work and when, and how long this was going to last, and where people’s paychecks were going to come from. And trust was broken because they didn’t try to communicate that. They held back until they had solid answers instead of communicating their uncertainty and just being able to say, you know, I don’t know the right answers, but this is all the information I do have, and I’m going to circle back around in 24 hours or in two days and give you any updates and any new information I have.
People can tolerate uncertainty if they know they’re getting all the information that is available and if they know when the next information is coming. So I think that’s been an area that’s so challenging, is helping leaders and physicians learn how to build trust through times of uncertainty.
Kevin Pho: So what I’m hearing from both of you is that a particular leader, leadership group’s intent may be OK. They may be good people, trusting people, but there are a lot of things out of their control, whether it’s uncertainty, whether it’s systems issues, that would cause them to lose trust among their organization. So Jess, you talk about uncertainty and some of these leaders sometimes admitting they don’t know during these times of uncertainty. That’s showing vulnerability, and not all health care leaders are good at that. So go into more detail in terms of how you train these leaders to be more vulnerable, to say, I don’t know, during these times of uncertainty.
Jess Bunin: I think the biggest thing is small steps, baby steps. I had a fellow in the critical care unit who was brilliant. He knew all of the answers to everything, but invariably he shut down the residents and the students on the team because they didn’t feel confident responding. And so my leadership hack for him every day was, one time on rounds, he had to say, I don’t know. Even if he knew, he still had to say, I don’t know. But just getting comfortable with the idea of not having the information all the time.
And then the second part that I would add to that is, we want people to be able to be vulnerable with us. We want to know who our followers are. We want to know who our patients are, and we can’t expect them to show us their authenticity and vulnerability if we don’t do it first. And we have the power in those differentials. And so it’s our obligation to do that first, to show that authenticity, to show that vulnerability, to admit what we know, what we don’t know, and what we’re going to learn.
Kevin Pho: It’s almost like you have to role-play vulnerability, because for health care leaders and physicians to get to where they are, they’re almost trained not to show any vulnerability during medical training. Because that obviously isn’t emphasized at all in our health care system.
Jess Bunin: Yeah. From day one, right, day one on rounds, we are asked questions and we are expected to have the right answer.
Kevin Pho: Right. We’re not expected to say, hmm, let me look that up. We’re expected to know the answer, and so we are trained to think, I have to come forward with the right answer, or people are going to think I’m incompetent. And it’s just not the case.
Kevin Pho: So George, I’m going to put you on the spot. Is there an example that you could share of a health care leader approaching uncertainty and successfully navigating those waters using some of the techniques you talked about today, by maybe admitting that they may not know the answer, by becoming more transparent during those times of uncertainty? What’s an example of a health care leader successfully navigating those waters?
George Mount: Yeah, I think where I would probably go first is something that Jess had alluded to earlier, which was a huge stressor and put trust in a lot of peril, was, you know, the COVID pandemic. And certainly felt like I saw a couple different examples of trust that worked really well within a team during that environment, as well as those that, when it broke down. And so I’ll focus my answer on the individual I felt most comfortable with.
And it gets back to what Jess was just alluding to and the pieces of that triangle we talked about, the authenticity, the empathy, and then the ability to kind of show you that you know what you’re doing and communicating clearly. So I think what I saw there was, there were times, yeah, we just didn’t know what the next day was going to bring with COVID. I think that was something we all experienced. But this individual took that time to say, you know what, I’m not sure, but we’re going to find out and I’ll get back to you.
And then the communication piece was really important. You know, I think communication, oftentimes we like to tell these stories and stories resonate with people, but in times of uncertainty, you kind of want to flip that on its head a little bit and start with the bottom line up front and be able to communicate that clearly to people so they’re not getting lost in all the details. They understand what the key points are, so starting with that and then building the evidence behind it helps people really feel like trust there.
