Tag: Building Trust Essay Contest

“They’re anti-vaxxers – they won’t listen.” My resident whispered to me as we finally walked away from Johnny, the 6-month-old baby boy in Room 9, one hour and some odd minutes later.^1,2 His tone is heavy, laden with implicit meaning. The pediatric hallway mural flashes by as we walk, a jewel-toned jungle depicting grinning monkeys gamboling amidst a wash of bright emerald-green leaves.

After several formative interactions with the family, a palpable sense of dread began to accompany our daily prerounds. My resident and I struggled daily to convince them to allow basic blood draws; we failed utterly on the topic of flu shots. 

My resident, usually composed, started displaying a series of nervous tics, from pausing outside the door to breathing deeply just before knocking. Eventually, we resort to maintaining an exit pathway to the door, as if to subconsciously escape the daily question bombardment on our clinical judgment and the veracity of scientific rationale, all delivered in an aggressive tone by the parents and fueled by anti-science skepticism. By the third morning, I found myself too exhaling in relief by the time we exited Room 9. 

The fourth morning, an attending who favored bedside rounds joined our team. Huddled en masse outside Johnny’s room, I was stunned to see how calmly and patiently my attending fielded the family’s questions, modeling compassionate patient-centered care for the entire team and serving as an important reminder to us all. 

Like Dr. Paul Kalanithi once wrote in his gripping memoir When Breath Becomes Air, “The easy human connections he formed, the trust he instilled in his patients, were an inspiration to me.”³ I felt ashamed, realizing I had allowed anxiety to cloud my normal interactions. Antivaxxers or not, the family in Room 9 deserved care to the best of my ability. I returned to Johnny’s room that same day, resolved on immediately changing my attitude. 

When Johnny’s family initially responded to my discourse invitation with closed-body language, I was frank yet sincere, “I want you to know I am here to listen with an open mind. I would deeply appreciate the chance to hear your feelings.”  

As if suddenly unfettered, they spilled their fears out to me. I left the room hours later, humbled with my heart in my mouth. I realized what we had formerly written off as an aggressive tone was a tone of utter terror; the anti-science skepticism in Room 9 was actually a first-time mother and father’s panic over their acutely sick child and an understandable distrust of a confusing medical system.

In his Harvard Business Review article on eroding trust in U.S. health care, Dr. Richard S. Isaacs aptly notes, “Every [patient] encounter… is an opportunity to build trust,” a countermove to the deepening credibility crisis in the medical system, especially prevalent in conservative spaces.^4-6 Our initial mistake was attempting to convince Johnny’s parents about scientific evidence, thus creating a patient-provider impasse, rather than first empathizing with their concerns.

The day Johnny took a turn for the worse, my team advised urgent placement of a central venous catheter under anesthesia during attending rounds. Johnny’s parents balked, immediately wary of the potential harms of unknown chemicals and an invasive procedure on their precious baby. 

Afterwards, I stopped by to check in gently. “What are your concerns?” I remember asking them as I stroked Johnny’s hair soothingly. As Dr. Kalanithi aptly described, those moments in Room 9 became “an opportunity to forge a covenant with a suffering compatriot: here we are together, and here are the ways through – I promised to guide you, as best as I can, to the other side.”³

By the time evening rolled around, I emerged from Room 9, hopeful. 

The next morning, Johnny’s parents consented to the central venous catheter placement, provided I accompanied their baby boy every step of the way. I promised to stay with him, asked permission from my chief, donned an OR bonnet for the first time in my life, and wheeled Johnny out from Room 9. Later, in the same bonnet, I brought Johnny back to his tearful parents.

In the operating room, the blue curtain behind which anesthesia often sits is a common sight. But in the world of patient care, that curtain can exist unseen. It is essential to remember to peek behind that curtain in each of our Room 9s, see our patients behind a stereotype or impression, and take the time to listen rather than explain. It is our role as providers to make every single one of our patients feel heard.

Melodyanne Cheng, MS, is a fourth-year MD/MBA candidate at UCLA David Geffen School of Medicine. Originally from San Diego, CA, they are focused on improving surgical health disparities, redesigning more equitable health care delivery systems, and impacting patient care from bench to bedside.

