My last patient of the day had been to four other doctors before coming to see me. She was coming in for abdominal pain that had been going on for about two years and had seen multiple specialists that resulted in multiple tests, in hopes to get an explanation for her symptoms. She came in wanting answers, but also skeptical of me. Skeptical of my ability to help her, skeptical of my expertise, skeptical of me even caring. She did not trust that I have the tools, capability, desire, and empathy to care for her, listen to her, and help her. She had never met me, but her experiences thus far had led her to her current state of belief, or lack thereof.
Just as trust is vital for an infant’s survival, it is a vital part of provider-patient relationship. Historically, physicians were regarded as very trustworthy in the public eye and their advice was sought out and respected. Over the years, this level of trust in physicians has declined, and since the start of the COVID-19 pandemic until just last year, the percentage of people that trust their health care provider has dropped by 30 percent. This is a drastic fall, during a time when health care professionals (both practitioners and public health officials) should have been sought out for expert opinions and guidance of how to navigate the pandemic based on their knowledge of scientific evidence and incoming research.
Why, over the years, has there been a decline, and why, during one of the largest pandemics in history, did trust in scientific professionals drop even further? Why does it continue to do so every day? While it would be nice to have a single root cause, which could be addressed easily and the trust restored, this unfortunately is not the case. The decline of trust is multifactorial, complex, and involves some things we can pinpoint and some we still don’t understand.
Health care has drastically changed over the years. Doctors used to make home visits, treat the entire family, treat almost every problem a patient had. They were even considered extended members of the family. They were regarded as healers. They were not burdened by loans, the need to meet RVUs, and did not have to worry about the coverage of the prescriptions they wrote. There was no big pharma, no social media, no discordance with the government. As people are living longer, the disease burden increases and how to prevent, manage and treat them becomes more complex. Conducting good research is difficult enough and the multifactorial nature of disease processes makes definitive answers sometimes impossible. Combine that with the need for immediate answers about why something is happening or how to deal with it, misinformation, disinformation, and the politicization of health care, you have the perfect recipe for distrust in our health care system.
The multi-faceted root of distrust so many patients have, has led to many patients coming to the offices with skepticism and leaving placated at best, but often disappointed and dissatisfied. While the resolution of this may seem daunting and almost impossible to achieve, the reality is we as health care providers must work both individually and collectively to re-establish the trust. There is no room for failure in this. We need to think of trust as a determinant of health; without it, we cannot provide the care that we want to, the care that led us to wanting to be health care providers in the first place. Without it, the patient’s health suffers.
We need to listen, ask questions, find out the path patients were on before seeing us, in order to understand where they are at. We need to be culturally curious and competent. We need to learn our implicit biases. We need to learn what platforms are being used by different age groups, genders, and ethnicities to obtain health information. We need to connect with our patients. We need to look at them while talking. We need to show them we care, not just assume they think it is a given. We need to include them in the decision-making process, hear their goals, hear their concerns, hear their limitations when it comes to their care plan. We need to learn to have a conversation and ensure they feel comfortable, cared for, seen, and heard. This is in our power as a health care provider, and while so many other things that have led up to the state of distrust (things that may seem much more difficult to address, and quite frankly, bigger than us), the interactions we have with our patients can be under our control and guided by our words and actions.
When I was applying to medical school, my naïve self did not realize my ability to help people in the future would be so drastically shaped and impacted by forces bigger than me. Impacted by policies, institution finances, insurance companies, burnout, patient finances and even the zip code in which a patient lives. My naïve self had no idea that a patient believing what I had to say when it came to their care, believing that I was on their side and wanted to help them would ever be an issue. My naïve self did not know much about the social determinants of health, or the non-medical factors that influence health outcomes, and I never imagined that trust in our provider or health care system would end up being in this category.
I hope we all can be a part of a movement towards re-establishing that trust, that provider-patient relationship. The relationship that will ultimately make my patient with chronic abdominal pain not feel like she had to doctor shop, not feel unseen or unheard. The relationship that will ultimately lead to addressing her root cause and hopefully resolution of her symptoms. Whatever is in our control, we have to take ownership and create the vision we had when we started training as our naïve selves.
Mansi Kotwal is a pediatrician.
