Category: Guest Blogs

As medicine becomes politicized, trust in our physicians matters more than ever. High professional standards help them earn it.

“How can I find a doctor I can trust?” I keep hearing this question—from those feeling confused about a vaccination decision to those looking for an ob/gyn who shares their personal values. There’s unprecedented angst, uncertainty, and mistrust. During two decades as a patient and citizen advocate, I’ve encountered the mistrust that arises when systems that are supposed to protect us cause harm. I’ve learned that trust is an asset our health system cannot do without. It is at the heart of our relationships with our physicians and care teams and an essential foundation for the institution of medicine. Yet as our social fabric continues to fray, even the most trusted relationships come under strain. Our relationships with our physicians feel more fragile when the practice of medicine is politicized, and misinformation compounds our uncertainty and confusion about our health choices. 

As an independent volunteer public (non-physician) member of the Board of Directors of ABMS (the American Board of Medical Specialties), a nonprofit organization that oversees the standards for physician certification across 24 medical specialties (the American Osteopathic Association is another), I have a window into what happens inside the network of institutions that oversee the practice of medicine in the United States. The medical profession is dealing with its own trust challenges as it negotiates the tensions between freedom, regulation, and professionalism. In recent months, certifying boards have taken further steps to uphold their accountability by addressing unprofessional behavior and pledging to withdraw or deny certification to physicians who publicly share information that is directly contrary to the prevailing medical evidence.

While some physicians are uniting to defend their ability to take care of their patients and protect those patients’ reproductive freedom and bodily autonomy, others are asserting a questionable freedom to prescribe unproven treatments or disseminate misinformation that leads to medical harm or death. Some physicians are rejecting the institutions that enact and enforce standards of performance and conduct and oversee physicians’ accountability to the public. Efforts by these institutions to overcome mistrust should be welcomed. Self-regulation is a privilege that makes physicians accountable to their peers and importantly, the public. It is grounded in a set of agreed-upon standards and behaviors based on a common set of values and ethical commitments. It represents a social contract between physicians and the community that includes a promise to put the interests of patients first. 

But when mistrust in institutions manifests itself as legislative interference in that professional self-regulation, the politicization of the practice of medicine becomes an assault on medicine itself. The assault is already happening in states where state legislatures have told the state boards that license and regulate physicians that they may not take disciplinary action against physicians who disseminate misinformation or disinformation about COVID-19, vaccination, or scientifically valid treatments. The effects are harmful to physicians, nurses, and patients alike. In some states, physicians no longer have the freedom to provide the care they are trained to provide.

As patients, we are left wondering who we can turn to as trusted navigators as we make sense of our medical choices. As medicine becomes politicized, the answer to that initial question “How can I find a doctor I can trust?” is not as simple as reading patient reviews or going to a top-rated hospital. It’s important to know how to recognize a physician who has gone through rigorous and objective assessment of their knowledge, skills, judgment, and competencies.

The fourteen years I spent with the nonprofit Consumer Reports taught me to recognize a rigorous testing process and the ways it helps to build trust. That rigor is critical for the process of physician board certification. I’ve been reassured to find it at the American Board of Medical Specialties and its member boards: the research underlying every step, the collaborative process of standard-setting, the scientific methods that inform assessments, the secure examinations, the evaluation of ethics and professionalism, the verification that a physician is clear of any professional wrongdoing, the requirement to contribute to improving health and health care, and the cycles of continuing certification to stay current and maintain competency throughout a physician’s career. As a result, specialty board certification is one of the strongest signals that we can trust our physician. It represents a commitment to both learning and accountability.

Patients choosing a physician for themselves or loved ones would be wise to check online if a physician is currently board-certified. But if we want to help build a culture of trust in medicine, based on facts and not ideology, there are things we need to do as citizens to push back against the assault on the medical profession as well. We can communicate our support to elected representatives and candidates who oppose legislative interference in the practice of medicine and its self-regulation. As civic-minded community members, we can ask to be appointed as “public members” of the state boards that regulate medical practice or join a local hospital board as an advocate for patient safety and physician wellbeing. We can run for school boards where we can participate as champions of science education and children’s health. Civic engagement is as critical for building trust in medicine as it is for strengthening our democracy.

