Trust

I went on an Apple odyssey this week. I was trying to create a second Apple ID in order to download apps both in the US and in the UK, and I kept running into an error on Apple’s website. Two days and many hours and two visits to an Apple Store and 6 different Apple reps later, I finally succeeded in creating the new ID. 

Technology is supposed to be empowering, but too much of the time it does just the opposite and disempowers. Disempowerment is closely related to trust. You don’t trust your own ability to solve your problems, but you also don’t trust the system itself, because its behavior doesn’t seem to make sense. And that’s why it’s critical to have humans and processes that reduce information imbalances and reassure in order to restore trust. In my Apple interactions, every one of the reps had excellent customer service skills. They were patient with me and transparent about what they did and didn’t know. Critically, when they couldn’t solve my problem, they didn’t give up. They reassured me that there was a solution out there somewhere, and we just needed to keep trying to find it. All of which reinforced my trust that my Apple products will do what I need them to do in the future.

Healthcare is a lot like technology, and not just because it uses technology. Healthcare involves myriad trust issues, in part because human biology is complicated, in part because so many healthcare systems are set up so poorly, and in part because healthcare corporations regularly violate trust when they prioritize their own self-interest of that of patients. Do you trust your doctor to know the right answers? Do you trust the hospital or health system to organise your care? Do you trust your health insurer to cover the costs? Do you trust pharmaceutical companies to be fully transparent about drug safety and effectiveness? Do you trust healthcare companies to prioritise patient benefit over return to shareholders? Just like the helpful Apple reps I spoke with this week, a caring doctor or nurse or receptionist can make a big difference in turning what might be a maddening experience into a tolerable, and occasionally even pleasant one. But in addition to caring individuals, trust also requires well-designed systems and good corporate behavior.

My thoughts about trust were triggered this week by a biting NYTimes column on Elon Musk. There’s a lot in the piece — I encourage you to read it — and one of its main themes is the relationship between trust and technology. Entrepreneurs like Musk (and Mark Andreesen — check out my newsletter from a few weeks back entitled “My techno-safety optimism manifesto”) believe that technology replaces the need for human trust. If you don’t believe me, google “trustless” and see how many articles on cryptocurrency come up. The irony is, new technologies require more trust, not less. The more powerful the technology, the higher the stakes for trust. Think of Reagan’s famous quote “Trust, but verify” about nuclear weapons diplomacy.

Technology, well-designed, can enhance trust. But it’s not guaranteed to, and it’s at least as common for technology to diminish trust. Take one of Musk’s favourite examples, self-driving cars. Technologically it might be true that self-driving cars are safer than human drivers, though personally I don’t trust Tesla to compile and analyse those statistics in an honest way. More importantly, the general public (emphasis on "general" here, I recognise there are exceptions) doesn’t trust the safety of driverless cars. The tragedy is that if all of that self-driving technology R&D had instead been used to develop apps to make human drivers safer, they could have accomplished a great deal in terms of both safety and our trust that other drivers won’t kill us.

Musk’s biggest trust debacle, and the one that takes up most of the NYTimes article, is X (né Twitter). It’s not just that you can’t trust the content of an X (tweet), you can’t even trust that the person who sent it is who they say they are. Musk seems not to care, recently X-ing “Trust no one, not even no one.” In a world lacking sources of objective truth, the spoils go to those who can best manipulate trust.

In the medical space, a useful example is pharmaceutical marketing. Pharmas have billions of dollars riding on whether doctors and the public trust their products more than the alternatives. Theoretically, the FDA is the watchdog who ensures that pharmas conduct rigorous studies of safety and efficacy, and then fully disclose the results of those studies in a scientifically objective way. I have no doubt that most of the time, FDA does a good job with this. But all agencies are vulnerable to regulatory capture, in part through the revolving door of pharmas hiring former FDA officials. Patrick Radden Keefe’s book Empire of Pain chronicles the ways in which Purdue Pharma and other components of the Sackler empire succeeded in corrupting the FDA. But there are a lot of good guys out there too. This week saw the passing of Dr. Sidney Wolfe, a physician who became a full-time activist in order to hold the FDA accountable to their job of holding pharma and device companies accountable.

Last summer, a friend loaned me the book Trust by Hernan Diaz. The title is a play on the world of finance, but the real theme of the book is storytelling. Four different characters tell the story of a woman, in four completely different ways. Each story seems credible on its own. By the end of the book, though, the reader trusts one of the stories over than the others. Stories can be well-told, or they can be widely believed, or both — but those criteria don’t make them true.

Healthcare corporations must earn the trust of patients and the public. This requires honesty and transparency, reducing the information gaps between the underlying truth and whatever people happen to understand (or not understand). There should be no place for spin when it comes to people’s health. (One of these days I may do a newsletter entirely on the ethics of advertising healthcare products and services.) Trust also requires clear and effective communication. And once the honesty and clarity are both in place, the last component is emotional, providing sensitive, empathetic and caring support to patients and their families at the times they need it most.