Elise Peterson Lu, MD, PhD

A functioning healthcare system requires trust on many levels. In its simplest form, this is the trust between an individual patient and their physician that allows for candor, autonomy, informed decisions, and compassionate care. Trust is a central component of medical education, as trainees gradually earn the trust of their supervisors to achieve autonomy. And, on a much larger scale, societal trust in science, the facts, and the medical system influences individual and group decisions that can have far-reaching consequences.

Defining trust is challenging. Trust is relational, an often subconscious decision “by one individual to depend on another,” but it can also be as broad as trust in an institution or a national system.¹ Trust also requires vulnerability—trusting another person or system means ceding some level of personal control and accepting risk. Thus, to ask patients and society to trust in physicians, the healthcare system, or public health institutions, though essential, is no small request.

Physicians and the medical system at large have not always behaved in ways that warrant trust. Medical research on vulnerable populations (historically marginalized communities, prisoners, residents of institutions) has occurred within living memory. Systemic racism within medicine has led to marked disparities in access and outcomes between White and minoritized communities.² These disparities have been accentuated by the pandemic. Black and Brown patients have higher infection rates and higher mortality rates but less access to healthcare.³ Vaccine distribution, which has been complicated by historic earned distrust from Black and Brown communities, revealed systemic racism. For example, many early mass vaccination sites, such as Dodger Stadium in Los Angeles, could only be easily reached by car. Online appointment scheduling platforms were opaque and required access to technology.⁴

Public trust in institutions has been eroding over the past several decades, but healthcare has unfortunately seen the largest decline.⁵ Individual healthcare decisions have also been increasingly politicized; the net result is the creation of laws, such as those limiting discussions of firearm safety or banning gender-affirming treatments for transgender children, that influence patient-physician interactions. This combination of erosion of trust and politicization of medical decisions has been harshly highlighted by the global pandemic, complicating public health policy and doctor-patient discussions. Public health measures such as masking and vaccination have become polarized.⁶ Further, there is diminishing trust in medical recommendations, brought about by the current media landscape and by frequent modifications to public health recommendations. Science and medicine are constantly changing, and knowledge in these fields is ultimately provisional. Unfortunately, when new data are published that contradict prior information or report new or dramatic findings, it can appear that the medical system was somehow obscuring the truth in the past, rather than simply advancing its knowledge in the present.

How do we build trust? How do we function in a healthcare system where trust has been eroded? Trust is ultimately a fragile thing. The process of earning it is not swift or straightforward, but it can be lost in a moment.

In partnership with the ABIM Foundation, the Journal of Hospital Medicine will explore the concept of trust in all facets of healthcare and medical education, including understanding the drivers of trust in a multitude of settings and in different relationships (patient-clinician, clinician-trainee, clinician- or trainee-organization, health system-community), interventions to build trust, and the enablers of those interventions. To this end, we are seeking articles that explore or evaluate trust. These include original research, brief reports, perspectives, and Leadership & Professional Development articles. Articles focusing on trust should be submitted by December 31, 2021.

A functioning healthcare system requires trust on many levels. In its simplest form, this is the trust between an individual patient and their physician that allows for candor, autonomy, informed decisions, and compassionate care. Trust is a central component of medical education, as trainees gradually earn the trust of their supervisors to achieve autonomy. And, on a much larger scale, societal trust in science, the facts, and the medical system influences individual and group decisions that can have far-reaching consequences.

Defining trust is challenging. Trust is relational, an often subconscious decision “by one individual to depend on another,” but it can also be as broad as trust in an institution or a national system.¹ Trust also requires vulnerability—trusting another person or system means ceding some level of personal control and accepting risk. Thus, to ask patients and society to trust in physicians, the healthcare system, or public health institutions, though essential, is no small request.

Physicians and the medical system at large have not always behaved in ways that warrant trust. Medical research on vulnerable populations (historically marginalized communities, prisoners, residents of institutions) has occurred within living memory. Systemic racism within medicine has led to marked disparities in access and outcomes between White and minoritized communities.² These disparities have been accentuated by the pandemic. Black and Brown patients have higher infection rates and higher mortality rates but less access to healthcare.³ Vaccine distribution, which has been complicated by historic earned distrust from Black and Brown communities, revealed systemic racism. For example, many early mass vaccination sites, such as Dodger Stadium in Los Angeles, could only be easily reached by car. Online appointment scheduling platforms were opaque and required access to technology.⁴