The ABIM Foundation’s Building Trust initiative is bringing attention to the need for greater trust in relationships throughout health care, including trust in organizations. The initiative has created a repository of trust-building examples, all conducted at the meso or macro level of organizations and made possible by some level of organizational sponsorship (whether it be financial support or buy-in from the leadership team).

We would like to call attention to organizational trust-building at the micro level, which can be initiated by anyone, requires no extra resources, and can take place within existing work structures and processes. All that’s required is a bit of awareness, intention, and courage.

Trust building at the micro-level is all about creating culture. Whether we are aware of it or not, we are all creating culture in every moment by the way we treat each other as we do our work. Culture is the aggregate of what happens in all the little moments of every day.

The phrase “whether we are aware of it or not” makes a crucial point. If we are not aware of and intentional about relationships, problematic patterns – and toxic cultures – can arise accidentally. Consider, for example, a scenario in which an honest misunderstanding or a problem that crops up suddenly causes tension and anxiety, resulting in some some harsh words being spoken. Others observe this and out of friendship or loyalty they take sides. Before long, there is a pattern of conflict – us versus them – that draws people into it and keeps itself going, sometimes for years after the initiating event. The fact that no one intended this to happen doesn’t matter; the damage is done. In the absence of active ongoing attention to the quality of relationships, a bad pattern has been established and performance will suffer.

It is extraordinarily rare for a problematic culture to be created deliberately. Almost always it results from neglect – a lack of awareness, a lack of active tending.

Now replay that scenario, this time with an awareness of relational quality and an intention to maintain trust and respect. The harsh words might be toned down or retracted with an apology after a moment’s reflection. The recipient of those words or a bystander, recognizing the underlying anxiety, might offer some empathy to help everyone feel supported and to lower the emotional temperature. With these small actions, delivered intentionally to maintain trust, the group can avoid a long-standing conflict that would likely sap commitment and divert energy from the real work.

We all have the power to be intentional about the kinds of relational patterns we create and our direct contributions to organizational culture. More than that, we can encourage and help others to learn how to do it, too. One step higher, organizations can encourage a culture of trust through recruitment, selection, and onboarding processes that favor emotional intelligence; equitable values and practices; individual and team development programs; meeting practices that encourage inclusivity, psychological safety, reflection and dialog; and meaningful behavioral standards and accountability processes.

Even as these organizational interventions can help us become more heedful and skillful, the ultimate responsibility for culture always remains in our hands. It’s about what we do in every moment. There’s much to gain and no extra work if we can approach each interaction with an awareness of relationships and the intention to create trust.

A substantial early-bird discount is available for registrations received by December 23, 2022.  

In the winter of 2020, during the height of the COVID-19 pandemic, “Ava” presented via video visit for our appointment. Ava and I are similar in several ways. We are both Black women in our 30s, and neither of us have children, although I was starting to think about the possibility. As we wrapped up the appointment, she asked a seemingly routine question about the safety of the recently approved COVID-19 vaccines. I was acutely aware of my position as a trustworthy bearer of medical news, which I was afforded due to my racial congruence to the patient. I had given my response countless times and immediately launched into my spiel – the vaccine is safe, has been tested on many people and will protect you from a severe infection, hospitalization, ventilator or death.

She then asked a question that made me pause. She had heard that getting the vaccine could impact her future fertility. She worried it would be hard to get pregnant and that she would need assistance.

I did not expect this question, so it caught me off guard. I fell silent, and hesitated to respond. Several thoughts ran through my head at that moment. I had not specifically considered the implications of the vaccine on future fertility. Nor had I heard this discussed in my clinical circles or read data deterring women of childbearing age from getting the vaccine. Since the vaccines were so new, how could I definitively state that they would not impact her fertility? There was also an earned mistrust in medicine in the Black community. She and I are from a vulnerable population and she was already skeptical of the medical system. I did not want to do anything that would make her hesitate more. 

My pause continued, verging on uncomfortable silence. I finally informed her of my plans for vaccination, and that there was no data that I was aware of linking them to decreased fertility. I knew right away that she could sense my hesitation. Her body language and facial expressions clearly showed that she knew I was not as confident in that recommendation as I had been when initially discussing the vaccine. It was a fleeting moment, but I knew I had squandered the opportunity to provide sound guidance that would impact her decision about the vaccine. I felt disappointment and sadness. She declined the vaccine that day and continued to decline it until several family members fell ill and she wanted to travel.

