AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. July 2006, Volume 8, Number 7: 449-451.

Clinical Cases

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Can There Be Healing without Trust?

Physicians should be aware when developing a treatment plan that patients' lack of trust in the medical profession can affect their willingness to seek medical treatment and comply with the treatment.

Commentary by Joseph B. Layde, MD, JD

Dr. Burton is an internist at a student health center. Julie, a freshman at the college, made an appointment for an initial medical evaluation. It was flu season and Dr. Burton was running 30 minutes late. He apologized for the delay immediately after introducing himself to his new patient. He asked Julie routine medical questions, thinking to himself that she was rather disengaged. Julie reported a recent onset of gastrointestinal cramping, bloating and constipation which caused her to miss classes. Midway through the medical history, she matter-of-factly told Dr. Burton, “I’m just here for a sick note.” Dr. Burton patiently explained to Julie that he needed to collect further medical information to complete the evaluation. Julie reluctantly acquiesced, and Dr. Burton discovered that her father had died in a motor vehicle accident two years before, and this had led to some significant financial stress.

Following the interview and physical exam Dr. Burton diagnosed Julie with irritable bowel syndrome. He educated her about the condition and made some treatment recommendations including a prescription drug. Julie stated she had been surfing the Web, figured that was her diagnosis and ordered a month’s supply of several herbal supplements for approximately $50 because she knew she could not afford the copay for Dr. Burton’s prescriptions.

Later, when Dr. Burton discussed this case with the clinic nurse he learned that Julie’s father had actually been in a relatively minor car accident in which he had sustained a fractured femur. His death, Dr. Burton discovered, had been the result of preventable medical complications during surgery. The surgeon in this case was known in the medical community for his brusque interpersonal manner and his cavalier approach to patient care. According to the clinic nurse, the outcome of the case was widely known to have been avoidable, but no one on the treatment team had discussed the situation forthrightly with Julie’s mother. The family suspected that someone was to blame and had been very upset by the apparent cover-up. Dr. Burton was sure his patient’s previous experiences with the medical profession had affected her ability to trust him as her internist.

One month later Dr. Burton notices Julie’s name on his afternoon clinic schedule and wonders how he should address what he has learned.

Commentary

The trust a patient holds in the medical profession informs all aspects of her relationship with every physician she encounters. This scenario illustrates how a breakdown in trust can damage a patient’s relationship with a physician who was completely uninvolved in the clinical situation that led to the rupture.

In a thoughtful discussion of what makes the patient-physician relationship special, John Bruhn characterized trust as “the glue that bonded physicians and patients” and worried that “the glue has become a rubber band” [1]. The fact that patients and their families have contact with an increasing number of physicians within the fragmented U.S. medical system means that less personal, less durable ties bind doctors and patients [1]. In this case, the deeply troubling experience that Julie and her family had with her father’s surgeon lessens her willingness to form a relationship with Dr. Burton. When medical specialization and patient mobility were not as pronounced as they are today, entire families might have gotten all of their medical care, including necessary surgery, from the same small town general practitioner. Today a patient is likely to have contact with many physicians, any one of whom can potentially spoil the atmosphere of trust between the patient and the medical profession as a whole.

Fortunately, there are things that physicians can do to enhance the patient-physician relationship, the most basic of which is to talk to patients in a caring way and discuss the specifics of their problems with them. Patient trust in primary care physicians has been shown to be associated with the physicians’ behavior in eliciting and validating patients’ concerns, inquiring about their expectations and responding to their emotional distress with empathic language [2-4]. Better relationships can lead to improved care. HIV-infected patients, for example, reported better adherence to antiretroviral therapy when they communicated well with and trusted their doctors and felt as though their doctors shared HIV-specific information with them and talked about the difficulty of following complicated antiretroviral regimens [5].

Dr. Burton now faces the dilemma of how to deal with Julie during her second clinic visit with him. Should he mention her rejection of his recommended prescriptions for irritable bowel syndrome and perhaps discuss the origin of her skepticism toward medicine? On the one hand, Dr. Burton may be able to give better care to Julie if he talks with her about what he has heard concerning her father’s death and helps her to separate her distrust of her father’s surgeon from her relationship with him. On the other hand, Julie may consider it an intrusion for Dr. Burton to presume to know the origin of her skepticism toward allopathic medicine, especially since he learned about her father’s experience through a discussion with the clinic nurse and not from her.

Perhaps the best course for Dr. Burton would be to talk to Julie about her first clinic visit with him. Dr. Burton could ask how she is feeling. He could ask if there is anything about that visit she would like to discuss with him, including her feelings about the use of prescription medications and herbal supplements. Such an approach would give her the opportunity to raise the subject of her family’s bad experience with the medical profession if she chooses to do so. If she is willing to discuss her feelings toward doctors, Julie may be more likely to move beyond her distrust and to benefit from her visits with Dr. Burton. In turn Dr. Burton would be better able to use his professional skills to heal whatever ails his patient. If he cannot help his patient form a trusting relationship, he is likely to be reduced to a machine that cranks out “sick notes.”



References

  1. Bruhn JG. The lost art of the covenant: trust as a commodity in health care. Health Care Manag (Frederick). 2005;24:311-319.
  2. Fiscella K, Meldrum S, Franks P, et al. Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care. 2004;42:1049-1055.
  3. Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA. 2000;284:1021-1027.
  4. Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997;277:678-682.
  5. Schneider J, Kaplan SH, Greenfield S, Li W, Wilson IB. Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection. J Gen Intern Med. 2004;19:1096-1103.

Joseph B. Layde, MD, JD, is associate professor and vice chair for faculty affairs in the Department of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin in Milwaukee.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.