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Trust: The Evolution of Professionalism

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Jaime McClennen


Daniel Wolfson

Since the release of the Physician Charter on Medical Professionalism in 2002, the ABIM Foundation’s core mission has been to use professionalism as a lever to improve health care. The Charter maps out a social contract between physicians and society and, for more than 20 years, has guided the Foundation’s work, including:

The Charter is widely recognized as a seminal document in professionalism scholarship, and more than 100 organizations have endorsed it. However, it’s important to note that the document has always been aspirational; individuals and organizations must take specific actions to bring it to life. For example, the 80+ medical specialty societies and consumer organizations participating in Choosing Wisely have created a framework to advance the Charter’s commitment to a just distribution of finite resources by encouraging clinicians and patients to talk about what tests and treatments might offer them little or no benefit.

More recently, the Foundation has turned its attention to issues of trust in health care through the Building Trust initiative, motivated by a variety of factors:

  • Trust in the U.S. health care system declined 50% during the last 25 years;
  • a rise in misinformation leading to a growing mistrust in science; and,
  • the unequal power dynamics of clinician-physician conversations, particularly about low value care and Choosing Wisely recommendations with historically marginalized communities.

In taking on this work, I was influenced by Jo Shapiro, MD’s definition of  professionalism, “that which supports relational trust, applied to all relationships: between physicians and other health care providers and society, between health care providers and patients, and among all members of the health care team.”

This contrasted with the prevailing construct of professionalism, which mostly focused on the responsibilities of individual physicians toward society rather than on relationships, and how physicians’ unique knowledge, training and skills justify the profession’s desired autonomy from regulations.

Trust, on the other hand, is largely about relationships; it extends professionalism to a larger organizational and community context by focusing on the caring and compassion needed to forge binding human connections. Or, as Avedis Donabedian said in his famous Health Affairs article before his death, “quality is love.”

Trust extends to all participants in the health care system, including patients, health plans, health systems/hospitals, medical groups, public health, physician organizations and specialty boards. We have seen these important connections play out in the pandemic. We have also seen the consequences of poor trust between historically marginalized communities and the health care system. We must strive to act as a system of health care that eliminates silos and fosters trusting relationships.

How we improve those connections and relationships is at the core of the Foundation’s new Building Trust initiative. What drives trust will also drive better performance, improved patient and physician satisfaction, and result in better health care. As part of this work, we will need to find ways to overcome the earned distrust of those we’ve historically marginalized.

The ABIM Foundation is now on a journey to promote trustworthiness in all relationships as a means of achieving excellence in the health care system. I believe this is the natural evolution of professionalism, and invite everyone in health care, including patients and caregivers, to join us on this journey.

Daniel Wolfson
Executive Vice President and Chief Operating Officer