When I reflect on that encounter, I cannot help but feel as though my hesitation somehow played a role in Ava delaying the vaccine. This was a moment lost, a space that clinicians will experience throughout their careers. It does not feel good and yet there are valid reasons why we have those pauses. I know as a trusted medical professional that there are real consequences when we hesitate and I do not take the responsibility lightly.

Dr. Adetoye is an Assistant Professor in the Department of Family Medicine at the University of Michigan. She attended medical school at Michigan State University and completed a residency in Family Medicine at the University of Michigan.

For many, the COVID-19 pandemic has illustrated up close and personal how misinformation can spread rapidly in underserved communities. One story in particular sticks out for me when I think of this notion.

I am a practicing internal medicine physician at a community health center on the south side of Chicago. Last year, I treated a middle-aged woman who, after her fourth discussion with me, decided to get a COVID-19 vaccine. She was relieved and excited about finally being protected as best as she could be, and I was relieved as well, as she has serious chronic conditions including diabetes and hypertension. She received her vaccination and went on her way.

Several days later, I saw her name show up on my schedule and I was not sure why. I gave her a call and she began to describe the symptoms that started the evening after receiving her vaccination – including abdominal pain, loose stool, and nausea. She denied fever, chills, or upper respiratory symptoms. I asked her to come in to my office as soon as she could that morning. She appeared to be dehydrated, but otherwise her exam was normal. I asked her questions about the history and onset of her symptoms and then I asked her: “What did you eat after getting your vaccine?”

She told me that she went out to celebrate and had raw oysters and fish. As soon as her symptoms started, she believed that it was all due to the vaccine. She told her family and a dozen or so friends, and posted on social media about her experience – how the vaccine “made her sick” and was not safe.

Based on her history, exam, and labs, I let her know that she had symptoms from a virus caused by food poisoning and not from the vaccine. We then discussed trust, misinformation, and jumping to conclusions, and how all three can have a vast impact on a community. Her loved ones, friends, and followers trust her and believe her experiences to be true. I validated her fears and concerns about the misinformation that she had already spread, and then reinforced the importance of talking with your health care team about symptoms and all of the medical possibilities related to those symptoms before spreading information so widely.  

As a result of that experience, I have had similar discussions with most of my patients about the harms of misinformation, and I’ve reinforced the importance of contacting me before attributing symptoms to the COVID-19 vaccine. I provide my phone number and email to each and every one of my patients so they know how to get ahold of me.

Within six months of instituting this new practice that helps build trust and stop misinformation, I received two dozen calls from patients who needed someone they trusted to turn to in times of vulnerability and uncertainty.

Americans spend 145 minutes daily on social media, where false information spreads about six times faster than the truth.[1] We need to curb this epidemic of misinformation and it will take all of us working together to do so.

Dr. Jay Bhatt is a primary care physician in community health centers in Chicago, and co-founder and on the leadership team of #ThisIsOurShot – an initiative to bring credible and trusted information from clinicians to communities to increase vaccinations. He is also Executive Director of the Deloitte Health Equity Institute.

[1] 1. Daily social media usage worldwide. Statista. 2022; Accessed Jun 22, 2022. https://www.statista.com/statistics/433871/daily-social-media-usageworldwide/#:~:text=Currently%2C%20the%20country%20with%20the.

The American Medical Student Assosciation and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

Learn more about this year’s contest: www.abimfoundation.org/essaycontest

What could I say? I looked at her, two piercing blue eyes staring back at me over a yellow polypropylene mask. The mask had muffled her voice but the words she spoke, courteous yet firm, were unmistakable:

“No, thank you.”

She held my gaze for a moment longer before turning in her chair, reaching a hand out to the man lying in the hospital bed beside her.

“It’s our fiftieth wedding anniversary next week,” she added, almost as an afterthought, her gloved fingers interlacing with his – black and gnarled.

The clicking and whooshing of the ventilator echoed in my ears as I stepped back out of the room into the quiet hallway. 

I had been on my sub-internship two months before when Mr. Marshall was first admitted, hypoxemic, gasping for air. I had listened as my attending spoke to his son over the phone to get consent to intubate. I had seen his heart rate rise, his blood pressure fall, and our team order one, two, three vasopressors. Now, on an infectious disease elective I was back in the medical ICU, Mr. Marshall was dying, and Mrs. Marshall still did not want a COVID-19 vaccine.

