Ep 23 In Doctors We Trust

Today’s episode is about something that’s on my mind all the time, and that is trust, specifically trust as it applies to the doctor patient relationship. If you’ve heard pretty much any of my prior episodes, you know that I bring this up a LOT. My strong belief and one of the reasons why I started this podcast in the first place is that healthcare works best when the doctor patient relationship is strong, and these days for many people including me at times, it’s not. On this show I’ve talked about other topics that touch on trust, like a day in the life of a doctor, which is crazy by the way, a day in the life of a patient, which can be incredibly challenging, the way doctoring used to be, how doctors burn out, and how some doctors and patients are pushing back.

But today I want to circle back to the basics, to step 1, which is the relationship itself. How are things when it’s just the 2 of you in the room or on the phone or on the screen as happens these days. Is there a feeling of trust or not? This may seem like a minor thing, but in my mind, it’s huge. It can make or break the entire relationship. It can influence everything about your healthcare – whom you choose to see, where you go for care, IF you go for healthcare at all, how and what you communicate with them about, how you make decisions for yourselves and for those you’re responsible for. Think for a moment about a romantic relationship you’ve had and consider for a minute how essential trust was in that, (I mean hopefully). Consider other relationships in your life: friends, teachers, coaches, coworkers, and so forth. Expecting some foundation of trust seems obvious with these types of relationships, so shouldn’t it be the same with your doctor? The implications of this relationship working or not can be huge.

Do you get that vaccine because your doctor told you you should? If you trust them, yeah, probably.

Do you go see that specialist that they recommended that you follow up with? If you DON’T trust them, maybe you won’t.

Do you take the diagnosis they’re giving you at face value and believe it? If you trust them, yes.

Do you take that cholesterol lowering medication that they strongly recommend that you don’t want to take because of the potential side effects? If you DON’T trust them, maybe you won’t.

The point is, how much or little you trust your doctor is probably affecting your health in more ways than you might realize.

So, let’s start at the beginning. What is trust, anyway? Good old Webster’s dictionary defines it as “an assured reliance on the character, ability, strength or truth of someone or something”. Direct that towards the doctor patient relationship and it means that you believe that you can rely on your doctor’s words and actions, and have faith that they have your best interest in mind. Over the decades a few medical researchers developed questionnaires to assess a patient’s trust in their doctor. And I literally mean just a few. There’s loads of research out there on patient satisfaction, and a growing body of research on doctor satisfaction and also burnout, but not as much out there on trust over the years. I’m not sure why this is the case, beyond just that it’s a pretty difficult thing to figure out because it’s so intangible and subjective. So. These surveys asked patients to rate how much they agreed or disagreed with statements about the care that they were receiving from their doctor. I’m going to read a whole bunch of them now, because these questions themselves will get us all reflecting on this topic. This is sort of a group exercise, if you will. And, I’m putting a screenshot of these survey questions in the show notes if you want to read ALL of them and think it over more later. Before I start, please get a couple of doctors that you’ve seen in your mind and consider how you would rate them on these statements:

1.     My doctor is usually considerate of my needs and puts them first.

2.     I trust my doctor so much that I always try to follow his or her advice.

3.     My doctor sometimes pretends to know things when he or she is really not sure.

4.     My doctor cares more about holding costs down than about doing what is needed for my health.

5.     If my doctor tells me something, then it must be true.

6.     My doctor cares as much as I do about my health.

7.      I trust my doctor to tell me if a mistake was made about my treatment.

8.     My doctor is a real expert in taking care of medical problems like mine.

So, what other statements would you consider when thinking about how and if you feel trust for your doctor? If there’s one you would like to add, get in touch with me and let me know and I might just read it off on social media.

Now that we’ve established what trust is and what it looks like in the doctor patient relationship, we have to talk about the factors that are working against it.

1.     For example, one of the troubles with trust is that it’s NOT an automatic, right? You don’t meet someone and 3 minutes later say I completely trust that person! In most types of relationships, developing trust takes a lot of time and purposeful attention and repeated interactions to develop. However, this is sort of at odds with how trust has to work between a doctor and patient, because you are expected to have at least some amount of trust right off the bat the first time you meet a doctor. It’s not too much unlike when you enlist the services of somebody with expertise in something. For example, when I call an electrician to come fix something at my house, I have to have some minimum amount of trust right off the bat that they know and understand electricity and how to work with it. And so it is with doctors. You hopefully go into that first visit with a modicum of trust simply because they spent a minimum of 7 yearslearning and training so that they can take good care of you. And then from there you work on building more and more trust.