Notes and References

1. Johnny is a fictional pseudonym to maintain patient privacy.
2. The room number and Johnny’s exact age are both modified/fictional to maintain patient privacy.
3. Kalanithi, Paul. When Breath Becomes Air. Random House, 2016. 
4. Isaacs, Richard S. “5 Steps to Restore Trust in U.S. Health Care.” Harvard Business Review, 8 Sep. 2022, https://hbr.org/2022/09/5-steps-to-restore-trust-in-u-s-health-care.
5. Boyle, Patrick. “Why Do People Believe Medical Misinformation?” AAMC, 3 Nov. 2022, www.aamc.org/news/why-do-people-believe-medical-misinformation. 
6. Boyle, Patrick. “Why do so many Americans distrust science?” AAMC, 4 May 2022, https://www.aamc.org/news/why-do-so-many-americans-distrust-science.

My dad turns off the Wi-Fi at 10:30 every night. He bought an automatic timer last month so he can’t forget. He wants to minimize the amount of time our bodies are exposed to the electromagnetic fields generated by Wi-Fi signals. I’m ready to tell him it’s ridiculous, but I know that won’t change his mind. After all, it has nothing to do with education (he has a graduate degree) or irrational thought (studies have looked at the effect of phones on sperm count). It’s just how he copes with something unfamiliar.

During the past few years, more and more health conspiracies and conspiracy-like ideas have found their way into the spotlight. COVID-19 generated a new thread of conspiracies, partly in response to mRNA technology.¹ There were theories about vaccines injecting 5G microchips that Big Tech and Big Brother were using for surveillance. There was Donald Trump suggesting we inject bleach to kill the virus. There were people declaring that COVID-19 wasn’t real and neither were the death rates. There were the usual conspiracies igniting anti-vaxx and anti-pharma and anti-establishment furor. Studies found that increased exposure to conspiracy theories led to increased reluctance to engage in COVID-19 prevention measures, such as social distancing and vaccination, along with increased willingness to engage in alternative treatments, such as chloroquine and garlic.² Such phenomena are not specific to COVID-19 either.³ 

Health conspiracies often sound similar to the messaging associated with alternative health movements and wellness culture, terms that broadly encompass everything from yoga to acupuncture to reiki. Wellness culture arose from 1960s counterculture that sought to experiment with holistic practices and increase access to healthcare.⁴ But today, wellness culture is primarily dominated by chatty influencers promoting trends on unregulated platforms, at times creating fodder for conspiracy theories that can align with far-right political agendas.⁴ Not only does this debase alternative medicine practices that can actually help people,⁵ but this also creates demand for people who consistently make unsubstantiated and misleading claims.⁶

But it’s not helpful to deride conspiracy believers as outright delusional. That’s not entirely fair. Conspiracy theories have a long history rooted in distrust of political elites and central authority. They are attempts to understand sociopolitical events, especially during times of upheaval, by claiming that people in power are colluding for malevolent purposes.⁷ They share four principles: they are universal in that they are not specific to a group of people or to a period of time but rather part of basic human survival mechanisms; they are emotional in that they are a product of emotion-driven sense-making processes that often draw upon automatic cognitive systems; they are social in that they seek to uphold collective identity and protect the ingroup from the outgroup; and they are consequential in that they influence the way individuals and groups decide to act.⁸ Many false beliefs, even those that do not qualify as conspiracy theories and especially those that hold the vaguest hint of plausibility, share similar principles and similar consequences. But no matter where they lie on a spectrum of truth, they all stem from the same sentiment: fear of the unfamiliar. They are all driven by epistemic crises and existential threats—things we all experience.⁷

Preserving truth and building trust is not just about censuring all falsehoods and all believers. Whether it’s in medicine, politics, or daily life, it’s foremost about understanding why someone chooses to think the way they do. Most of us don’t respond to scientific literature or hard evidence. We respond to our own versions of truth, versions based on our individual lived experience and on our shared struggle to be human.  

Fifty years from now, I wonder how I’ll cope with a technologically unfamiliar world. When AI has found a grip on many parts of our lives, I can imagine myself being distrustful of most information—I’m already wondering if the Reddit video of a Russian man brushing a bear’s teeth is just a figment of the AI imagination. When that happens, I might also find myself turning off the Wi-Fi at 10:30 every night, in part to get off the grid, maybe also in part to avoid unnecessary electromagnetic radiation. Deep down, we all have a voice like this, a voice that is anxious about the unfamiliar and perhaps unsure of the science. And that’s okay. We should talk about it with each other because we’re all just trying to make sense of the same things.