Public trust in institutions has been eroding over the past several decades, but healthcare has unfortunately seen the largest decline.⁵ Individual healthcare decisions have also been increasingly politicized; the net result is the creation of laws, such as those limiting discussions of firearm safety or banning gender-affirming treatments for transgender children, that influence patient-physician interactions. This combination of erosion of trust and politicization of medical decisions has been harshly highlighted by the global pandemic, complicating public health policy and doctor-patient discussions. Public health measures such as masking and vaccination have become polarized.⁶ Further, there is diminishing trust in medical recommendations, brought about by the current media landscape and by frequent modifications to public health recommendations. Science and medicine are constantly changing, and knowledge in these fields is ultimately provisional. Unfortunately, when new data are published that contradict prior information or report new or dramatic findings, it can appear that the medical system was somehow obscuring the truth in the past, rather than simply advancing its knowledge in the present.

How do we build trust? How do we function in a healthcare system where trust has been eroded? Trust is ultimately a fragile thing. The process of earning it is not swift or straightforward, but it can be lost in a moment.

In partnership with the ABIM Foundation, the Journal of Hospital Medicine will explore the concept of trust in all facets of healthcare and medical education, including understanding the drivers of trust in a multitude of settings and in different relationships (patient-clinician, clinician-trainee, clinician- or trainee-organization, health system-community), interventions to build trust, and the enablers of those interventions. To this end, we are seeking articles that explore or evaluate trust. These include original research, brief reports, perspectives, and Leadership & Professional Development articles. Articles focusing on trust should be submitted by December 31, 2021.

A functioning healthcare system requires trust on many levels. In its simplest form, this is the trust between an individual patient and their physician that allows for candor, autonomy, informed decisions, and compassionate care. Trust is a central component of medical education, as trainees gradually earn the trust of their supervisors to achieve autonomy. And, on a much larger scale, societal trust in science, the facts, and the medical system influences individual and group decisions that can have far-reaching consequences.

Defining trust is challenging. Trust is relational, an often subconscious decision “by one individual to depend on another,” but it can also be as broad as trust in an institution or a national system.¹ Trust also requires vulnerability—trusting another person or system means ceding some level of personal control and accepting risk. Thus, to ask patients and society to trust in physicians, the healthcare system, or public health institutions, though essential, is no small request.

Physicians and the medical system at large have not always behaved in ways that warrant trust. Medical research on vulnerable populations (historically marginalized communities, prisoners, residents of institutions) has occurred within living memory. Systemic racism within medicine has led to marked disparities in access and outcomes between White and minoritized communities.² These disparities have been accentuated by the pandemic. Black and Brown patients have higher infection rates and higher mortality rates but less access to healthcare.³ Vaccine distribution, which has been complicated by historic earned distrust from Black and Brown communities, revealed systemic racism. For example, many early mass vaccination sites, such as Dodger Stadium in Los Angeles, could only be easily reached by car. Online appointment scheduling platforms were opaque and required access to technology.⁴

Public trust in institutions has been eroding over the past several decades, but healthcare has unfortunately seen the largest decline.⁵ Individual healthcare decisions have also been increasingly politicized; the net result is the creation of laws, such as those limiting discussions of firearm safety or banning gender-affirming treatments for transgender children, that influence patient-physician interactions. This combination of erosion of trust and politicization of medical decisions has been harshly highlighted by the global pandemic, complicating public health policy and doctor-patient discussions. Public health measures such as masking and vaccination have become polarized.⁶ Further, there is diminishing trust in medical recommendations, brought about by the current media landscape and by frequent modifications to public health recommendations. Science and medicine are constantly changing, and knowledge in these fields is ultimately provisional. Unfortunately, when new data are published that contradict prior information or report new or dramatic findings, it can appear that the medical system was somehow obscuring the truth in the past, rather than simply advancing its knowledge in the present.

How do we build trust? How do we function in a healthcare system where trust has been eroded? Trust is ultimately a fragile thing. The process of earning it is not swift or straightforward, but it can be lost in a moment.

In partnership with the ABIM Foundation, the Journal of Hospital Medicine will explore the concept of trust in all facets of healthcare and medical education, including understanding the drivers of trust in a multitude of settings and in different relationships (patient-clinician, clinician-trainee, clinician- or trainee-organization, health system-community), interventions to build trust, and the enablers of those interventions. To this end, we are seeking articles that explore or evaluate trust. These include original research, brief reports, perspectives, and Leadership & Professional Development articles. Articles focusing on trust should be submitted by December 31, 2021.

