Trust First

Dr. Aaron Stupple is a resident physician in internal medicine at Beth Israel Deaconness Medical Center. He is a founding member of Who’s My Doctor. Follow @astupple.

Leana Wen’s
Who’s My Doctor? campaign is an important step to help health care. Detailed on her blog as well as recently on KevinMD, she endorses a total transparency manifesto where physicians can describe their sources of revenue and other potential conflicts of interest. It’s an effort to build trust.

We can’t fix health care without patients’ help. A quick look at the numbers for chronic disease are compelling enough—
half of Americans have at least one chronic disease, and it accounts for 75% of all health care costs. If we don’t make an impact there, we really won’t make an impact at all.

The trouble with chronic disease is that it depends so heavily on behavior—eat well, exercise, don’t smoke, and take your meds every day. Until we can truly engage patients, we will struggle.

How do we engage patients? How do we get them to literally restructure how they live their lives? How do we get them to agree that they have a disease, that they need to swallow pills every day and risk the side effects, that they need to fit in time for exercise, that they need to arrange with family and friends and coworkers different ways to eat, to not smoke? If we truly want them to get better, we’re truly asking the world. We’re asking them to adopt our world, on our say so. Doctor’s orders.

We simply can’t do it if they don’t trust us.

If we have an obligation, a professional and moral contract with society, to which we swore an oath, and for which society has granted us privileged knowledge at great personal and civic cost, then we need to demonstrate our trustworthiness to our patients.

There’s no one way to do this. But Leana Wen
has offered an excellent place to start: declare, openly and publicly, the totality of our agenda. The truth is, we don’t have to be a foot soldier for a pharmaceutical company to have an agenda.

A patient came to see me the other day, and I was in a fantastic rush. I was behind in my clinic schedule, and I was set to deliver a lecture to our medical students in five minutes. Thankfully, my last patient only needed a tuberculosis skin test. As I hurried about setting things up, he mentioned he was having a lot of stress. I asked him if it was impairing his ability to live and work, and he said no. The calculator in my head told me that the stress in this otherwise healthy young man’s life couldn’t be thoroughly addressed in this one visit, that he’d get his day’s value with the skin test, and I could make it to my presentation on time.

Watching my vigorous preparations, he apologized for taking up my time.

I realized that I had allowed my own desire to be an important teaching figure to supersede his need for health care. Apologizing for my rush, I sat down and listened to him tell me about the causes of his stress. We had a long chat, and afterward I gave him some perspective that he genuinely took to heart. I emailed my powerpoint to the med students.

In the busy life of medicine, establishing trust is hard. The forces that inform our priorities as physicians are often subtle. If nothing else,
Dr. Wen’s transparency campaign offers us an opportunity to reflect on those forces. Rather than a threat, I see it as one of many tools that I can use make patients comfortable with what I’m asking them to do.