Tag: Trust

Ms. Meyer was standing in the center of the room, arms crossed. Smartly dressed and thin, she lived in one of the affluent Philadelphia suburbs – on “the Main Line” – and it showed, in her subtle but clearly expensive jewelry as well as her demeanor. She looked out of place in my resident-run medical clinic, which primarily catered to less wealthy inhabitants of West Philadelphia. But what struck me most was the emotion that radiated from her. Ms. Meyer was angry. “What brought you here today?” I asked her, using my standard first question. Later in my career, I would learn to replace that line with something more open: “How can I help you?” or even “Tell me about yourself.” But it hardly mattered.

She was exhausted, she said. Almost no energy. So drained she could barely get out of bed. Unable to focus during the day, she tossed and turned all night and repeated the cycle day in and day out. It was, she said, simply untenable. I asked how long it had been happening.

One of the most important skills a doctor has is to read the room. So I switched from respectful listening to diagnosing. I tried to troubleshoot symptoms of possible thyroid dysfunction, anemia, sleep apnea, lymphoma and other cancers. I asked about her family history, her history of drug or alcohol abuse, her sexual history. I even made sure I didn’t miss questions pertaining to pregnancy, because (this one comes from experience) you should never assume someone isn’t pregnant. I reviewed her lab work: Pages upon pages of blood and urine tests. Even CT scans of the head, chest, abdomen, and pelvis. Nothing was out of order. Nothing that we can measurein a lab or in the belly of a CT scanner, at least.

But her affect was off, and her mood was sad. Ms. Meyer seemed, frankly, depressed. There is a formal way to diagnose major depressive disorder; a patient must display five of nine classic symptoms (such as loss of interest in activities they used to enjoy, fatigue, or weight changes). Ms. Meyer had eight of nine, a clear-cut case of major depression, according to the diagnostic manuals. But was it depression? Or was it something else, and the frustration of living with that something else had led to depression?

I didn’t see her for another year. When I did, she was having a seizure in the emergency room, the result of a “water cleanse,” anaturopathic practitioner had prescribed. Forcing herself to drink gallons of water a day, she had diluted the sodium content in her blood. When her sodium level got too low, her brain could not appropriately send electrical signals, and seizures ensued. She would survive, thankfully, and tell me later that she had never feltbetter. She had been told all her problems were due to heavy metal toxicity. (Lab work would not confirm this.) This diagnosis had led her into a slew of questionable medical practices, including regular “cleanses” and chelation therapy – where substances similar to what you might find in water softening tablets are injected into the blood to bind harmful metals. Chelation therapy runs around $10,000 to $20,000 per year and is not covered by insurance.

The striking thing was that she positively shone with confidence and hope. Lying in a hospital bed, recovering from life-threatening seizures, she was, in a word, happy.

Why were people turning to their family and friends or social media for medical advice when physicians are willing and able to provide the best possible information? Was it simply the cost of healthcare? Or was something deeper going on? And though it took time, what I figured out will shine a light on why doctors have lost touch with their patients, why patients have lost faith in their doctors, and how we can get back to that therapeutic alliance that we all need in order to be truly healthy. That is what this book is all about.

It turns out the most powerful force in Medicine is not an antibiotic. It isn’t stem cell therapy, genetic engineering, or robotic surgery. The most powerful force in Medicine is trust. It is the trust that lives between a patient and a physician, and it goes both ways. I trust you to tell me the truth about how you feel and what you want. You trust me to give you the best advice I can possibly give. We trust each other to fight against whatever ails you, physical or mental, to the best of our abilities. Ms. Meyer did not trust me. That was my failure, not hers. And that personal failure is a mirror of the failure of Medicine writ large – our failure to connect with patients, to empathize, to believe that their ailment is real and profound, and to honestly explain how medical science works and succeeds, and why it sometimes doesn’t. We doctors have failed to create an environment of trust. And into that vacuum, others have stepped.

It’s not entirely doctors’ fault, of course. The average primary care physician has less than fifteen minutes to conduct a typical new-patient visit. If the doctor doesn’t stick to that time, the practice will go out of business – overwhelmed by payments for malpractice insurance, overhead, and dwindling reimbursements from insurers. It’s hard to create trust in fifteen minutes. Combine our limited schedules with a seemingly unfeeling healthcare system, which sometimes charges thousands of dollars for an ambulance ride to the hospital and tens of thousands of dollars for even routine care, and it is no wonder why, according to a study in the New England Journal of Medicine, trust in physicians is lower in the United States than in twenty-three other economically developed countries.

While the healthcare system and physicians are not synonymous, physicians are the face of that system. In earlier times, we ran that system. It is no longer the case. Most physicians haven’t realized this yet, but we are no longer a managerial class. We are labor, plain and simple, working for others who, without medical training but with significant business acumen, use our labor to generate profit for companies and shareholders. Part of the key torestoring trust between patients and doctors is for all of us to start fighting to reform the system. And doctors should be on the front line of that battle.

There is a right way and a wrong way to earn someone’s trust.One key lesson in this book is that it takes a keen observer to tell thedifference. Honesty, integrity, transparency, validation: These are good ways to create trust, and physicians need to commit to them wholeheartedly if we ever want our patients to take us seriously. Patients need to commit to honesty and transparency as well, even when the truth is painful. But less-than-scrupulous individuals can also leverage certain cognitive biases to create trust in ways that are manipulative. Trust hacking like this is a central reason modern medicine has lost ground to others who promise a quick fix for what ails you. It’s important not only to evaluate your own methods, but also to be able to spot whether someone is trying to earn your trust in an ethical way, to spot bad actors whose intentions may have little to do with actually helping you.

