The Medical Trust Gap
In 1985, my medical school professor led our class astray. “Anti-viral science,” she said, “gets better every year. We did a great job with polio, but by the time the next pandemic rolls in, we’re gonna crush it.” In the past two years, her words have clanged in my head like an alarm in an empty firehouse. As the death toll from COVID-19 grew, I realized we were not prepared to put this fire out.
What the hell happened?
The truth is, my professor was spot on about the science. Decades of preliminary work put us in just the right place to quickly develop an mRNA vaccine to target the virus that had targeted us. Then an unforeseen ingredient fouled the formula—mistrust.
In early 2022 as Omicron raged, I sat in a tiny exam room and stared at my patient’s dad, whose face mask sat squarely under his chin like a facial push-up bra. “Please put your mask back on.” He was the third person I had to admonish in that morning’s clinic, and he looked as annoyed as I felt. I held my tongue. The words on the tip of it felt stale. I understand where he’s coming from, but despite our collective hopes and desires, the pandemic is simply not over.
He grumbled at me as he adjusted his mask. “It’s all a hoax, anyway.”
I shifted the N-95 mask across the painfully chafed bridge of my nose. We’d been asked to be gentle and empathetic in our response to these challenges. Instead of responding to the man, I turned and addressed my patient, a teenager I’ll call Tiff. “Are you vaccinated?”
“No,” she said. Then pointing her finger at her dad, “He won’t let me.”
I nodded and turned to her father. “I’m vaccinated. So are my kids and my wife. Is there something specific that’s holding you back?”
He ran through the “blood clot” speech and then moved to the “heart inflammation” story about a friend of a friend’s relative. I sat down before presenting him the data on thrombosis and myocarditis being ten times more common in those who had a COVID infection than in those who received the vaccines. He just shook his head. “It’s no worse than a cold.”
I’d been caring for Tiff for over two years. He’d been comfortable enough with my care to bring her back a half dozen times, yet here he was, doubting every word I uttered.
Welcome to the medical trust gap: the distance between data and doubt. When the gulf grows unbridgeable, rational debate is doomed. As a physician of thirty-plus years, I think back on how we got here. I’ll start at the beginning.
There’s a light grey line etched deep into the rock layers of earth’s history, an inch-wide border that spans the globe. (When I said the beginning, I meant it.) This is the K-Pg boundary, the chalk outline of earth’s murdered dinosaurs. The culprit, a six-mile-wide meteorite that slammed into the Yucatan 66 million years ago. Perhaps our human history books will include a chapter on today’s “B-C” line, the marker between the “Before Times” and “COVID times.” Instead of a city-sized meteorite, we were slammed by a microscopic virus.
Two years into this latest pandemic, the world has seen over 400 million cases of COVID-19 and lost roughly 6 million people (likely an undercount on both fronts). Some say the staggering loss of life in the U.S. (currently past 921,000 lives) and the suffering of their families and those with long-haul symptoms were inevitable. As a physician, I’ll admit that illness and death are an eventual part of life, but in the case of COVID, many among us deliberately chose to speed up the process.
Now, to the finger-pointing. Who can we blame? Politicians, media, conspiracy theorists? Certainly, they own a substantial share of this fiasco. As to the role of our healthcare system; my father used to say, when something goes wrong, figure out what portion of the problem is yours, add ten percent for good measure, then own the sum.
We doctors do not represent the healthcare system as a whole, but we do bear some responsibility for this viral scourge. For thirty years, or more, we’ve fallen back from our responsibility to advocate for our patients first, our communities second, and lastly for ourselves. Our medical societies have morphed from educational and ethics headwaters to little more than political action committees, with a bit of teaching on the side.
According to The New England Journal of Medicine, our healthcare system has been losing the American people’s trust for decades. In 1966, 75% of the public had “great confidence” in the leaders of the medical profession. By 2014 that number had dropped to 23%. Yet, that same study showed 75% of people still had faith in their personal physicians. More recent polls show confidence stuck in the 30 to 40 percent range. Political affiliation skews the numbers even further. Are politics a sphere of physician influence? No, but we still own our portion of the trust gap.
Over the decades, too many of us physicians distanced ourselves slowly, inexorably, from the people we swore to care for—our patients. The word “patient,” derived from the Latin, means “to suffer.” Our careers have one purpose, to mitigate suffering, yet in today’s world, we constantly admonish our patients to “have patience!” Trust erodes under endless forbearance.
Even pre-pandemic, our patients had a progressively difficult time getting through to us. The frustrating interaction starts with our “front door,” a typically maddening phone tree, or a glitzy but unaccommodating website. “Communication,” I’ve told my students, “is 95% of medicine.” That dialogue isn’t just between healthcare providers; it begins with our patients’ ability to talk to us, to write to us, and to see us face to face.
The patient-doctor relationship has always represented an uneven power dynamic. I speak as a surgeon, who is also a patient. I’ve lived on both sides of the equation, both sides of the knife. When I hear my doctor simply acknowledge this tilted partnership, it goes a long way toward empowering me as a patient. It’s liberating to speak the words, “I’m frightened and frustrated.” And comforting to be heard.
