Senior Investigator Michael Parchman, MD, MPH, recently spoke with the American Board of Internal Medicine (ABIM) Foundation about the importance of building trust in primary care, particularly when de-prescribing opioids and other potentially harmful medications. He offered the following insights and advice, drawing on his work with the Center for Accelerating Care Transformation (ACT Center) as well as his decades of experience as a family practitioner and health services researcher.
This work began several years ago, when the Robert Wood Johnson Foundation approached us about the issue of engaging clinicians and other health care professionals in addressing medication overuse and promoting high-value care. The more we explored this issue, the more we became aware of how trust is woven deeply into the fabric of every aspect of delivering high-value care. It came up over and over again, and also came up repeatedly in our opioid work, where we are supporting primary care clinics in redesigning their care systems for patients who are on long-term opioids for chronic pain. (To learn more about this work, see Improving safety, managing pain with trust and rapport.)
Our work focuses on 6 building blocks for opiate medication management. When clinics engage with our team, our practice coaches or facilitators help them look at how they are managing opioid medications. Clinics sometimes come to us when they unexpectedly find themselves inheriting patients who have legacy opioid prescriptions from a retiring provider. When those patients come in for refills, there’s that difficult conversation about why they are on the medication and the potential for harm. Then they ask why they were started on the medication in the first place. It entails having what I call a “sense-making conversation” with patients, and we worked to develop scripts for those conversations. We suggest saying things like, “Well, you know we used to think these medications were safe. We now know they are not. There’s new evidence that these medications probably are not as safe as we thought.” So, you blame the medication and don’t blame the retiring provider.
It usually requires several visits. You have to build a relationship and frequently you find yourself in a position of saying, “OK, let’s not upset the apple cart today. We will give you enough to last you for another month or two. But, I need to see you back, and we need to continue this conversation. In the meantime, I want to give you some materials for you to read and think about and then we can talk about some options for your care.” The number one message is “I am never going to abandon you as a patient. I just want to make sure that you’re safe.”
To have a conversation with the patient, you don’t have to go into a 20-minute-long conversation. The other thing is, not to put it all on the shoulder of the prescriber. The clinician can train medical assistants and nurses on how to have these conversations with patients so everybody on the team is on the same page.
We’re currently funded by the IMPACT Collaboratory, which is a National Institute of Aging-funded initiative, to work with 2 large health care organizations on de-prescribing potentially inappropriate medications for patients with dementia. This raises clear issues of trust with both patients and their family members or caregivers. For example, they may ask, “Why was I started on this medicine in the first place?” So, there’s a trust-in-the-medical-profession issue that arises.
Clinicians may also not trust data that’s presented to them about how often they prescribe these medications. Clinicians may not trust patients to follow through on replacement services that might be safer and sometimes more effective than some of the medications. And then there’s the issue of clinician and patient trust in the evidence about the potential harm from these medications. Some clinicians say, “I know these studies show there’s potential for harm from these medications but the patients in the studies are not like my patients.” Finally, as a clinician there’s trust in your organization to support you in decreasing the use of a service for which the potential for harm is greater than the benefit and trust in your peers not to re-start these potentially inappropriate medications.
We’re training 20 clinicians across 2 large health care organizations to become clinician champions. Through a curriculum and a project workbook, we’re going to partner with these clinicians to look at how they implement this work in their own setting and use the data they enter in the project workbook to discover how often issues of trust come up, what kinds of trust issues come up, and how they address them. (The workbook and curriculum are available on the ACT Center website.)
Be patient. This work takes time.
Adapted with permission from Building Trust, an ABIM Foundation initiative that aims to elevate the importance of trust as an essential organizing principle to guide operations and improvements in health care.
KPWHRI’s ACT Center offers online training to help clinicians identify and curb overused services in clinical practice.
Led by Dr. Michael Parchman, research team uses new way to support small clinics in reducing opioid use in rural Pacific Northwest.