Meilynn Shi is a medical student at Northwestern University, pursuing a path in academic cardiac surgery. She received her bachelor’s in American Studies and Political Science at Northwestern University. She likes running, cooking, reading, and writing.

References

1. Dolgin E. The tangled history of mRNA vaccines. Nature. Sep 2021;597(7876):318-324. doi:10.1038/d41586-021-02483-w
2. Bierwiaczonek K, Gundersen AB, Kunst JR. The role of conspiracy beliefs for COVID-19 health responses: A meta-analysis. Current Opinion in Psychology. 2022/08/01/ 2022;46:101346. doi:https://doi.org/10.1016/j.copsyc.2022.101346
3. Oliver JE, Wood T. Medical Conspiracy Theories and Health Behaviors in the United States. JAMA Internal Medicine. 2014;174(5):817-818. doi:10.1001/jamainternmed.2014.190
4. Baker SA. Alt. Health Influencers: how wellness culture and web culture have been weaponised to promote conspiracy theories and far-right extremism during the COVID-19 pandemic. European Journal of Cultural Studies. 2022;25(1):3-24. doi:10.1177/13675494211062623
5. Yang Y, Li X, Chen G, et al. Traditional Chinese Medicine Compound (Tongxinluo) and Clinical Outcomes of Patients With Acute Myocardial Infarction: The CTS-AMI Randomized Clinical Trial. JAMA. 2023;330(16):1534-1545. doi:10.1001/jama.2023.19524
6. Korownyk C, Kolber MR, McCormack J, et al. Televised medical talk shows—what they recommend and the evidence to support their recommendations: a prospective observational study. BMJ : British Medical Journal. 2014;349:g7346. doi:10.1136/bmj.g7346
7. Douglas KM, Uscinski JE, Sutton RM, et al. Understanding Conspiracy Theories. Polit Psychol. 2019;40(S1):3-35. doi:https://doi.org/10.1111/pops.12568
8. van Prooijen J-W, Douglas KM. Belief in conspiracy theories: Basic principles of an emerging research domain. European Journal of Social Psychology. 2018;48(7):897-908. doi:https://doi.org/10.1002/ejsp.2530

“For the most part, our patients are wonderful individuals but…,” our Psychiatry clerkship director paused to start passing out personal safety alarms, “you should always have your device nearby while on the unit.” 

Her instructions seemed a bit dramatic for my rotation, which was set to take place on the 

Child and Adolescent (CAP) unit. When we submitted our site preferences, I envisioned bleached white walls and squashy couches where I would learn how to best support young minds during that tricky transition from adolescence to adulthood. 

“Raymond” was the first patient I admitted from the Emergency Department. His parents brought him in after he barricaded himself in the bathroom and texted the family group chat that he was going swallow 10 bottles of Tylenol pills. I asked Raymond if he had any details that he wanted to add from his parent’s account, but he wasn’t interested in answering my questions—or talking to me —in any capacity. 

Once he arrived on the unit, Raymond mostly kept to himself. He was highly intelligent but socially isolated. He spent time outside of mandatory group therapy sessions working on puzzles or sometimes, staring out the window overlooking the main boulevard in front of the hospital. I wondered what kind of life existed for him in the outside world, but he refused to engage in any meaningful conversation about his thought process. 

Our CAP fellow was not surprised by this behavior. He, like Raymond, was raised by Chinese immigrants and initially decided to pursue Child and Adolescent Psychiatry because he saw the need for more culturally sensitive providers to destigmatize mental health for Asian Americans. 

“You have to understand, this is a sixteen-year-old kid who maybe never learned how to have an open conversation about his feelings because some of those words don’t even exist in Mandarin. Give him time.” 

In Child and Adolescent Psychiatry, we were instructed to think of our patient’s presenting problem in the context of their environment. Scribbled on the workroom whiteboard were a series of concentric circles labeled “Patient,” “Family,” “School/Peers,” and “Community.” Each circle played a role in their disease pathology and as providers we needed to think about treatment options that offered the most over-lap between all the circles. 