I have thought a lot about Mr. and Mrs. Marshall in the months since I met them: their pets, children, and grandchildren; the birthdays, vacations, and anniversaries they celebrated together over half a century. And I have thought about where we, as a medical community, failed them, and millions of others like them. How did they become so alienated? How have we become so mistrusted? Moreover, what if I told you that Mr. Marshall’s son had pressured my attending to start ivermectin? Or what if I told you that their real last name was Martinez? What if it was Ming?

Regardless of the origin – disinformation, medical racism, neglect of and disinvestment in marginalized communities – the roots of skepticism grow deep and intertwined. How else, despite the breathing tubes and necrotic digits, could a loving, devoted partner like Mrs. Marshall remain unconvinced?

So, there was nothing I could say to her then; but that does not mean there is nothing we can do. As Dr. Rudolf Virchow wrote in the nineteenth century:

“Medicine is a social science and politics is nothing else but medicine at a larger scale.”¹

It may seem counterintuitive to suggest that the answer to mistrust of the medical establishment in the wake of this pandemic is to push it further into the bitterly divided, polarized environment that did so much to exacerbate the problem in the first place. However, when party affiliation is the strongest predictor of whether someone will get vaccinated against COVID-19, it is indisputable that partisanship is a social determinant of health.²

More to the point, it is key not to conflate partisanship with politics. I am not suggesting this; in fact, I would explicitly urge that medicine should not align with any particular ideology. Instead, I am calling for the medicine – its practitioners and institutions – to fully embrace its crucial role in the body politic. This means more advocacy education for students and trainees.³ It means more healthcare providers participating in community organizing, petitioning legislators, voting, and even running for elected office; and it means their employers and organizations actively encouraging and supporting this work. Finally, it means a greater willingness on the part of the medical community to recognize its mistakes, acknowledge scientific uncertainty where it exists, reject groupthink, and engage openly, honestly, and with good faith about policy disagreements.

Politics is not a dirty word. It is instead how a diverse, multicultural, pluralistic society solves its most pressing issues; and a revitalized civic discourse is the only way that we will address and rebuild public trust in medicine.

Teva Brender is a first-year internal medicine resident at the University of California, San Francisco. He completed his medical degree at Oregon Health & Science University. His academic interests include health policy, physician advocacy, and narrative medicine. In his free time he enjoys reading, cooking, rock-climbing, and spending time with his fiancé and their miniature wire-haired dachshund Winston. 

References:

1. Mackenbach JP. Politics is nothing but medicine at a larger scale: reflections on public health’s biggest idea. J Epidemiol Community Health. 2009 Mar;63(3):181-4. doi: 10.1136/jech.2008.077032. Epub 2008 Dec 3. PMID: 19052033.
2. Kirzinger A, Kearney A, Hamel L, Brodie M. KFF COVID-19 Vaccine Monitor: The Increasing Importance of Partisanship in Predicting COVID-19 Vaccination Status. Kaiser Family Foundation. Published November, 16 2021. https://www.kff.org/coronavirus-covid-19/poll-finding/importance-of-partisanship-predicting-vaccination-status/?utm_campaign=KFF-2021-polling-surveys&utm_medium=email&_hsmi=2&_hsenc=p2ANqtz–Da1u1V7IKYdhRp6Bka4x7FhGIifNIszjMBdITNNweqiz1Lr3KqBkI33Wd6F7T6mGuuNfn8klOKaFeolETdxO1-AsIZg&utm_content=2&utm_source=hs_email. Accessed May 17, 2022.
3. Brender TD, Plinke W, Arora VM, Zhu JM. Prevalence and Characteristics of Advocacy Curricula in U.S. Medical Schools. Acad Med. 2021 Nov 1;96(11):1586-1591. doi: 10.1097/ACM.0000000000004173. PMID: 34039856.

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

Learn more about this year’s contest: www.abimfoundation.org/essaycontest

It was my first day on the internal medicine rotation. A 77-year-old male, Mr. Marrow, had been admitted overnight for disseminated MSSA bacteremia. I went to his room and introduced myself.

“Good morning Mr. Marrow, my name is Sunil and I am the medical student on the medicine team that will be taking care of you.”

Before I could ask any questions, he looked up with his blue eyes, stared at me for a good ten seconds, and in a sharp tone said, “Who let you into this country?”

