Sunday, April 26, 2015

Grieving the Loss of Trust

We come here today to memorialize a time when medical care was based on a sacred trust.  This is a celebration of a concept so basic to care that for centuries, trust was the only aspect of medical care.  Before the advent of modern medicine, the sacred trust between a physician and a patient, and the physician’s knowledge and experience with helping a person through the illness journey was all there was.  There were no imaging exams and lab tests to make a diagnosis.  There were no effective surgeries, antibiotics and other modern medicines.  There was only the physician, laying on hands, able to predict the course of an illness, and staying with a person through their suffering. 
    
An article this week in Bloomberg Business Week reported on the increasing tendency of consumers to order their own blood tests.  While I am a staunch advocate of patient autonomy and of shared decision making, and believe that consumers should be able to order their own tests, as a physician I wonder why anyone would want to do so.  Lab tests are most useful when they are ordered for a specific purpose, understood by both doctor and patient, and when the results are openly discussed by a patient and a health professional.  I, as a physician, never order my own tests even though I understand how they are used and what they mean.  I trust my physician to work with me to order tests and to interpret the results together.  The objective, caring perspective of my physician is critical to me as I decide what to do about my ailments.  I suspect that this trend towards self-service medicine is a symptom of a larger malady – that being a loss of the trust that once defined medical care. 

At one time, the relationship that you had with your doctor and your nurse was seen as sacred.  You opened yourself up in every way, physically and emotionally to your health professional and believed that they would help you and have your best interest at heart in everything they did.  You truly bared your soul as well as your body in the hope that the physician would help you survive – even thrive – with the fragile vessel that is the human body.
 
But today, physicians are told that they must not have their total focus on you, the patient, but also on the population.  They are taught that they must adhere to the bio-medical rigidity in specific care paths and be efficient while doing so, rather than address the unique values and hopes of the individual they are treating.  Patients are told that they must take responsibility for their own care, must embrace self-service and use apps and the Internet instead of a trusted professional, all for their own safety and the greater societal good.   No wonder the trust is dying. 

Michael Millenson wrote a blog post this week entitled, “Parsing Patient Engagement: Better Compliance or Better Decisions?”  Michael is an expert on quality of care and rightly notes that quality care is not about technology but about how that technology is used in order to transform the health care experience.  He wrote, “Transformation in the doctor-patient relationship must recognize the importance of the medical evidence, the patient’s preferences and values and the doctor’s clinical experience.”  It is hard to see that in self-service lab tests. 

 A client at Accolade, my company which uses technology to put human relationships first, had a bad experience with a primary care physician.  The Health Assistant, who is that client’s trusted resource, came to me for help.  The client and his wife had seen a new primary care physician and believed that the physician had over-tested them for financial gain.  I reviewed the claims and found that all the ordered tests were consistent with a first new patient visit.  I then spoke to the Health Assistant and suggested that the real problem was that they did not trust this physician.  Upon further discussion with the Health Assistant who knew the client as a person, I learned that the client and his wife were relatively new to the United States, having emigrated from India.  The husband spoke heavily accented English and the wife spoke very little English.  The primary language in their household was Hindi.  We then found them a new primary care physician who was Indian-American and who spoke Hindi.  They loved and trusted their new doctor and no issue of testing for financial gain came up again. 


The sacred trust in health care is the secret ingredient that allows care to be effective.  The loss of trust that I see saddens me but also leads me to action.  For trust hopefully is not dead.  It is on life support but we can work to make it central to medical care once again.  To again quote Michael Millenson’s blog post, “clinicians—with a persistent nudge from patients and payers – will have to lead the transformation themselves.”  I include in the term clinicians, the professional Accolade Health Assistants, and all health professionals, not only physicians.  We must all lead the effort to ensure that trust remains a central element in all of our health care.  Without the trust, all of the apps, new tests and self-service options will only take us into worse and even more expensive care.