 2.     Second, I believe that people often, and on a big picture scale, conflate trust in doctors with trust in the healthcare system, which for the most part is a completely different beast. During the pandemic I think that the difference between trust in the healthcare system and trust in a particular doctor in general was brought to the forefront more than it has been before, and the system is negatively affecting the doctor by association. If you don’t trust the system at large, you might be coming to the doctor’s visit with a pre-conceived feeling of mistrust. I got this comment on one of my social media sites after posting an audio blurb about how crazy drug costs are in the US: “The past 4 years, doctors showed us how much we can trust them. Not AT ALL. Avoid them at all costs is my motto” I’m not reading this publicly to shame this person in any way, but I’m using it to point out that this is how a lot of people think, especially after the pandemic, when their mistrust in the healthcare system overall, or the politics of it, or the availability of vaccines, or whatever your local news station was saying about covid at the time makes you think that doctors are the ones to blame for everything. 

3.     Third, on a day to day scale, people can also conflate frustration with how the healthcare system is set up with frustration with doctors themselves. But the reality is that the way that the healthcare system often works today is not set up to value you having a lot of time and attention from your doctor. Most doctors are bound by very strict requirements of having to see a certain number of patients per day, which leads to less availability and rushed visits. Then the doctors, many of whom don’t like to practice medicine this way, get frustrated and move practices or leave medicine altogether. And to many people, these deficiencies in how a doctor visit is run appear to be the doctor’s fault, and it is probably more challenging to feel trusting of someone that you feel annoyed with. But, you have to separate things like wait times for appointments, poor front office communication, endless phone mazes and longer wait times from the doctor themselves. Friendly reminder that doctors are stuck in the same screwy system that you are; we’re in it together, if you will. More on all this in last week’s episode called Doctors In Distress, where I talked with Dr. Karen Leitner on how the system is making doctors feeling dissatisfied, when what they really want to do is focus on what they loved in the first place: seeing patients and helping people. 

4.     Lastly, race clearly plays a role in the trust of physicians, especially in the US, where people of color have the lowest rates of trust in both physicians and the healthcare system at large [DATA CITATION]. This is completely understandable if you look at the history of healthcare delivery in the US and hear about how badly mistreated black people were by the very doctors that should have been helping them. Public healthcare mistreatment such as the Tuskegee syphilis study, the misappropriation of Henrietta Lacks’s cells for research, the under-prescribing of pain medications for people of color and more all contribute to an ongoing mistrust. Listen to episodes 14 through 16 of this podcast to hear an in depth look at how this all went down and how morbidity and mortality rates are still so much higher in black men and women for many diseases because of century old approaches to healthcare delivery.

So. PAUSE Lots of factors are working against developing trust between a doctor and patient – to recap, trust is not an automatic and takes time, the system itself doesn’t value you having that time, the system is whacky and dysfunctional but that doesn’t mean that the doctor is too, and if you’re a person of color you have centuries of mistreatment to somehow work past.

Why is this important at all, you might be wondering? You might think I just go to my doctor when I need something, I’m not their friend, so what does it matter? It turns out that having trust for your doctor does affect your health. Research has shown that patients who report greater trust in their doctor tend to have better adherence to treatment recommendations, are more likely to follow preventive health advice, and have higher continuity of care, sticking with the same doctor and practice over time. So building trust doesn't just feel good - it's associated with real, measurable benefits in patient behavior and outcomes."

I’ll never forget how during the pandemic so many friends and family members called me to ask whether they should get the covid vaccine. When I asked them, “did you ask your doctor what they thought?” most said, “no, why would I? I barely know them” OR “it didn’t even occur to me”. Hopefully there won’t be another pandemic in our lifetime, but something else will come up at some point that you want direction on, related to your health, and wouldn’t it be awesome to have a doctor that you trust enogh that you simply believe what they say and follow their advice?

Also, I think that as the healthcare system becomes more complex and convoluted, and more middlemen come into the process, the average patient starts drowning in the administrative shortcomings of the system just as much as the doctors are. So in these times I argue that working on strengthening these relationships becomes even more essential, and is one of the few things about the healthcare system that is actually in your control. Does that surprise you, by the way? That you have a little say in your relationship with your doctor? I mean, you probably do. I say probably because there are more offices, clinics and systems today than ever. I AM at my core altruistic and optimistic and hope that all doctors actually want a relationship back with you. Maybe I’m wrong and yours doesn’t. And if that’s the case, I’m really sorry and that sucks. You can accept that or switch doctors and find someone who more closely aligns with your values on this. I did something like that recently that you can hear about in episode 17 called Big Hospital Breakup.

Back to some things being in your control. Here are some steps you can take towards building trust with your doctor to get you started. 

1.     Be truthful. I can’t stress this enough. It’s really common for people to purposely not tell the whole story to their doctors, whether because they’re embarrassed about something or are worried about being judged. But in reality, we’ve heard it all. And a good, caring doctor does not judge. They simply want to help. If you’re withholding a truth from them, you will not receive as great of advice, and YOU are not investing in the relationship. Trust requires honesty.