His words were palpable. I felt my face, hidden behind an N-95, go pale. My hands and feet went numb. Still, I plodded forward with the lessons my parents always instilled within me: Do your part well and with purpose.

I gently deflected his comment: “I am happy to tell you more about myself, but we should focus on getting you better first. I am worried you have an infection in your blood that needs to be treated before it worsens.”

Despite his unwillingness to fully cooperate, I performed a focused physical exam. I walked out of his room, doffed my N-95, and took a deep breath of relief.

This was not my first experience with racism, nor will it be my last. But each experience has weighed on me. As I walked away, I was reminded of my very first patient experience from seven years ago when I began my journey as an MD/PhD student. My patient in that encounter thought I was their janitor. Two years ago, while running in my neighborhood one evening with a mask early during the COVID-19 pandemic, I was questioned and inspected by a police officer. I also recalled the feedback I received just last year as I began clinical rotations from a middle-aged, white male attending; he suggested that I religiously wear my white coat, exude overconfidence,apply hair gel, iron my clothes, and disclose that I have a PhD so that patients took me more seriously.

And so, my experience with Mr. Marrow was no exception, but rather part of a continuum. Despite this, my interaction with him unique because there was no ambiguity in what he was inferring. To him, my dark skin and thick black hair coupled with a masked face were not to be trusted.

Given his comment, it would have been very easy for me to request being reassigned to a different patient. However, that would not be a solution but merely a compromise. Systems only change if people change. To change people, initiating dialogue is essential. I chose to continue working with Mr. Marrow.

Over my 4-week rotation, I consulted various specialists to drain the many pockets of infection that were seeding throughout his body. Despite his relentless pain, I made every effort to comfort him. Such efforts led us to develop rapport, laugh together, and most importantly build trust. This was most evident when I held his hand through the placement of his chest tube to drain an infected area in his right lung. A procedure that he had delayed for too long, given his anxiety and ongoing pain.

He saw me at the procedure and burst into tears. He looked up yet again with his blue eyes and said, “Thank you for being here. It means so much.”

The next day during morning rounds, Mr. Marrow stopped me and said, “My initial words were extremely racist for which I apologize.” He went on to say that he grew up where “everyone looked alike.” I was startled. No patient had ever apologized to me.

I walked away with a new sense of hope. I now recognize that for people to change, apart from initiating dialogue, building trust is paramount. Don’t impress, just express. And with time, Mr. Marrow began to trust me.  I’d like to believe that our rapport allowed him to be reflective. His newly gained insight reminds me that there is no age limit to growing. Importantly, no age limit to becoming more inclusive and open-minded.

On my last day, Mr. Marrow said “…I don’t know if my infection is gone but you are leaving me with a new perspective, one that I overlooked for years.”

While he was simply expressing himself, in doing so, he impressed me.

My care for Mr. Marrow was no different from what I provided to other patients. I did nothing extra to impress him. I didn’t change my appearance or personality despite an attending’s suggestion. I simply continued to do my part with purpose.

Sunil K. Joshi is an MD/PhD student at the Oregon Health & Science University (OHSU). He completed his PhD in cancer biology under the mentorship of Dr. Brian J. Druker. Sunil is passionate about empowering and advocating for patients from underserved and socioeconomically disadvantaged communities through clinical practice, scientific research, and education. He is currently applying for residency in internal medicine.

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

“Is this going to hurt?” The words rang from a young, noticeably anxious girl who gripped her mother’s arm. Reassuringly, I smiled and told her she would experience a slight pressure on her arm that would feel like a hug from her teddy bear. While she was still visibly shaken, my words brought about a reserved smile across her face. As I was adjusting the blood pressure cuff, I made a joke about the SpongeBob SquarePants shirt she was wearing. With similar effect, this quip brought about a small chuckle from the child as she became more relaxed. “Just sit tight and it’ll be over in a jiffy!” I gave these instructions as the cuff slowly began its monotonous inflation. On the radiating green screen, the results read 110/70. I congratulated her on having perfect numbers and began to prepare for the next patient when she asked a question that stopped me in my tracks: “What does blood pressure mean?”

I could define blood pressure using cardiac output and vascular resistance, and I could describe the effects of blood pressure on the cardiovascular system. However, my head scrounged for an answer to what blood pressure is and how I could relay that information to an 8-year-old.

