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Trust Me.

July 29, 2013

The Mayo Clinic has definitely been shaking things up.  It’s journal, The Mayo Clinic Proceedings, just came out with a study that shows that many of the treatments that doctors once swore by are useless or worse.  I can talk about this at another time, but if you want a good review there is one by my friend John Mandrola at drjohnm.org.  The NYT did a piece on it and the commentary contained a great deal of doctor-bashing.  So of course I opened my big mouth and pointed this doctor hatred out.  The comment I got back was this:  “It’s not hatred, it’s fear.”

Wow.  Guys, if people are starting to fear physicians then we’ve got a real problem.  Trust has always been the basis of the doctor-patient relationship.  If you can’t trust us then we might as well go back to the days of charlatans and quacks.  I know, some people are going to say we’re all quacks anyway but those folks had shoddy upbringing.  If you can’t trust us then we’re done.  If you can’t trust us then our relationship becomes adversarial; you against me. If you can’t trust us, you won’t tell us things, you won’t do what we say, you will constantly be doubting our motives.  And vice-versa.  Actually, now that I think of it, the doctor-patient relationship becomes basically teenager-parent.

The literature on doctor-patient trust suggests that a patient’s health or recovery depend in part on the doctor-patient relationship.  Judith Hall, a researcher at Northeastern University wrote with colleague Debra Roter in 2006:

“Once the patient and physician are brought together, they enter a relationship predicated on the expectations each olds for the conduct of the other.  The relationship thus formed has substantial implications for how the curing and caring process will be accomplished and the extent to which needs and expectations will be met, satisfaction achieved, and health restored.”(Doctors Talking with Patients/Patients Talking with Doctors, 2006).

Trust has many components.  It is based partly on compatible communication styles.  The Journal of General Internal Medicine  points to the patient’s assessment of the physician’s communication, level of interpersonal treatment, and knowledge of the patient (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495476/).  In these times of short visits, short-tempered doctors and patients, and fragmented treatment, all those factors are in jeopardy.   Patient dissatisfaction implies poor trust.  Race and gender of both patient and doctor has an impact. Patients who genuinely LIKE their doctors tend to trust them more. In the 1950s it was thought that the basis of physician trust is the understanding that doctors treat everyone equally.  The media has made sure we all know this is not true, and this has to do with economics and geography as well as regional differences in standard of care.  That old-fashioned trust of the physician resulted in a paternalistic approach to medicine with the resulting backlash by the autonomy movement.  The basic function of the doctor, to diagnose and treat, has been called into question by the Mayo Clinic article as well as a number of other stories such as over-prescribing, doctors taking money from drug companies, the guy who performed illegal and unsanitary abortions, doctors turning down medicaid patients, etc.  Doctors trust patients less too.  Part of the reason doctors don’t follow the latest recommendations is fear of litigation, especially if they DON’T do something.

All the data is mushy in the research on doctor-patient trust and a lot of it is old.  Anecdotal evidence, like my interchange in the NYT comment section, suggests doctors are losing ground on this issue.  The following things might help a little:

1. Doctors cannot take money from drug companies.  Ever.  Not even a pen.  Just don’t do it.

2. Practice good communication, or learn how if you don’t know.  This goes on both sides.  If you don’t understand, ask.  If you are the patient, bug the doctor until you are satisfied.  If you are the doctor, ask and answer for as long as it takes.

3. Take money out of the conversation.  Universal health care is the only way to do this successfully.

4. There is nothing wrong with finding a doctor who is the same gender or ethnicity as you.

5. Understand that nobody has all the answers.  Doctors don’t know everything, patients don’t always know what they want, and none of us like this fact.  We like to think medicine is an exact science but it is NOT.

6. Doctors must keep up with the latest real research.  We must go to our annual conferences.  Where I work, the only people who get to go to the annual conference are the people who are presenting, who are the researchers, who always go, and who do less clinical work.   No.  Everyone goes.  Close the ORs.  Close your office.  Can’t afford to close your office?  Use the databases like UpToDate, which has a hundred doctors employed solely for the purpose of gathering the latest clinical info.

7. Tort reform.  All the research and conferences in the world don’t do anything if people are afraid to follow what the research says.

8. Patients cannot expect miracles.  Those days are over.  Patients cannot expect that they can get every test and treatment known to man.  Those days are over too.

9. Let’s all recognize our humanity.

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From → Healthcare

3 Comments
  1. “Practice good communication, or learn how if you don’t know” is sound advice. There are resources for learning better communication skills and gaining confidence applying those skills in real-life clinical settings. An issue: most clinicians seem to be from Lake Wobegon, Garrison Kiellor’s fictitious town where “…all the children are above-average”. Hurrah for the clear-eyed folks who understand that each and every one of us could do better. Check out online and in-person courses from the Institute for Healthcare Communication–they are transforming practices for clinicians throughout North America!

    • Thanks for reading Barbara – Thanks for the tip. Communication skills are not evaluated by admissions testing, and the good grades in physics and chemistry that get you in to medical school are not the best preparation either!

      • Hi Shirie, Thanks for your response. You may be interested in an excellent recent article in Medical Teacher by Henry, Holmboe and Frankel, “Evidence-based competencies for improving communication skills in graduate medical education…” 2013; 35; 395-403. Regards, Barbara

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