There are several ways to hack trust. One is to give an impression of certainty. The naturopath who treated Ms. Meyer was unambivalent. He told her exactly what was wrong with her: heavy metal toxicity. There was no long list of potential alternative diagnoses, no acknowledgment of symptoms that were typical or atypical for that diagnosis. He provided clarity and, through that, an impression of competence. To know who you can truly trust, you have to learn to recognize this particular trick – you have to be skeptical of people who are overly certain, overly confident. Health is never clear-cut; nothing is 100 percent safe and nothing is 100 percent effective.

Anyone who tells you otherwise is selling something. This book will show you how to grapple with medical uncertainty and make rational decisions in the face of risk.

Traditional doctors like me are trained early on to hedge their bets. Patients hate this. Ask a doctor if the medication you are being prescribed will work, and they will say something like “For most people, this is quite effective” or “I think there’s a good chance” or (my personal pet peeve) “I don’t have a crystal ball.” This doctorly ambivalence is born out of long experience. We all have patients who do well, and we all have patients who do badly. We don’t want to lie to you. We’re doing the best we can. And, look, I know that this is frustrating.

Neil deGrasse Tyson, the astronomer and brilliant science communicator, once wrote, “The good thing about Science is that it’s true, whether or not you believe in it.” When it comes to the speed of light, the formation of nebulae, and the behavior of atoms, this is true. The laws of the universe are the laws of the universe; they “change” only insofar as our tools to study them have improved. But Medicine is not astrophysics. It is not an exact science. Or if it is, we have not yet explored enough of the nooks and crannies of the human machine to be able to fix it perfectly.

This skill, consciously avoiding the cognitive bias known as “motivated reasoning” (the tendency to interpret facts in a way that conforms with your desired outcome), is challenging for all of us – doctors included. But it is probably the most critical skill to have ifyou want to make the best, most rational choices about your health. The answer you are looking for might not be the right answer. That’s why we will discuss, right in the first chapter, how before you know who else to trust, you have to learn to trust yourself.

The community of people vying for your trust is truly massive. It spans individuals from your neighbors and your friends on social media to the talking heads on the nightly news. All of them are competing in a trust marketplace, and not all of them are playing fair. A smattering of recent headlines illustrates the overwhelming amount of medical-sounding “facts” you may have been exposed to: coffee cures cancer; depressed mothers give birth to autistic children; marijuana is a gateway to opiate abuse; eggs increase the risk of heart disease; eggs decrease the risk of heart disease. Each day, we are inundated with confusing and conflicting headlines like these, designed more to shock, sell, and generate clicks than to inform. I will give you the skills to figure out what health information can be trusted and what is best left unliked and unretweeted.

The information age brought with it the promise of democratization of truth, where knowledge could be accessed and disseminated at virtually no cost by anyone in the world. But that promisehas been broken. Instead, the information age has taught us that data is cheap but good data is priceless. We are awash in bad data, false inference, and “alternative facts.” In that environment, we are all – doctors and patients alike – subject to our deepest biases. We are able to look for “facts” that fit the narrative of our lives, and never forced to question our own belief systems. If we can’t interrogate the quality of the information we’re consuming, we can’t make the best choices about our health. It’s that simple.

When you read this book, you’ll learn that doctors aren’t perfect. As humans, we have our own biases. Rigorous studies have shown that those biases lead to differential treatment by race, sexual orientation, and body mass index. While most physicians are worthy of your trust, not all of them are. I’ll teach you how to recognize those who aren’t putting your interests first.

It’s not wrong to be skeptical of Medicine. Medical science has been developing, evolving, and advancing for the past one hundred years, and has had many stumbles along the way. Scandals from the repressing of information about harms linked to Vioxx (a drug that was supposed to relieve pain), to the effects of thalidomide in pregnancy (which was designed to reduce nausea but led to severe birth defects), to the devastating heart problems caused by the diet pill fen-phen remind us that the profit motive can corrupt the bestscience. Alleged frauds like the linking of the measles, mumps, and rubella (MMR) vaccine to autism diagnoses pollute the waters of inquiry, launch billion-dollar businesses, and leave the public unsure of what to really believe.

Here we stand, in the midst of a torrent of information that would have been inconceivable thirty years ago. Some of it is good, some is bad, but all is colored by our own biases and preconceptions. Decisions about your health happen every single day. If you want to be in control, you need to know how to separate the good from the bad, whether it comes from someone sitting atop the ivory tower, or from your friend on Facebook. This book is about medical science. But it’s really about learning to trust again. When you finish reading it, you will no longer be swayed by the loudest voice, the most impassioned plea, or the most retweeted article. You will be able to trust your doctor, trust yourself, and trust Medicine – our imperfect science and the single greatest force for good in the world today.

Excerpted from the book How Medicine Works And When It Doesn’t: Learning Who to Trust to Get and Stay Healthy by F. Perry Wilson, MD. Copyright 2023 by F. P. Wilson, MD. Reprinted with permission of Grand Central Publishing. All rights reserved.