Should I answer that blood pressure measures pressure against artery walls? Should I mention how the systolic and diastolic numbers correlated with the cardiac cycle? Luckily, the attending physician overheard our interaction and jumped in. “Blood pressure is just a sign of how your heart is doing. If it’s too high or too low, that means your heart is sick and needs to be treated.” Amazed, I observed the rest of the interaction with my mentor as he easily simplified complex concepts into digestible material for the girl. Although I had just finished my cardiology unit in medical school, I was humbled by my inability to provide a simple definition.

After the event, I began to garner an appreciation for medical communication between health care providers and their patients. Although it is important to retain updated medical knowledge, it is of even more importance to ensure that our patients understand this knowledge and how it affects their lives and health. Through these interactions, trust is fostered between the patient and health care provider.

I began to volunteer at more health fairs offered by my school in hopes that I could gain more exposure to medical communication and promote trust between our free clinic and the underserved communities that we served. We created pamphlets that instructed patients on at-home blood pressure monitoring and informed them of the importance of cardiovascular health. Though this was a small feat, it was astonishing to find that many of the patients at our health fairs expressed immense gratitude at having someone to sit down with them and clarify their medical concerns.

Having served as a tutor throughout my undergraduate career, I quickly recognized the ‘a-ha’ moments many of the patients expressed as their faces beamed at finally understanding the intricacies of their health. Oftentimes, we assisted patients through discussion of blood pressure and its effects, the importance of monitoring blood glucose levels, and the need to adhere to medication for better outcomes. Through these candid conversations, we found that patients became more comfortable and more willing to discuss their medical ailments and concerns.

By explaining the relevance of blood pressure to a patient’s health or discussing the progression of diabetes, I found that many patients felt comfortable in discussing their medical ailments. Instead of outright diagnosing a patient with heart disease, it may be more meaningful for the patient to learn they have heart disease and how it will affect their life; patients may wish to hear about the feasibility of living with heart disease and how the medication regimen will fit into their busy lives.

Due to a plagued history of medical mismanagement against minority communities in medicine, many patients in these communities are wary of trusting a health care worker. Through my work, I want to improve trust in underserved communities by providing holistic, empathetic care that allows the patient to rest assured that I will prioritize their autonomy and health.

Nicholas Wilson is a second-year medical student at Morehouse School of Medicine in Atlanta, GA. With aspirations of becoming an Internal Medicine-Pediatrics (Med-Peds) physician, Nicholas plans on treating a wide variety of medical problems throughout his career. His research interests are health disparities, sickle cell disease, biomarkers, and improvements in patient care. In his spare time, Nicholas enjoys trying (and occasionally) cooking new foods, improving his painting skills, going for relaxing runs, and catching up with friends and family.

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

Sitting in an old, creaky school chair in Panama, I beckoned a mother and her children to sit across from me. Still nervous about meeting new patients, I tried to avoid meeting their gaze and instead focused on innocuously gathering information. After all, I was a foreigner and even though I was in Panama as a medical volunteer, I felt like I was forcing my way into my vulnerable patients’ lives with nothing more than my broken, inadequate Spanish.

At first, I was hesitant when interacting with them because I thought that providing health care professionally meant that I had to be serious or even solemn. As I took the mother’s blood pressure, the weight of the silence grew, until it finally became overbearing.

Not knowing any other way to connect with the woman, I decided to smile at her. To my surprise, she immediately returned the gesture. Suddenly, the tension in the air seemed to break. Her smile melted away my anxiety. The patient, too, opened up and looked happier while I took her children’s vitals.

From that moment onward, I put myself and my personality out there. I tried to converse and smile more with locals, learning more about their lives than just their medical history. After this change, when I engaged a patient in conversation, they seemed more comfortable when listening to the medical information I provided. Even though I was far from fluent in Spanish, the patients appeared more interested than before in understanding me and supporting my effort.

This experience has repeated itself time after time. When I volunteered at a soup kitchen in Chicago, a pop-up clinic in Tampa, or a vaccine distribution center in Philadelphia, I was always quite uncertain about my presence in the room. It was only when I interacted with the guests and patients that I felt more comfortable. My own comfort eventually allowed me to open up, hear other people’s stories, and understand my community.

Medical students come from various backgrounds and interests. They become involved in their communities in a variety of ways – by leading their own initiatives, by advocating with policy non-profits, by creating music to bring peace to patients, by creating videos to increase awareness of health disparities, and many more.