We’ve relentlessly cut down on the amount of time we give our patients. The amount of time we paste our butts to rolling stools and just listen. We use the word “efficiency,” a code word for “dollars.” Insurance premiums have far outpaced inflation, year after year. Employees tend to see insurance as a “benefit,” a gift from their employer. In reality it comes from their income. And now, we add ever-increasing deductibles, hard cash pulled straight out of peoples’ wallets. Suddenly, the monetary pain is palpable and only adds to the pain that brought people in.
Over my career, the number of medical specialties has burgeoned to an unnavigable web. We now have sub-micro super-specialists who deal only with one part of one body system and don’t work past two o’clock. Super-specialists might be great for research and medical “progress,” but should we all specialize? If we trained one group of firefighters only to hook up hoses and another group only to drive the trucks, who would be left to put out the fire?
A primary care doctor, who struggles to see more patients each day, will oftentimes refer a slightly complex patient to the siloed and overtaxed specialists. If the specialist determines they are not the right doctor for this patient, they flip the patient back to the primary physician or toss them into another silo, hoping the next doctor can “figure it out.” The system is inefficient, costly, and downright cruel. A system like this never breeds trust.
Then there are ads in the media, implicitly telling people not to trust their doctor. The pill and potion pushers urge their audience to “Ask your doctor, ask your doctor….” The unstated statement, “Because your doctor is holding out on you.” Distrust dished up with a fast-spoken disclaimer.
Hospitals situated three-thousand miles away advertise in my hometown, inferring, “Your local hospital is not up to the task.” And for dessert, a plate of sugar-coated doubt.
To be clear, I am not saying all doctors are greedy and only look after their own interests. Still, the system has become so disjointed, so unaccommodating, it feels as if we’re all trying to deliver care on an ice rink, without skates. Each of us stuck in separate corners. Families have legitimate questions like, “Who’s gonna manage my mom’s seventeen medications from her six different doctors?” Only to hear a frustrating response, “Sorry, but it’s not me.”
It is my generation of physicians that fell back, year after year, in front of a wave of business-minded administrators who told us they knew how to make healthcare more efficient and affordable. Thirty years later, U.S. healthcare leads the world in dollars spent by almost two times our nearest rival, and for all those dollars, we rank 44th in life expectancy. I might not be finance-minded, but I don’t think I’d invest in that stock.
How can people trust us when doing something as simple as getting an appointment can take weeks or months? Even then, it might be through the lens of a webcam. Then, when patients are granted an audience, it’s an all-or-nothing data dump. They feel the pressure to blurt out every detail because who knows when they’ll be seen again? Or they send an email to the doctor’s assistant who answers their question with a question.” Relationships take time and effort to build. And relationships are the soil in which trust grows.
Is it any surprise when COVID hit that forty percent of our patients shrugged at us and said, “No thanks, I’ll do my own research.”
How do we rebuild trust? We can start by changing the modern medical paradigm. U.S. Healthcare should never have been an open-air “market” where we hawk our wears, hoping to shout louder than the doctor one wagon over. Who has that helped?
Our free-market approach to medicine has been a cancerous failure, and the pandemic was the latest scan to show us how bad the prognosis is. The American people didn’t feel they could trust their doctors, so they turned to talking heads, snake-oil salesmen, and politicians for their advice on unproven treatments. If our seven to twelve years of training wasn’t enough to rank us more trustworthy than urine drinkers, we have a messaging problem.
In his brilliant treatise, ”Escape Fire,” (2002) Dr. Donald Berwick urged us to let go of a cumbersome medical system, so broken, it no longer serves its purpose. He compared our situation to the tragic story of thirteen firefighters who lost their lives trying to outrun a wildfire up a 76 degree mountain slope. Encumbered by the heavy equipment they’d been taught never to drop, they succumbed to their inability to see the novel problem for what it was. In the decades since Dr. Berwick’s warning, we’ve doubled down and inexplicably held on to our market-driven medicine at the cost of hundreds of thousands of needlessly lost lives.
The eye-opening loss of the public’s trust during this pandemic is another peal of the alarm bell. Will we heed it? If we’re to reclaim the high ground, we need to take responsibility for our profession’s wrong turn. It’s time to reject the trending substitute terms for the word patient. We don’t take care of “clients,” “customers,” or “members.” We’re not a Walmart. We’re not a country club. In the pandemic, people truly suffered. We all suffered. Our nurses and doctors did not weep for their “customers,” they wept for their patients. The people lost belonged to a family, and some were colleagues.
At the beginning of the pandemic, I thought this micrometer-sized virus, this common enemy, would bridge our growing political divide. I could not have been more wrong.
It’s time for something different, a unionization of sorts. The upcoming generation of physicians should band together and demand a change, not for more money, but for more time with their patients, more time to thoughtfully care for them. It takes time to avoid ordering expensive and unnecessary tests, images, and referrals.
Like all wildfires, this pandemic will burn itself out, but the level of destruction will hinge on the skepticism of those we’ve pushed to arm’s length. Trust is and has always been the currency of the medical realm. Over the last thirty years, thousands of families have granted me the privilege of caring for their kids, of whisking them off to an unseen surgical suite to mitigate harm through the tip of a knife. As I prepare to retire, the warmth in my heart glows not for a fancy car or house but from the audacious privilege of being granted this level of trust.
Ron Turker is a staff pediatric orthopedic surgeon for Northwest Permanente and Assistant Clinical Professor of Orthopedics, Oregon Health and Science University
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