I arrived at the hospital one recent morning to find a team of doctors gathered just outside a patient room. The patient was struggling — his breaths too fast and too shallow. For days we had been trying to walk the line between treating the pain caused by his rapidly growing cancer and prolonging his life.
Overnight he had worsened. His family, wrestling with the inevitability of his death, had come to a tentative plan, and I needed to make sure that his wife understood what was ahead. I explained that if we inserted a breathing tube, as she had decided overnight, her husband would be sedated. When the rest of their family arrived in Boston, we would take out the tube and he would die. We would not be able to wake him up — to do so would only cause him to suffer.
At this, his wife stiffened. Why wouldn’t he be able to wake up? I explained that his cancer was so advanced that to wake him would be to give him the conscious awareness of drowning. I watched as she took me in, this doctor she had never met before, telling her something she did not want to hear. Her expression shifted. “Why should I believe you?” she asked me. And then, her voice toughening: “I don’t think that I do.”
The room was silent. My patient’s wife looked into her bag, rooting around for a tissue. I glanced down at my feet. Why should she believe me? I was wearing sneakers with my scrub pants, and I found myself wondering whether she would have trusted me without question if I appeared more professional, or if I were older or male. Perhaps, but there was so much more at play in that moment.
This was not just about one doctor and one family member, but instead, about a public for whom the medical system is no longer an institution to be trusted.
We are at a crossroads in medicine when it comes to public trust. After a pandemic that twisted science for political gain, it is not surprising that confidence in medicine is eroding. This was not about one doctor and one family member, but instead, about a public for whom the medical system is no longer an institution to be trusted.
As a result, more people are seeking out less conventional voices of “authority” that hew closer to their beliefs.
Robert F. Kennedy Jr., a longtime vaccine skeptic campaigning for the presidency, is finding double-digit support in some polls and has made medical freedom a recurring theme of his candidacy.
But our medical system relies on trust — in face-to-face meetings as well as public health bulletins. Distrust can lead doctors to burnout and can encourage avoidable negative outcomes for our patients. This is partly what is driving increasing rates of measles among unvaccinated children, failure to follow recommended cancer screening and refusal to take lifesaving preventive medications. There are no easy solutions here. But if we do not find ways to restore and strengthen trust with our patients, more lives will be lost.
This is relatively new terrain for American physicians. When I was in medical training, we did not talk much about trust. During my early years as a doctor, I barely trusted myself and in fact felt uncomfortable with the responsibility I had to keep my patients alive. Only recently have I found myself thinking about what happens when this ephemeral ingredient in the doctor-patient relationship is lost.
Medical skepticism is not the same as medical nihilism. The data behind the drugs doctors prescribe and the decisions we make need not be the purview of us alone; the public has the right to review the numbers and to make their own decisions about risk and benefit.
But when that skepticism shifts into abject and irreparable disbelief, we see some patients make dangerous decisions. And when doctors respond with frustration, that only further separates us from those patients.
Trust can sometimes be repaired by clearly presenting facts and figures, but it is about more than explaining numbers. We tell patients things about the body that are unseen. We recommend lifestyle changes and medication to treat or to prevent problems that may not be felt. Surgeons refer to a profound version of trust called the surgical contract: the idea that when people go under the knife, they are allowing their surgeon to make them sicker — to cut them open — in order to make them better. That trust must be earned.
In emergencies, patients don’t have the luxury to choose whom to trust, and medical decisions must happen hastily, in minutes even. So part of our job is to build rapport quickly. That becomes harder, impossible even, when we enter into the climax of a medical crisis to find that whatever trust our patient may have once had long ago has since been eroded.
