Sunday, January 21, 2007

Trust

Was really taken aback by a couple of patient comments today. One was from an elderly woman who we were asked to consult on. She refused to have anything to do with us, stating that we were there to experiment on her. Didn't think too much of this comment - the lady could have had a touch of paranoid schizophrenia, or schizotypal personality. But then later in the day, a family member of another patient jokingly said, "are you guys experimenting on XXX?!" Although it was meant to be a joke, and I don't think the family member really believes that we would be experimenting on their loved one, all jokes come from some version of reality...

The comments really caught me off guard. The more I thought about where they were coming from, the more I realized that, for all they knew, we could be experimenting on their loved ones. After all, unless they were in the medical field, all they knew was that teams of physicians came in and out of the room, all of them perplexed by the strange medical condition affecting their loved one, all of them poking and proding, all of them asking for different tests to be done to try and see if they could figure out what was going on, and day after day still with no good answer as to what the medical problem was. Meanwhile, from our point of view, there was a multi-disciplinary team including almost all the subspecialties of medicine consulting on this complex patient, trying to figure out what in the world was causing his constellation of symptoms, and truly, no one having a clue.

I can see how it could be extremely difficult on patient's families to see their loved ones sick and see physicians struggling with figuring out what is going on. But the leap from "how come these doctors can't figure it out" to "gee, they must be experimenting on my loved one" is still a hard one for me to take. I mean, I guess it's a possible reaction to stress. And fortunately most patients give us their trust without asking for much proof. But to think that there may be a significant number of patients who suspect that we may not be honest, or that we may be trying to trick them, or experiment on them, makes me nauseous. I've heard two such comments this week. How many more patients think these things but don't say them?

To these people, I'd really like to say - do you know that I swore an oath never to harm and only to try and heal? Do you know that I've been working like a madwoman, up at odd hours, tired beyond belief, for you? Do you know that the thought of "experimenting" on any living being had never, ever crossed my mind before you brought it up? And that while I'm sacrificing the best years of my life to take care of you and others like you, hearing that you think I may be trying to harm you makes all the long days and nights that much harder to bear?

I'm as human as you are. I'm not saying that we will always know the answers. We may not always be able to heal, or cure. I chose this profession to try to relieve suffering. But I can't help you if you don't let me. All I'm asking is that you trust that we have your best interest at heart. Because if you don't trust me, how can I take care of you?

While trusting us may seem like blind faith, it's not that new of a concept. After all, you trust that the Starbucks kid isn't lacing your coffee with arsenic. You have to believe that the babysitter isn't going to harm your kid. You trust that the random taxi driver isn't going to take you somewhere and kill you. You have to operate with a level of blind trust to get through the day. Is it so much to ask that you trust us as well?

photo credit

13 Comments:

Anonymous Anonymous said...

Schizoid? Don't you mean, say, schizotypal or paranoid?

5:50 PM  
Anonymous Anonymous said...

anon - you're right, change made :)
-wv

10:29 PM  
Blogger Shinga said...

It sometimes seems as if trust has been replaced not by a spirit of enquiry but cynicism. Is it possible that a cynicism about the marketing of pharma is spreading to doctors who have no part in it?

Regards - Shinga

6:59 AM  
Blogger Almost A, DO said...

I get similarly upset when I read conspiracy theories about how there is really a cure for (HIV, cancer, insert-terrible-disease-here) but that doctors won't use it because they make more money off of sick patients.

When I think of the huge investment that doctors make - not just monitarily, but spiritually - those claims just become so absurd and insulting.

On the other hand, what about the patients who go to teaching hospitals and have students "practice" on them? That's pretty darn close to experimentation sometimes. I myself started an IV on a guy the other day. Assured him that I'd done it before. I had - I'd done two prior to his, one successfully. His went in easily, but when my attending congratulated me on it afterwards, he seemed a little disturbed to find out that I was one of his first - in essence, a participant in the great experiment of clinical education.

12:50 PM  
Anonymous Kim said...

Interesting. It seems that if a patient is going to ask me how long I've been a nurse, it's always right before I'm ready to put in the IV. I guess they need reassurance I know what I'm doing, because once I tell them "almost 30 years", there is a palpable feeling of relief!

I have to agree with Shinga, patients are very cynical and sometimes suspicious when told they need a medication or procedure.

5:22 PM  
Anonymous Anonymous said...

To the young doc who said,
don't they know I took an
oath to first do not harm, I need to say that we always do harm sooner or later even though we never
mean to do so.

First of all, we do our medical care on one and all
with out knowing the absolute truth. What I was
taught as "true" many years
ago in med school, has been
replaced with new knowledge
in many areas, for instance: cholesteral, PUD,HIV, estrogen replacement therapy, etc.
I hate to think about the
hundreds of post menopausal
women that I treated with
hormone replacement therapy
to "prevent heart disease
and osteoporosis."