Bronchiolitis, the most common cause of hospital admission for infants, is responsible for more than $500 million in direct medical costs in the United States yearly. Recent efforts have focused on what can be safely avoided when caring for patients with bronchiolitis (eg, continuous pulse oximetry, bronchodilator administration). While there remains substantial room for improvement in avoiding such low-value (or no-value) practices, the incremental improvements from these de-escalations will reach an asymptote over time. Further improvements in care and value must occur by doing things differently—not just simply doing less.

In this month’s Journal of Hospital Medicine, Ohlsen et al¹ describe an intervention to decrease length of stay (LOS) for patients with bronchiolitis They employed an interrupted time series analysis to evaluate implementation of an observation unit and home oxygen therapy (OU-HOT) model of care and found that LOS dramatically decreased immediately following implementation. This reduction was maintained over 9 years. Use of home oxygen decreased over the study period, while LOS remained low, suggesting that the most important intervention was a structural one—the admission of patients to a unit dedicated to efficient discharge.

Observation units, staffed 24/7 with attending physicians, are well adapted to care for patients with illnesses like bronchiolitis, where hospitalization, though often needed, may be brief.² These units are designed more like an emergency department than an inpatient unit, with protocolized care and the expectation of rapid turnover.

Multiple studies have shown that physician-related delays are a primary driver of delayed discharge from inpatient units. Such delays include delayed or variable clinical decision-making, inadequate communication of discharge criteria, and waiting to staff patients with an attending physician.^3-5 Addressing these issues could allow inpatient units to function more like observation units for specific diagnoses. Standardization of care around specific diagnoses can make decision-making and discharge more efficient. In 2014, White et al⁴ showed that standardizing discharge criteria for specific diagnoses (including bronchiolitis) and embedding these criteria in admission order sets resulted in a significant decrease in LOS without affecting readmission rates or patient satisfaction.

To address the issues of attending availability, we may need to rethink rounding. The daily structure of inpatient rounding has not meaningfully changed since the 1950s. While there has been a push for increased morning discharges, this approach misses many patients whose illness course is evolving and who may be ready for discharge in the afternoon or evening.⁶ The current structure of morning rounds on medical teams is based on the need for resident education, supervision, and time available for attendings to complete administrative tasks and teaching in the afternoons. Structural change in patient care requires academic institutions to rethink what “being on service” actually means. Since LOS in these cases is brief, multiple days of clinical continuity may not be as beneficial as with other diagnoses. Further, there is no reason that daytime rounding teams are the only teams that can discharge patients. Telemedicine could also offer an opportunity for attending physicians to remotely determine whether a patient is discharge appropriate. Standardization of discharge criteria at admission could allow for trainees to discharge patients when they meet those criteria.

Perhaps we should begin to adapt our work structure to our patients’ needs, rather than the other way around. In pediatrics, we have already made traditional rounding more patient-focused through the practice of family-centered rounding. We should identify, as the authors have, ways to do things differently to make further improvements in care.

Ultimately, the success of this OU-HOT protocol demonstrates the power of structural interventions aimed at changing how we do things rather than just doing more (or less) of the same.

Bronchiolitis, the most common cause of hospital admission for infants, is responsible for more than $500 million in direct medical costs in the United States yearly. Recent efforts have focused on what can be safely avoided when caring for patients with bronchiolitis (eg, continuous pulse oximetry, bronchodilator administration). While there remains substantial room for improvement in avoiding such low-value (or no-value) practices, the incremental improvements from these de-escalations will reach an asymptote over time. Further improvements in care and value must occur by doing things differently—not just simply doing less.

In this month’s Journal of Hospital Medicine, Ohlsen et al¹ describe an intervention to decrease length of stay (LOS) for patients with bronchiolitis They employed an interrupted time series analysis to evaluate implementation of an observation unit and home oxygen therapy (OU-HOT) model of care and found that LOS dramatically decreased immediately following implementation. This reduction was maintained over 9 years. Use of home oxygen decreased over the study period, while LOS remained low, suggesting that the most important intervention was a structural one—the admission of patients to a unit dedicated to efficient discharge.

Observation units, staffed 24/7 with attending physicians, are well adapted to care for patients with illnesses like bronchiolitis, where hospitalization, though often needed, may be brief.² These units are designed more like an emergency department than an inpatient unit, with protocolized care and the expectation of rapid turnover.

Multiple studies have shown that physician-related delays are a primary driver of delayed discharge from inpatient units. Such delays include delayed or variable clinical decision-making, inadequate communication of discharge criteria, and waiting to staff patients with an attending physician.^3-5 Addressing these issues could allow inpatient units to function more like observation units for specific diagnoses. Standardization of care around specific diagnoses can make decision-making and discharge more efficient. In 2014, White et al⁴ showed that standardizing discharge criteria for specific diagnoses (including bronchiolitis) and embedding these criteria in admission order sets resulted in a significant decrease in LOS without affecting readmission rates or patient satisfaction.

