There exists the classic axiom of Fenno’s Paradox — the idea that people hate Congress, but love their own congressperson. While some clever statisticians have called this into question, the lesson remains powerful and enduring: Institutions can often be far less than the sum of their parts.

This chasm between an institution and the individuals who comprise it is an example of what we would call a “Trust Gap” — a difference between our trust in individuals, versus our faith in the system they are a part of. When we think about institutions that suffer from this characterization, our nation’s healthcare system takes first place.

In healthcare, approximately 70% of individuals trust nurses, doctors and pharmacists’ ethical bearings implicitly, rating them the most trustworthy among all professions. However, only 23% of individuals trust our healthcare system, according to the NEJM. What is it that causes this yawning gap? How can we have so little faith in care delivered by individuals that, by and large, we hold in such high regard?

Fundamentally, these gaps are a consequence of system failures that result when individuals are systematically exposed to three crippling factors: Demoralization, Deleveraging, and Disorganization.


Demoralization runs rampant in healthcare, with provider satisfaction at all-time lows. In a recent Mayo Clinic study of U.S. physicians, over half reported at least one symptom of burnout, which is a substantial increase over recent years. In healthcare, providers all-too-often find themselves separated from the patient — whether by broad protocols that don’t take specific patient situations into account, or practice frameworks that, in the absence of individual insight into specific patterns about particular providers, take a broad-brush and “checkbox” approach to medicine and quality.

There’s still a great power we have yet to unlock in understanding the individual, as our new movement towards precision medicine has shown. One important cure to this gap that I’ve been impressed by is Kaiser Permanente’s approach to making provider metrics public as a key intervention. A dose of transparency allowed individual practitioners to see how they stacked up against their peers and naturally share best practices about hypertension control, creating camaraderie, competition, and improved morale (along with better patient outcomes).


Deleveraging of our provider workforce is another problem. Individuals are working incredible hours, often taking on huge amounts of extra work, but that work is being poured into a system with redundancies and waste that are nearly unfathomable — indeed some estimates put waste in our $3T health system at nearly $1T of that total. We simply don’t have people working on their competitive advantage — caring for patients — when we spend so much time making sure that they are completing checklists, documenting, and going through procedures that, while important, could often be automated.

The advent of the electronic health record (EHR) holds great promise — but it is, largely, as-yet-unlocked promise. We must make use of the data that’s being collected to identify inappropriate or suboptimal activity and systematically eliminate it, while also finding ideal practice patterns and new opportunities, and promulgating them further. Approaches as simple as hiring scribes, and as advanced as leveraging machine vision and natural language processing to automatically generate clinical notes, are both high-tech and low-tech ways that we can help close this particular component of our trust gap.


Disorganization is what results when an organization doesn’t even have sight of what a good outcome is, and how to determine when that outcome is achieved. All too often in healthcare, we have broad organizational goals, but are unable to understand how we’re really doing. Few health systems can pinpoint precisely which departments, let alone individuals, are leaders in the type of clinical care they deliver, are most contributing to their bottom line, or are, on the flip side, troublingly behind the curve when it comes to delivering effective outcomes, clinical or otherwise. Healthcare analytics platforms that are capable of deeply understanding each individual’s workflow in a hospital, and aggregating this information to provide real-time insights to leadership, are helping to provide this necessary transparency and align individuals with the institutions they’re a part of. Whether in targeting and eliminating bad behavior like privacy breaches or drug diversion, or elevating good behavior through workflow analytics, analytical sunlight is often the best disinfectant to endemic disorganization.

As the trust gap lingers, patients in our nation are living with the consequences: middling healthcare outcomes at staggering cost. Ultimately, to eliminate the trust gap in healthcare, we need to restore our sense of mission. We can build and maintain trustworthy systems through transparent metrics that connect to our broader goals, through allowing providers to function at their best by automating away trivial tasks, and through generating actionable insights (rather than just reports or dashboards) about our performance as an interconnected system.

By truly understanding what makes healthcare more and less effective, we can close the trust gap that threatens the fabric of healthcare institutions today.