In the first months of 2020, David counseled a patient that he needed to be intubated. 

“I trust you,” whispered the patient — wide-eyed, sweating, and with laboring breaths. It was one of the last things he said before passing away from COVID-19 in an intensive care unit in New York.

Poignant in itself, the moment also serves as a metaphor: The pandemic hastened the loss of trust in institutions that are the bedrock of society, including in frontline physicians and the health care system.

Of course, trust in institutions was declining well before 2020.  

Gallup reported that, over the past two decades, institutional trust in banks fell by 23 points, Congress by 21 points, organized religion by 21 points, and media by 22 points. 

The drop in confidence in the medical system over that period is a more modest eight points. Yet, the trend tells a worrisome story. Furthermore, the decline is at multiple levels: trust between doctors and patients; trust in institutions like hospitals; and trust of information and knowledge such as the credibility of guidelines.  

Physicians’ community connections are weakening, and they may lose more public trust by being seen as too close to the health systems that employ them.

What’s even more troubling is that at every level the path for rebuilding trust is unclear, despite efforts such as the Physician Charter, Choosing Wisely, and Building Trust campaigns by the American Board of Internal Medicine, and the recent Organizational Trustworthiness in Healthcare report from the Institute for Healthcare Improvement.

We might also draw useful lessons for rebuilding trust from an analogous field. Journalism and medicine share important qualities: a fiduciary relationship to local individuals and communities; the creeping influence of social media and polarized national politics; and the need to navigate trust-building tradeoffs of expertise and engagement. 

Journalism is tackling the problem of trust with training programs that focus on a few specific strategies, including good conflict, transparency, engagement journalism, and solutions journalism. 

Good Conflict and Danger Talk

Journalists are trying to reduce politically inflammatory references in their stories by recognizing that many news consumers are tired of reading about political fighting. 

Good conflict training does not seek to avoid conflict. Rather, good conflict training encourages reporters to find the story underneath the political conflict and humanize the people involved, emphasizing that not every political conflict needs to tie in references to national figures.

Nearby hospitals should cooperate, not compete, on local engagement efforts.

Navigating politically tricky framing of conflict is also a present concern in medicine. 

Take the idea of dangertalk. Dangertalk occurs when abortion providers self-censor narratives about their work to leave out nuance that might be seized upon by abortion opponents. 

Instead, practitioners might avoid language that situates abortion around binaries of good versus bad in favor of accurate descriptions of the nuanced, complex realities of individual clinical situations. Such dangertalk could contribute to a more constructive and complete narrative around abortion.  

Dangertalk may be a useful tool for talking about vaccines, too. As the topic has become more politicized and binary narratives emerge, a nuanced approach that embraces complexity could also be helpful.

Transparency

Journalists are also trying to earn trust through transparency with their readers.

In the media, transparency involves telling the audience what principles will guide reporters’ coverage of controversies. For example, a television and radio station in Pennsylvania, WITF, published an Election Coverage FAQ before the 2024 election explaining how it would cover polls, false statements by politicians, and 2020 election fraud claims. The station said that for hot-button issues, “We pledge to follow the facts wherever they lead — and not just if they support a certain narrative.”

Clinicians and medical institutions can also practice transparency. 

Medicine must find ways to re-engage with individuals and communities, to connect, build trust, and ensure the elevation of community priorities.

Medical institutions that have attempted price transparency have progressed unevenly, with little impact on lowering prices or improving institutional trust. However, many patients experience medical whiplash when medical consensus guidelines frequently change and back-and-forth headlines cause confusion and undermine informational trust. 

Take breast cancer screening with mammography, where conflicting medical society guidelines grappled with whether to screen women under the age of 50 since the 1970s, occasionally offering markedly different recommendations that easily confused the public. 

Transparent medical guidelines would describe the limits of our knowledge, communicate uncertainties, offer accessible explanations of risks, describe associated tradeoffs of different care pathways, and explain any divergence from federal recommendations. 

Engaging the Community

Engagement journalism aims to initiate stories with audience interests, concerns, and needs, through conversation and direct interaction. It involves sending reporters into the community to solicit input from audiences about which issues residents want covered more thoroughly. Feedback from the community often cuts against journalists’ preference for conflict, novelty, and personalization. However, a recent randomized experiment showed that engagement can add subscribers and increase audience satisfaction. 

What would engagement medicine look like? The Affordable Care Act requires community engagement from nonprofit hospitals, including community needs assessments and listening efforts. Unfortunately, enforcement rests with the Internal Revenue Service, leading to efforts that reward box-checking and process-based metrics. 

Instead, nearby hospitals should cooperate, not compete, on local engagement efforts. Competition may drive innovation and improvements in elective procedures like surgery, pharmaceuticals, or diagnostics. But competition mostly lowers quality of service, particularly in care where limited profit is on the line. This dynamic is not unlike how news markets with higher competition provide less substantive political coverage.

Solutions Journalism

Solutions journalism aims to increase trust through stories that abandon journalistic tendencies to stop at identifying problems. Solutions-focused stories inspire hope, compassion, and empathy. By discussing what works (or doesn’t) elsewhere and sticking to evidence-based frames, journalists can avoid accusations of bias and build trust.

A solutions-based approach to medicine would shift our sick care system to a health care system. Focusing on health would involve thinking about evidence-based preventive care. Outside organizations could provide infrastructure; for example, Solutions Journalism Network maintains a database of solutions stories for journalists to examine when writing their own. 

In health care, medical journals could feature solution-oriented care delivery models, like NEJM Catalyst and JAMA Health Forum. Similarly, the Common Health Coalition coordinates between health care and public health institutions, emergency preparedness, real-time epidemiological surveillance, and data exchange to focus resources where they have the highest impact.

Without trying new tactics, the future of medicine and health of a nation is at stake.

Of course, medicine and journalism diverge in some areas. Their business model is one where physicians are moving from owners of small independent practices to employees of hospital systems. Journalists have moved in the other direction as jobs have contracted by two-thirds in the past two decades. 

As journalists lean into Substack or YouTube content creation, they are finding increasing ways to build trust with their audiences. At the same time, physicians’ community connections are weakening, and they may lose more public trust by being seen as too close to the health systems that employ them. To buck this trend, medicine must find ways to re-engage with individuals and communities, to connect, build trust, and ensure the elevation of community priorities.

Cultivating trust in medicine will be a slow process. Already so much trust has been lost, and people are turning elsewhere for care for which medicine has long been a trusted source. When journalism offers solutions, engages audiences, embraces transparency, and presents alternatives to polarization, trust increases. It is worth knowing whether these tactics work across contexts.

Adopting strategies that work in journalism may be an effective approach for building trust in medicine. Without trying new tactics, the future of medicine and health of a nation is at stake.