To address the issues of attending availability, we may need to rethink rounding. The daily structure of inpatient rounding has not meaningfully changed since the 1950s. While there has been a push for increased morning discharges, this approach misses many patients whose illness course is evolving and who may be ready for discharge in the afternoon or evening.⁶ The current structure of morning rounds on medical teams is based on the need for resident education, supervision, and time available for attendings to complete administrative tasks and teaching in the afternoons. Structural change in patient care requires academic institutions to rethink what “being on service” actually means. Since LOS in these cases is brief, multiple days of clinical continuity may not be as beneficial as with other diagnoses. Further, there is no reason that daytime rounding teams are the only teams that can discharge patients. Telemedicine could also offer an opportunity for attending physicians to remotely determine whether a patient is discharge appropriate. Standardization of discharge criteria at admission could allow for trainees to discharge patients when they meet those criteria.

Perhaps we should begin to adapt our work structure to our patients’ needs, rather than the other way around. In pediatrics, we have already made traditional rounding more patient-focused through the practice of family-centered rounding. We should identify, as the authors have, ways to do things differently to make further improvements in care.

Ultimately, the success of this OU-HOT protocol demonstrates the power of structural interventions aimed at changing how we do things rather than just doing more (or less) of the same.

Bronchiolitis, the most common cause of hospital admission for infants, is responsible for more than $500 million in direct medical costs in the United States yearly. Recent efforts have focused on what can be safely avoided when caring for patients with bronchiolitis (eg, continuous pulse oximetry, bronchodilator administration). While there remains substantial room for improvement in avoiding such low-value (or no-value) practices, the incremental improvements from these de-escalations will reach an asymptote over time. Further improvements in care and value must occur by doing things differently—not just simply doing less.

In this month’s Journal of Hospital Medicine, Ohlsen et al¹ describe an intervention to decrease length of stay (LOS) for patients with bronchiolitis They employed an interrupted time series analysis to evaluate implementation of an observation unit and home oxygen therapy (OU-HOT) model of care and found that LOS dramatically decreased immediately following implementation. This reduction was maintained over 9 years. Use of home oxygen decreased over the study period, while LOS remained low, suggesting that the most important intervention was a structural one—the admission of patients to a unit dedicated to efficient discharge.

Observation units, staffed 24/7 with attending physicians, are well adapted to care for patients with illnesses like bronchiolitis, where hospitalization, though often needed, may be brief.² These units are designed more like an emergency department than an inpatient unit, with protocolized care and the expectation of rapid turnover.

Multiple studies have shown that physician-related delays are a primary driver of delayed discharge from inpatient units. Such delays include delayed or variable clinical decision-making, inadequate communication of discharge criteria, and waiting to staff patients with an attending physician.^3-5 Addressing these issues could allow inpatient units to function more like observation units for specific diagnoses. Standardization of care around specific diagnoses can make decision-making and discharge more efficient. In 2014, White et al⁴ showed that standardizing discharge criteria for specific diagnoses (including bronchiolitis) and embedding these criteria in admission order sets resulted in a significant decrease in LOS without affecting readmission rates or patient satisfaction.

To address the issues of attending availability, we may need to rethink rounding. The daily structure of inpatient rounding has not meaningfully changed since the 1950s. While there has been a push for increased morning discharges, this approach misses many patients whose illness course is evolving and who may be ready for discharge in the afternoon or evening.⁶ The current structure of morning rounds on medical teams is based on the need for resident education, supervision, and time available for attendings to complete administrative tasks and teaching in the afternoons. Structural change in patient care requires academic institutions to rethink what “being on service” actually means. Since LOS in these cases is brief, multiple days of clinical continuity may not be as beneficial as with other diagnoses. Further, there is no reason that daytime rounding teams are the only teams that can discharge patients. Telemedicine could also offer an opportunity for attending physicians to remotely determine whether a patient is discharge appropriate. Standardization of discharge criteria at admission could allow for trainees to discharge patients when they meet those criteria.

Perhaps we should begin to adapt our work structure to our patients’ needs, rather than the other way around. In pediatrics, we have already made traditional rounding more patient-focused through the practice of family-centered rounding. We should identify, as the authors have, ways to do things differently to make further improvements in care.

Ultimately, the success of this OU-HOT protocol demonstrates the power of structural interventions aimed at changing how we do things rather than just doing more (or less) of the same.