Humility and trust  

“A woman is a puppet; she only knows to cook the meals and wash the clothes of her husband and to care after the children.” My research informant, a 24-year-old in her seventh pregnancy, was describing why she felt a talk therapy program for perinatal mental health could not help women like her, living with antenatal anxiety in the cultural norms of Pakistan. Her words, an expression of powerlessness and distrust, were among the most powerful that I encountered in my studies. Her account gave voice to the lifeworld—one at the intersections of women’s disempowerment, gender norms, and psychological distress—in which she experienced her illness. 

While we are decades removed from Elliot Mishler’s 1984 study, The Discourse of Medicine, the patterns of distortion and fragmentation that he observed in doctor-patient communication remain as relevant as ever, even as the specific barriers—technocratic models of medicine, layers of electronic or virtual discourse, etc.—continue to shift. The permanence of this challenge is rooted in the timelessness of what our patients are urgently seeking from us: to be heard and seen as whole people. The art of building trust with our patients requires, above all else, the humility to meet them in the lifeworld they occupy.

This was a lesson first taught to me by my grandfather. Scribbled in the margins of his worn mus’haf—his copy of the Quran, passed down to me after he died—my grandfather left me a final reminder: that we are closest to God or al-Haq (the truth) at that moment of prayer when our heads touch the earth in prostration. It is humility, he wrote, that brings us closest to an understanding of truth. I imagine he penned these words toward the end of his 23 years of diplomatic service in Central Asia and the United Nations. Having lived through violence in Ladakh and exile from his home in Tibet, he dedicated his career to empowering communities that, like his own, were uprooted and marginalized by conflict. I internalized his ethic of service.

Inspired by my grandfather, I brought to medical school aspirations of helping the vulnerable, specifically to find within contexts of illness or crisis avenues of healing and relief. Of the many challenges that I faced while studying to become a physician, however, the most difficult was not relinquishing my humility along the way. Education and expertise are defined as much by what we learn to forget as by what we learn to remember.

In medical school, while memorizing dizzying amounts of information and formulas for efficient clinical communication, I am afraid I would at times unwittingly learn to forget my own limits—the limits of not only my own knowledge and abilities, but also the limits of my own importance. This was evident in every instance that I thought myself too busy or considered my time too precious to speak with my patients rather than at them.

I’ve since experienced firsthand the difference that empathic listening—listening with the heart as well as the ears—can produce in gaining patient trust.

Recognizing the distress in the voice of a teenage driver I was evaluating for whiplash injury in the Pediatric Emergency Department, I was moved to offer open-ended questions and extended moments of silence, thereby learning that he had been running from home at the time of the collision after his mother discovered a suicide note in his bedroom.

While caring for a terminally ill nursing home resident during one of several repeat hospital admissions, the patient and I decided together to explore the benefit of a palliative care consult. During the resulting discussion with her and her husband, I learned that while neither wished to pursue aggressive or curative treatment, both had a yet unspoken need for the other’s permission to accept that the patient was approaching death.

“Listen to your patient,” William Osler would tell his students. “He’s telling you the diagnosis.”

I believe our patients are telling us much more than their diagnoses. For our communication with them to produce genuine trust, for our care to be patient-centered, and for our interventions to produce therapeutic change in their lives and the lives of their families, we must be committed to always considering our patients as among our teachers: confronting complex yet intimate connections between health and social context, hearing their meaning-filled narratives, bearing witness to contextually-grounded suffering or dysfunction, and humbly recognizing behind each of our patients the multifaceted identity and lifeworld that they offer us.

Armaan Ahmed Rowther is a final-year MD-PhD student at the Johns Hopkins University School of Medicine who completed his doctoral studies in International Health at the Bloomberg School of Public Health. His thesis focused on structural and sociocultural factors shaping the design and implementation of novel telemedicine and task-shifting approaches for improving maternal and child health services in Pakistan. Prior to this, he was a research fellow under the Fulbright US Student Program in Jordan conducting a study on digital health intervention development and evaluation for cardiometabolic risk screening in medically vulnerable women receiving care from the Noor Al-Hussein Foundation’s Institute for Family Health near the Baqa’a Refugee Camp. Currently, his clinical interests include Reproductive Psychiatry while his research interests center on applying social science theories and mixed methods to understand perinatal mood and anxiety disorders and innovations for advancing maternal health equity.