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Trust in Conversation

Hessel, Frances C.

doi: 10.1097/ACM.0000000000002892
Teaching and Learning Moments
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F.C. Hessel is a fourth-year medical student, Baylor College of Medicine, Houston, Texas; email: Frances.Hessel@bcm.edu.

An Academic Medicine Podcast episode featuring this article is available wherever you get your podcasts.

Author’s Note: The names and identifying information in this essay have been changed to protect the identity of the individuals described.

Mr. C had no interest in making eye contact with the sizable lineup of “penguins,” as one patient had called our team—attending, residents, and medical students clad in white coats and dark scrubs. We knew from his record that Mr. C had been told he had diabetes mellitus during prior hospitalizations but wasn’t taking any medications for it at home. We were trying to explain that his blood sugar was in the 500s; without question, he needed insulin.

“Mr. C, you have diabetes, which—” one physician began.

“No. I don’t claim that!” he insisted. After further protests, we left to give him some time and space.

Later, as our team member tried to explain that his HbA1C was 18%, Mr. C became angrier than before, refusing insulin again. By the next day, Mr. C had developed a sore throat (and possible retropharyngeal abscess) that was bothering him enough to discuss a plan with us.

“Mr. C, we believe you have an infection in your throat, and we’re starting you on antibiotics for the bacteria. To improve your throat pain, we need to get your glucose down, so we’re not feeding those bacteria extra sugar,” our attending explained.

With the knowledge that insulin might help his pain, Mr. C agreed to receive it, and the team breathed a sigh of relief. Unfortunately, once Mr. C recovered from his acute illness, he left the hospital swearing he’d still never take insulin.

What struck me throughout these interactions was not the exceptionality of Mr. C’s story: Even as a medical student in my first year of rotations, I’d seen many patients receive diagnoses they could not or would not accept and many who chose not to take medications for various reasons. Instead, I was curious—Was there anything we could have changed during our interaction with Mr. C to alter the outcome?

From the beginning, this situation seemed to involve a lack of trust, stemming from any number of origins. In this age of information overload, where people Google their symptoms, poll friends (and strangers) through social media, or even use an app long before they see a physician, it is more important than ever for us to build trust with our patients. Biased, incomplete, and non-evidence-based medical information is increasingly accessible. Personalized, thoughtful, 2-way communication is therefore the most unique service we as current and future physicians can offer our patients.

During my internal medicine rotation, I learned about humanism rounds—the practice of returning to a patient’s bedside simply to chat, free from scripted checklists or formal objectives, focused simply on getting to know the person beyond the illness history. These rounds let me explore the role simple conversations can play in developing trust.

My first week, I followed Mr. M, a patient admitted for a stomach bleed related to an elevated international normalized ratio (INR) on warfarin. On the second day of Mr. M’s 2-week admission, I spent part of an afternoon talking with him and his wife about where they had lived, their daughter in college, the patient’s service in the military, his struggle with alcohol abuse, and his favorite fish to catch. He and his wife lit up recounting a New Orleans trip they had shared and how more recently they had come to terms with living in a trailer home. I’d entered Mr. M’s room intending to learn about him and his life, not expecting he would have similar questions for me—What would the rest of my training look like? What was I interested in? Each morning thereafter, we continued getting to know each other in brief moments. From this, I was able to provide my team insight on several lifestyle factors we didn’t initially realize could be affecting the patient’s INR from his brief social history on admission. Furthermore, I saw that patients often need to know a piece of us to form the connection that allows us to go forward in advising them on their health.

Around this time, at my yearly appointment, my primary care physician asked not only if I exercised but what I did to exercise. “Yoga and volleyball once or twice a week,” I said—and she laughed, admitting she was a terrible volleyball player. This exchange took all of 10 seconds, but it made me feel she was invested in me as an individual. She had gone beyond the required script to a form of precision medicine, tailoring her recommendations to my circumstances.

Later, I saw a distressed young patient with increasing chest pain 24 hours after a motor vehicle accident. She had been repeatedly told there was nothing to worry about. Her medical team meant “no risk of an acute coronary syndrome.” This patient perhaps felt her discomfort was being discounted, likely causing anxiety that could contribute to her pain. Recognizing this and speaking with her some more, we explained that, based on her labs and X-ray, we were not concerned about a heart attack or broken ribs. In accidents like this, we continued, a car’s seat belt and airbag can cause pain that often increases as the adrenaline from the scare wears off. It was immediately clear in her response—the teary desperation gone from her voice—that this explanation helped contextualize her symptoms and calm her.

In the chaos of managing crises, we often forget the power of these subtle moments. While the luxury of a half-hour chat is often unavailable, I’ve learned an extra 2 minutes of discussion when checking on a patient can make all the difference. This difference is not always measurable in outcome or prescription but in an individual’s experience and attitude. As our culture continues to shift away from blind faith in physicians, ensuring that patients go home feeling their doctor recognizes them as an individual is increasingly vital.

I’ll never know if the outcome for Mr. C and his insulin could have been changed. However, I am confident that going forward, the best way to build trust is to meet my future patients where they are and relate to them not only as physician to patient but person to person.

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Acknowledgments:

The author wishes to thank Dr. Andrew Caruso, internal medicine clerkship director, for reading and supporting submission of this piece, and Dr. Brett Styskel and Dr. Reina Styskel for spearheading the humanism rounds initiative at Baylor College of Medicine.

Copyright © 2019 by the Association of American Medical Colleges