Guest pen
Skepticism is healthy, but in medicine it can be dangerous
Our medical system depends on trust, both in in-person consultations and public health communications.
Recently, I arrived at the hospital in the morning to find a team of doctors gathered outside a patient’s room. The patient was in a precarious situation, his breathing was too fast and shallow. For days, we tried to balance relieving the pain the cancer caused and prolonging his life.
We are at a crossroads in the medical field regarding public trust.
During the night, it got worse. His family, faced with the inevitability of his death, had devised a tentative plan, and I had to make sure his wife understood what was about to happen. I explained that if we inserted a breathing tube into her husband, as she had decided we should do that night, we would have to sedate him. When the rest of his family arrived in Boston, we would remove the tube and he would pass away. We couldn’t wake him up…doing so would only cause him suffering.
At that comment, his wife became tense. Why couldn’t he wake up? I explained to him that the cancer was so advanced that if we woke him up, he would have the conscious sensation of drowning. I watched her as she analyzed me, this doctor who I didn’t know before today was telling her something she didn’t want to hear. Her expression changed. “Why should I believe you?” she asked me. Then her voice became firmer: “I don’t think I believe you.”
The room fell silent. My patient’s wife rummaged through her purse, looking for a handkerchief. I looked down at my feet. Why should you believe me? She was wearing sneakers with my scrub pants, and I suddenly wondered if she would have trusted me more if I looked more professional, or if she were older or a man. Maybe, but there were more important things at stake at that moment. This wasn’t just about a doctor and a family member, but about how society no longer views the medical system as a trusted institution.
We are at a crossroads in the medical field regarding public trust. In the wake of a pandemic that distorted science to benefit political interests, it is no surprise that trust in medicine is weakening. In fact, trust in medical scientists has declined to its lowest levels since January 2019. As a result, more people are seeking out less conventional voices of “authority” that are closer to their beliefs. Robert F. Kennedy Jr., a longtime vaccine skeptic and US presidential candidate, has double-digit support in some polls and has made medical freedom a recurring theme in his candidacy. .
However, our medical system depends on trust, both in in-person consultations and public health communications. Distrust can cause physicians to burn out and lead to negative outcomes for our patients that could be avoided. This is partly what drives rising rates of measles among unvaccinated children, trends toward not getting recommended cancer screening tests, and refusals to take life-saving preventive medications. This does not have a simple solution. But if we don’t find ways to regain and strengthen our patients’ trust, more lives will be lost.
This is relatively new territory for American doctors. When I was in medical school, we didn’t talk much about trust. In my early years as a doctor, I barely trusted myself and, in fact, felt uncomfortable shouldering the responsibility of keeping my patients alive. Until recently I started thinking about what happens when that ephemeral ingredient in the doctor-patient relationship is lost.
Medical skepticism is not the same as medical nihilism. We don’t have to be the only ones who know the data behind the medications we prescribe and the decisions we make; The public has the right to review the figures and make their own decisions about the risk and benefit involved. But when skepticism turns into abject, irreparable disbelief, we see some patients make dangerous decisions. And when we doctors respond with frustration, that only separates us further from those patients.
Sometimes trust can be restored by sharing clear facts and figures, but this goes beyond explaining some numbers. We tell our patients things about the body that cannot be seen with the naked eye. We recommend lifestyle changes and medications to treat or prevent problems they may not feel. Surgeons resort to a deep version of trust called a surgical contract: the idea that when people have an operation, they allow their surgeon to make them sicker—that is, to cut out and operate on part of their body. their body—in order to make them feel better. That trust has to be earned.
In emergencies, patients do not have the luxury of choosing who to trust, and medical decisions must be made quickly, even within minutes. So part of our job is to build empathy quickly. That becomes more difficult, or even impossible, when we enter the climax of a medical crisis only to discover that what little confidence our patient once had is now gone. Many of our patients began their health experience wanting to believe in their doctors. But then the medical system they wanted to rely on failed them, in ways small and big, from randomly rescheduled appointments to actual medical malpractice. How do we, as professionals and individuals, begin the repair process when time is short?
In medicine, we talk about the idea of shared decision-making, in which medical decisions are made jointly between the doctor and the patient, in contrast to the paternalistic tone of yesteryear. As doctors, we do not tell our patients what to do, but rather we offer them the information necessary for them to choose the path that is right for them.
All our training and medical knowledge is of no use if our patients are not willing or able to believe in what we offer them. And this is not our patients’ fault, no matter how much it may bother us. It is the fault of a system that does not deserve the blind faith of our patients, of a surrounding political environment that has turned scientific facts into fiction for many people.
This is how I arrived in that room, that morning, in front of my patient’s wife, her disbelief and the weight of the decision that carried the air between us. He knew her so little. I didn’t know her history or her interactions with the medical system. She did not know her husband’s history of diagnosis and treatment, or whether she had had trouble finding treatments for cancer. In our fractured system, I met her just that day. I had no recourse to get her to trust me except to sit with her, give her what little time we could with her husband, and hope that, no matter what had happened before, she would choose to believe what I was telling her.
I’m not sure what she believed, but she decided to refuse intubation. Her husband remained alive until the rest of his family arrived. And when he passed away, everyone left without saying anything, carrying with them bags of belongings and—I hope—the faith that we did everything we could.
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