And then finally, the empathy. Understanding that this was new and different for all of us. And so trying to take the time to understand what the stressors were for each particular piece of that team was really important. And that just took some extra time to kind of sit and listen and to listen intently. Not be on the computer or with the phone, or just to put those away, or even just have, you know, a cup of coffee with somebody and say, hey, you know, tell me what’s kind of going on. What are you worried about? Those little things all put together really built trust in a time of, certainly a time of significant uncertainty during the COVID pandemic.
Kevin Pho: And I’m going to flip that question on its head for a second. So I’ve had cancer three times, a three-time cancer survivor of three unique cancers. And I very distinctly remember the providers that I trusted and those that I didn’t. And the ones that I trusted are the ones that brought my imaging into the bedside with me and showed it to me and went through it with me, the ones who sat down and asked me what my fears were.
Jess Bunin: How this was going to impact my work, when I wanted to be back to work and if I wanted to be back to work, and whether I wanted pain medicine or if I didn’t want pain medicine at any given time. So finding out my perspective and having the empathy for my experience, and going back to that vulnerability piece, when I had that disease, I said, well, if this was you, what would you do? And they said, well, actually this was me.
And it was such a comfort to have a survivor as my physician who knew what that was like. So vulnerability comes back into it. Authenticity, the empathy part comes back into it. The sharing of any images they had along the way and telling me when they didn’t know the answers.
And then one thing that we haven’t talked about yet that I’m going to add, which is, I had one provider that every time they left the room, they touched my foot and held my foot and said, is there anything else you need right now? And there was something about that contact and that eye contact and that intensity of really caring about what I needed in that moment that made me trust that individual.
Kevin Pho: So let’s talk about that third part of the triangle, which is, and both of you alluded to it, the communication piece. I’m going to ask you any tips during hard decisions, during times of uncertainty that can build trust. Any communication tips? I’m going to ask both of you this, so Jess first and then George.
Jess Bunin: Yeah. The most important thing is active listening. If we don’t hear what someone else’s perspective is, if we don’t understand their emotional context at the start of a conversation, we’re not going to be able to have that good communication. And I think we underestimate just how hard active listening is.
So physicians, when we walk in a room, studies have shown we have an average of 11 to 16 seconds before we interrupt our patients. We’re trained to be good at this and we’re still not. It takes a lot of practice to think about, what is my body language? How am I showing that I hear this other person? How am I labeling the emotions I’m seeing to make sure we’re tracking and on the same sheet of music and that we’re attuned to each other?
And then the most important part is, how do I make sure that my phone is off and away? My watch isn’t going to buzz. I’m not going to catch an email out of the corner of my eye and be distracted. How can I be there 100 percent with that person? And your communication style changes completely when you’re attuned with the person you’re talking to before a word comes out of your mouth.
Kevin Pho: George, what are your communication tips?
George Mount: Yeah, I really love Jess’s answer, and so I’ll just build a little bit on that. In that, sometimes we feel like we have all this information we want to share. And our instinct is to just, all right, I’m going to give you all this. And I see this when I’m working with patients or with learners. You know, I have all this I want to share with you, and then in that trying to share too much, we lose the key message.
And so really being cognizant of, you know, what’s our key message, making sure that is clear for folks so they’re not trying to sort out between all these different things that you’re sharing with you. And that happens because of the things that Jess had mentioned. We’ve listened and we understand what their needs are or what their expectations are. We really are taking those other pieces besides the communication, thinking about empathy and our authenticity, and we’re coming to that, so they build on each other.
But certainly just being cognizant not to say, OK, I have all this, I want to share. What are my key two or three points? Start with those, and then if you need some additional information, you can build off that.
Kevin Pho: Now what happens when trust is broken? Because no leader is perfect. A leader may have grown. There are circumstances outside of a leader’s control. So George, when trust is broken between a health care leader and their organization, how can they regain that trust back?
George Mount: Really important piece, because we talk about building trust, but it’s not just a build and then forget it, set and forget it, right? You have to always constantly be thinking, you know, am I making sure the trust is staying stable and not wobbling? And so in these situations when things are broken, how do we kind of put this back together? Well, we have to kind of slow down and think first, what’s the wobble, or what are the wobbles? Because they’re oftentimes more than one.