However, a major factor which makes any activity or project successful is how connected the student is to the community. If an individual takes the time to get to learn about the people they are helping, and the people learn about the individual’s personal story and interests, trust is built. But building connections with a community on a personal level, by establishing trust, a medical student can maximize the impact of their work.

Medicine is the combination of small connections and larger-scale efforts, patient care and health advocacy. In pursuing this career, we, as medical students, have to always keep in mind the depth of our patients’ hidden stories and the importance of striving for health equity in our community. For each one of us, this will be different. However, by doing so, we will all build trust in our communities, and advance health care.

Veenadhari Kollipara is a first-year medical student at Pennsylvania State University College of Medicine. She graduated from the University of Pennsylvania in May 2022 with a summa cum laude in Health & Societies (Health Policy & Law Concentration) and a minor in Cinema and Media Studies. Her experiences as a Health Education Associate at the Netter Center for Community Partnerships, a volunteer at the Sayre Health Covid-19 Vaccine Distribution Center, and a Hoesley Digital Literacy Fellow have motivated Veenadhari to be passionate about both patient care and health policy/advocacy. In medical school, Veenadhari plans to become more involved in health equity initiatives focused on race and gender disparities.

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

“Social determinants of health” – four words that compose one of the most significant phrases to ever traverse health care. They have prompted me to explore exactly what these words mean: to myself as a person, my education, my future practice, and my impact on my community. How could I, a single medical student, work within the teams I have formed with my mentors, friends, and colleagues to improve the social determinants of health experienced by the members of my community?

The major public health threats of diet, exercise, smoking, addiction, housing, and so much more, can be resolved through the development of trust between health care professionals and the community members they serve. That trust also has to overcome a history of systemic racism, language barriers, and individual anecdotes of providers with implicit biases against gender, racial, and ethnic minorities.

I was recently part of a team that helped run a flu drive and perform diabetes and hyperlipidemia screenings for members of a predominantly Spanish-speaking community in South Dallas. During the event, I began to recognize the trusted sources of this particular community, especially of those who did not speak English.

I went to the flu drive equipped with only a 10^th grade level Spanish education and attempted to engage in conversation as I screened people for hyperlipidemia and diabetes. I was eager about the event, but nervous about how I would communicate with the participants. I immediately witnessed the immense trust many older participants placed in the hands of their children and grandchildren who knew English, as they straightforwardly relayed test result interpretations.

Over the next few hours, as the insecurities about my Spanish-speaking abilities diminished, I began to understand the importance of being able to communicate directly with whomever I was serving. Most of the interactions I made with a patient went this way: I would greet them with “Buenos Dias,” and then would preface the rest of our interaction with “Lo siento, mi espanol es muy mal, pero yo voy a intentar y quiero aprender mas,” or “Sorry, my Spanish is very bad.” This well-rehearsed phrase of mine was always answered with a reassuring chuckle from the other side of the table and “Bien.”

The people I spoke with understood that even though I could not converse with them fluently, I was trying to communicate with them as well as I could. I was given reassurance that they trusted what I had to say when they would fill in words for me as I spoke to them about their test results and lifestyle modifications. 

At the same event, I also saw the impact of a community’s leadership as a source of trusted information for its members. The health fair was hosted on a Sunday next to a church, and the biggest waves of participants came to us within the hour of the end of each service. I realized that we, as servants of our community, need to tap in to the currently trusted platforms of information held by the community – like the local church. We can use this foundation of trust to improve our relationship with the community to serve them in a more impactful way – a way in which they will feel comfortable disclosing conditions beyond their physical health, so that we can also address their social determinants of health. 

I’m now exploring the causes of vaccine hesitancy within this community. To improve trust, we do not need to start from scratch, and we do not need to work alone. We can continue to learn about the viewpoints held by this community to unlock where their trusted sources of information are to use these platforms to deliver accurate information.

During the flu drive, not only did we see the important role that young family members served – as translators for their community – but we also saw the importance of the local church in their social lives. We experienced the synergistic impact of the drive’s coordination with the church’s leaders in boosting participation in the flu drive. This clued us in to how we can continue to use places of worship to provide accurate information about vaccines, healthy lifestyle habits, and other public health information to the community. This is how we can serve our communities beyond the four walls of our hospitals and clinic buildings so that patients can take control of their health status on all fronts. 