Then there is the problem of all the medications allowed on the market that
turn out to be harmfull or
dangerous to patients and are then taken off the market. There have been a
dozen or more since I first
began practice.

So, do not be so defensive
and the secret word is communicate, communicate,communicate.

Some years ago, I figured out that I do not controll
one single thing except my
own behavior, and it
was
a humbling and relieving
discovery.
Peace to all.
retired Doc.

7:19 PM  
Blogger always learning said...

appreciate all your comments.

Shinga: hm, interesting thought.
Almost a DO, Kim: i've only heard a few odd ducks talking about conspiracy theories (of course, there may be many more that think it but are smart enough to keep it to themselves! :D). In terms of procedures, most procedures that matter are done by people who know what they are doing, or closely supervised by those who know what they are doing. And after a while, the RN, intern or resident may be "better" at doing a procedure than the most senior attending, just because they've been doing more of them, and more recently. Maybe it's a gray zone, but I think this is different that setting out to "experiment" on humans.

fat gardner: appreciate your words of wisdom. absolutely agree that we always have the potential to, and if we practice long enough, will inadvertently harm some of those we take care of. but the key point is that these are not intentional mistakes. We never set out with the goal of harming, and outside of the confines of a true clinical research trial, would never subject our patients to drugs or treatments where we thought the harm would outweigh the risk. And given that each and every intervention has the possibility of harm/side effects, in the spirit of informed consent, we always attempt to explain the risks/benefits before proceeding. Point being, we don't set out with the intention to harm or "experiment" on people.

8:39 PM  
Anonymous beesnest8 said...

Even worse, almost every day in the ER someone says "s/he doesn't know what their doing," sometimes meaning just that, or sometimes in frustration from feeling we just want them to go away. On both counts they are sometimes right.

9:49 AM  
Anonymous Anonymous said...

My sister has a child with cancer and she has recently started looking into some pretty scary alternative therapies. She told me that the cure is probably already out there, after all, why would any drug company want to stop making millions from treating sick children?

9:54 AM  
Anonymous Anonymous said...

To these people, I'd really like to say - do you know that I swore an oath never to harm and only to try and heal?
_____________

While all doctors do swear an oath, not all doctors keep it. There are doctors who cause great harm.

I was sexually abused by a doctor. If I am wary of you, it is for good reason. How is a patient who has just met you supposed to know that you honour your oath? Because you have earned an MD?

Please don't dismiss all patients who are afraid of you or who do not automatically trust you as mentally ill or act outraged that they do not blindly trust you. They do not know you and you do not know them or their history and past experiences with other doctors who were supposed to care for them and didn't

5:55 PM  
Blogger always learning said...

beesnest8 - :) your last line made me smile... reminiscing about the good ol' days in the ED with the frequent fliers

anon - i'm sorry to hear about your niece/nephew. why would anyone not want to treat sick children (or anyone who is sick!) should be the question, regardless of how much it cost? unfortunately, drug companies and their ideas on how to spend money are often not in line with the best interest of the patient. And while i don't know your story, often there are diseases that are less common that will not get drugs designed because the eventual monetary payback from the smaller number of patients isn't "worth" the investment for the drug company. they'd rather target diseases that everyone has, that way everyone can help make them rich... (pardon the cynicism)

anon - am sorry to hear your story. I don't dismiss patients who are afraid of or do not trust me. I think that's slightly different than someone who automatically assumes that I'm setting out to "experiment" on them. I understand where you are coming from. Many of us have experiences of our trust betrayed by another, and after the situation, it is difficult to trust again. Anyone, at anytime, could theoretically take advantage of us - the grocery store clerk, the taxi driver, the janitor. But my point was that in order to adequately function in this world of ours, we have to (whether it's safe or not) assume that most people are trustworthy. And I'm early enough in my training to be surprised to find that there might be a number of patients who think that we're out to experiment on them.

8:59 PM  
Anonymous Anonymous said...

Another thought. You didn't mention the ethnicity of your patients. If you are a newish practitioner, you may not be aware that in the not so distant past, even in this country, our citizens were experimented on. There was the Tuskegee study, in the early to mid part of the 20th century, where Black men with syphillis were deliberately not treated, so that the natural history of the disease could be studied. The men & their partners went on to suffer the complications of tertiary syphillis.

So, as a Caucasian physician who treats a number of African-American patients, I have bumped up against this suspicion several times. When I do, I try to reassure them that this is no longer legal & that there are review boards & consents & such. But, the fear lingers yet.
V

9:41 PM  
Blogger always learning said...

anon - point well taken. I thought about putting in "non-AA" in the initial post... but then felt like it was starting to become a full-on presentation: 40yo non-AA patient, etc etc... :)

I'm definitely aware of Tuskegee (what were they thinking!), have taken care of AA pts that are suspicious because of. Neither of these two patients were AA, which is what threw me off.

9:46 PM  

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