And with that structure that we’ve talked about allows you to kind of think about this in a little bit more of a framework kind of approach. Instead of just saying, yeah, it just doesn’t feel right, you can actually sit and kind of think, and then from there you say, OK, well that’s a wobble. Let me see how I’m going to work on that. And we give some tips in terms of how to do that. So I think having this structure allows you to examine when trust breaks down, and then also have some key practical ways to kind of get back and build that trust. And I know Jess has an example that I think is helpful in terms of when she saw something broken and how she was able to kind of repair that trust.
Jess Bunin: Yeah. Well first of all, I think it’s really important to remember that you can. And it’s slow and it’s hard, but you can. But I’m going to go back to that example of the government shutdown. Our scientists, our junior faculty members, any government employee, they were watching people get fired. They didn’t know where they were supposed to be. They weren’t getting their paychecks. It was terrifying. And the breach here was the empathy and the perspective taking.
But our leaders then, after the fact, myself included, put together a team to say, how can we hear your perspectives better? How can we be more prepared for this next time? What do you need? Do you need food banks? Do you need fuel cards? Do you need childcare? Like, how can we figure this out so that we’re not behind the eight ball next time?
And hearing everyone’s perspective and sharing the power so that everyone could contribute to a better way forward allowed trust to rebuild. It didn’t fix it entirely. It’s still a work in progress, but it’s starting from a better place. And it’s such an important lesson for leaders to think about, what is everyone on my team needing and handling at this moment? Do they have enough money for food? Do they have someone who can watch their kids? When you get a little later in your career, you forget what it’s like to live paycheck to paycheck and not be able to make things come through.
So I think the perspective taking is key. The perspective taking is also key in your clinical care. Remembering that it’s the worst day of someone else’s life, even if it’s just your normal Tuesday. So, constant perspective taking.
Kevin Pho: We’re talking to George Mount and Jess Bunin. George is a rheumatologist. Jess is an intensivist. They are both co-founders of All Levels Leadership. Today’s KevinMD article is “The secret sauce of leadership: Trust in health care teams.” Now we’ll end with just asking each of you to share some takeaway messages to the KevinMD audience. George, I’m going to have you go first.
George Mount: Yeah. Thanks, Kevin, again for this opportunity. Appreciate it. So I think what was really helpful for me when I started thinking about this, and for us as we put this article together, was just to say, OK, this is not just some, you know, I label it, or we label it, secret sauce, right? But it is more than that. There are some key components of it, and having that framework’s been really helpful for me, and specifically, as Jess alluded to just now, in terms of the clinical environment.
In that first couple minutes I’m in with a patient, I really think about, am I being my true self? Am I clearly communicating? Am I setting expectations? Trying to get a sense of who this person is and why they’re in the room. And that trust is such a key component that I’ll spend a couple minutes before I even jump into what brought them in for their chief complaint or whatever it might be. Because you can almost see it in the room as the patient kind of just relaxes. And then I can jump in and have that clinical encounter with the individual or their family, and it just builds that ability to do that effectively.
So you know, we talk about this as a leadership tool. It’s a clinical tool too. And really, to use that, think about how you’re building trust with your patients and families is one of the key takeaways I would ask people to think about.
Kevin Pho: And Jess, one with you, your takeaway messages.
Jess Bunin: I’m going to say spending time reflecting on trust will always be worth it. And if you can think about, any time you feel something is off, whether it’s with a relationship or a team or a patient, going back to this triangle model and saying, am I truly thinking about what the patient needs right now? Am I communicating what I mean to be communicating, and am I doing that well, and am I bringing my whole self to take care of them? And reflecting on where that might be wobbling and how I can make it better. Whether that’s the night before, after an interaction happens, whenever that is, that time spent reflecting is really worthwhile.
Kevin Pho: Jess and George, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.
Jess Bunin: Thanks for having us.
George Mount: Yeah. Appreciate it. Thanks very much.