Suman Vadlamani is a second-year medical student at UT Southwestern Medical Center in Dallas. She is also in her second year of her MPH degree through UT Health. She has an interest in Women’s health, which is the direction in which she wants to take both of her degrees. She hopes to become an OB/GYN doctor and focus her public health work on progressing women’s health initiatives.           

The American Medical Student Association and the ABIM Foundation partnered to launch the Building Trust Essay Contest. Medical students were asked to reflect on a time where they built, lost, or restored trust in a health care setting.

Learn more about this year’s contest: www.abimfoundation.org/essaycontest

It took exactly three Tuesdays. Each week, I knocked timidly on the door, waiting for his characteristic gruff “come in” before I dutifully entered the room clad in the paper gown. I would approach the bed, chipper as ever, as he glanced at me through lidded eyes of disdain.

A brief history of our interactions would read as:

Tuesday #1: A cup of Jell-O and please turn off the lights.

Tuesday #2: Do you guys have Call of Duty? Fine, can I just have FIFA.

Tuesday #3: I’m good for today.

and then…

“Tomorrow was supposed to be my prom, you know,” barely a whisper behind me.

My tongue felt as if it was glued to the roof of my mouth as I turned ever so slightly, waiting. I could sense the air saturated with tension.

He laughed bitterly. “They told me I’d be out of here by now. I promised my girlfriend I would take her.”

Each word dripped with acid that ran off his tongue and pooled at my feet.

I swiveled slowly, afraid I might spook off this moment of rare vulnerability. I mustered a weak, “I can’t imagine.”

I had hoped this would be a benign offering, but his head snapped towards me so sharply that I stepped backwards.

“No. You CAN’T imagine. I bet you got to go to your prom, didn’t you?”

It was more of an accusation than a question. Bracing myself for his next inundation of rage, I nodded my assent wordlessly.

But his anger dissipated as quickly as it came. He shut his eyes tightly and leaned his head back against the steel bar of his hospital bed. The movement was so familiar, so practiced, that I could tell he had assumed this exact position before, searching for meaning in this unholy campground.

I suddenly realized that when I entered every week, I was intruding on the most intimate moments of his life. I could see it more clearly: my knock, the threat of an invader as he haphazardly tucked in the corners of his Tuesday.

“They promised I would be out of here. I don’t know why I believe them anymore.”

Suddenly, I remembered a slight caveat, a correction to my previous answer.

“Well actually… I only made it to one prom. The other prom I was in a full leg cast because I tripped and broke my knee.”

He glanced at me beneath the curtain of sandy-brown hair as I looked back at him, no longer afraid to meet his eyes. We challenged each other in silence for a few moments until his bubbles of laughter burst forth.

“That has to be the dumbest thing I have ever heard.”

We were both doubled over at my clumsiness as I assured him that I had fallen onto the pavement with a satisfying thwack.

There was an imperceptible shift. Our Tuesdays were now intertwined. In sharing a piece of my history (and an embarrassing one at that) I had reminded him that I was also fallible and human.

“Damn. Well at least cancer is a better excuse to call a raincheck than being a klutz.”

I see medicine as an opportunity to forge relationships in unexpected ways, its core remaining the in-between moments of people connecting in shared spaces. As the hours of my shift unraveled, he confided in me his tricks to get extra dessert and his frustrations that his hair was falling out in clumps.

It took three Tuesdays for me to learn that fostering trust is a broken and messy process, oftentimes taking one step forward and three steps back. It is no easy feat for someone in their most vulnerable moments to invite you into the complicated prism of their lives. Instead of expecting an easy connection, I have learned to sit with the awkward and uncomfortable. Even when it feels like no headway has been made, continuing to knock on the door is its own kind of promise. I may not always find a quick joke or common thread, but I can choose to show up anyway.

As I stepped outside onto the slick sidewalk that Tuesday, I knew without turning that he was watching from the window. So, I let my feet skid on the asphalt as I pirouetted dramatically to the ground.

From a dimly lit window on the 4^th floor of a children’s hospital, I was rewarded by a toothy grin and slow clap before the curtains swung shut.

Meher Kalkat is a second-year student at the Johns Hopkins School of Medicine and is originally from West Palm Beach, Florida. She is passionate about medical education, physician and trainee wellness, and combating mental health stigma. In her free time, she loves to sing karaoke, bake, and take photographs.