2.     Don’t see a different doctor because it’s more convenient for you. If you want to get to know someone and for them to know you, you have to see them multiple times, and that sometimes might mean that you go at a less convenient time or day, or have to wait a little longer. I’m not AT ALL suggesting that if you urgently need care that you don’t get it in the name of continuity. I’m saying when the timing isn’t a huge factor, and you have a choice, which I acknowledge is not often the case, try to stick with the same person. If they just don’t have any availability, consider sending them an electronic message or leaving a phone message that you’re doing your best to see them to keep up the relationship, but can’t get in. And ask if they have a suggestion. This has at least a slim chance of working. Just remember, each time they see you, they know you and your health a bit better. 

3.     Ask them about how they are, their life. I mentioned this to someone the other day and at first they thought I was nuts. “Why would I do that?!” they asked. “It’s not like we’re friends”. Right, you’re not friends, but you ARE in a relationship, albeit a somewhat weird one because you’re telling someone that you don’t know very well some incredibly personal things about yourself. By asking them about THEMselves, you show that you care about them as people, and as human beings with emotions just like you. Trust requires mutual understanding.

4.     Ask questions: If you don't understand something, ask for clarification. Engage in a dialogue with your doctor to ensure you're on the same page.

5.     Follow through on agreed-upon plans: If you and your doctor decide on a course of treatment, follow the recommendations. If you have concerns or side effects, circle back and discuss them with your doctor.

6.     Provide feedback: If you have a positive experience, let your doctor know. If you have concerns, raise them constructively.

7.     Show some respect for the relationship itself by giving visits your full attention. Silence your phone and don’t take calls and texts while you’re together. And, show up and show up on time. This demonstrates that you value your health and your doctor's time. Respect for each other builds trust.

8.     Ask them how you should communicate with them about different things. Think of this as setting out the terms of your relationship. Some doctors prefer the EMR. Some prefer a phone call. Some unicorn doctors might even have an email to give you. Getting the communication basics down will help establish trust because you are more likely to be able to reach them if and when you need them. Relability and dependability are integral to developiong trust.

9.     Be respectful: Treat your doctor and their staff with courtesy and respect, even if you're frustrated or upset.

10.  Lastly, maintain realistic expectations: Recognize that while doctors have extensive training and experience, they're not infallible. Medicine is complex and not always exact.

 Beyond these concrete steps you can take, there are other things that patients state make them trust a doctor more, like what a doctor’s reputation is, whether they’re affiliated with a medical center or university, what their level of experience or number of years in practice is, whether they have a title of professor, if they display sensitivity when giving bad news, how much time is given, showing respect for patient’s opinion about a plan, and being open minded to being asked questions. Also, some of this is just based on personality. The truth is, every patient won’t like every doctor AND vice-versa. Some patients like a doctor who tells it like it is with no frills. Some like a hand-holder or a hugger. Some like a paternalistic type of doctor and some don’t. So personality, which is sort of out of everyone’s control, probably also plays a role in trust. I think. I mean, would you trust someone you dislike as much as someone you like? [pause] I guess I’m not sure. Some people might be able to separate personality out of it better than others and can say “I don’t like this doctor, but I trust them.” I’ll finish with saying that this is something you need to work out for yourself.

Also, this is not all up to just you, by the way. There are some things that a doctor can do on their end that might help foster trust right off the bat, and these are actually taught and evaluated in medical school and sometimes, though probably not often enough, evaluated during their training years. I’m not going to go more deeply than just listing these, since this will end up being some other episode. But some examples are: making eye contact while speaking to you, facing the patient while speaking, explaining what they’re doing as they do things, sitting down during a visit, paraphrasing what patients say to show that they’re listening and get it. I think it will be really interesting to see if there’s a difference in how the current graduates of medical schools interact with their patients, as I’m told that they did not get to do as much in-person shadowing of great clinicians, which is one of the ways that they learn, because of the pandemic restrictions.

 To wrap up, we’ve talked about what trust is - that you can rely on your doctor’s words and actions, and have faith that they have your best interest in mind. We’ve talked about how I think it probably leads to better long term health, and I outlined some steps that you can take to work on this part of the relationship with your doctor. Take it from here and see if you can foster some more trust between yourself and your doctor.

If you enjoyed today’s episode, please let me know by leaving a review on any of the podcasting sites. Also, in case you didn’t know, you can read more about these topics on my website where I randomly write blog posts about some of the episodes. And there’s a new tab coming on the website that will house resources and links from all of the prior episodes. Lastly, sign up for my newsletter through that same website, www.drpatientpodcast.com so that you can be notified when new episodes drop and get a tip on navigating the health system with each one. Thanks for listening everyone.