Eventually we untangled a complicated dynamic of intense feelings of sadness and loneliness that started when Raymond was in middle school. He knew that his parents loved him but didn’t know how to describe why he felt so alone, especially after knowing how much his parents sacrificed to raise him in America. 

Raymond’s experience reflects current demographic data that shows Asian Americans are less likely to receive mental health treatment compared to other racial and ethnic groups. A study from Health Affairs found that 58 percent of Asian Americans reported worsening mental health after the COVID-19 pandemic and accompanying wave of racially motivated hate crimes, exacerbating an already profound need for culturally and linguistically sensitive mental health providers.¹ There is no panacea for eliminating health disparities. Some professionals call for greater education about the science behind pharmacologic agents such as SSRIs to dispel thinking that mental health conditions are a result of personal failure. Others emphasize greater acceptance of traditional healing methods through integrative medicine. However, the literature consistently shows the importance of acknowledging cultural background in establishing patient-provider trust and building a strong therapeutic alliance. 

One morning during rounds our attending asked Raymond to consider family therapy as a communication tool with his parents so they could learn from each other how to best support Raymond. This would be a change in their family dynamic, but something his parents were open to when the treatment team privately explained to the importance of speaking frankly about his mental health. 

At first, Raymond didn’t respond. Just as the silence was becoming awkward, our fellow asked Raymond a question. 

“Raymond, are you scared?” 

He sunk his teeth into his bottom lip before nodding in agreement. 

“I’ve been speaking with them every day and they’re not mad at you. They love you and really want to help you get better. Even if it means trying something new.” Challenging centuries old behavior and creating space for emotional vulnerability is scary. But when there is mutual respect and understanding of someone’s background, physicians can empower patients to build the confidence necessary to take the first step in the right direction. 

Kaveri Curlin is a third year PRIME LEAD-ABC medical student at University of California, Irvine School of Medicine. She attended Yale University for her undergraduate studies, and she is interested in using story telling as a form of patient advocacy.

References 

1. “Addressing The Mental Health Needs Of The AAPI Community,” Health Affairs Blog, September 1, 2021. DOI: 10.1377/hblog20210827.800655

Max stumbles into the kitchen, sees me sipping my coffee, and hugs my neck – he’s got a fever. “Hi, Aunt Meg,” he mumbles, his sweet 5-year-old voice slightly muffled. I ask my sister when my nephew was last on antibiotics – two weeks prior. 

“I think he might have strep again…” My current status as a medical student, coupled with the knowledge that Max had been treated for recurrent streptococcal pharyngitis gave me the confidence to make this statement. “Dios mio,” my brother-in-law mutters under his breath. “Are you sure?” I tell him that I am not, but I recommend a trip to the pediatrician.

A couple of hours later, the diagnosis is confirmed. It is Max’s sixth time to have strep throat in as many months, and he has been prescribed yet another round of amoxicillin. His pediatrician has made a referral to an ear, nose, and throat (ENT) specialist to discuss a possible tonsillectomy.

“Absolutely not. They are not cutting into my son!” my brother-in-law declares, making his position clear. A college professor with a PhD in physical chemistry, W is one of the most intelligent people I know. He is thoughtful, analytical, and rational. He also has a deep distrust of the medical system.

W was born and raised in the Dominican Republic. His earliest memories of the medical system are entangled with the death of his father; later health care memories are tied to the death of his older brother. While in Puerto Rico for his doctoral studies, he said his final goodbyes to a close friend who died due to complications from an elective heart procedure. W’s distrust of the medical system is not without good reason, and he is understandably hesitant about the possibility of his young son undergoing surgery.

“Can you talk some sense into him?!” my sister huffs as she moves to put the pink liquid medicine into the refrigerator. I look from her to him to Max, who, feeling miserable, has curled himself up on the couch.

My gut reaction is to play the role of the concerned aunt – appeal to my brother-in-law’s emotional side and talk about how much better his son will feel once his infection-prone tonsils have been removed. But then I consider how deeply W loves Max. His resistance to surgery does not come from a disregard of his son’s comfort, rather, I can see on his face that he is terrified about what outcomes may arise from a tonsillectomy.

“What concerns do you have?” I ask, reminding him that, as a student, I likely will not be able to address them all. “That doctor talked too fast. It was like she didn’t want me to know what was going on, and she just wants to operate!”

We talk. He wants to know why a tonsillectomy is favorable to repeated courses of antibiotics. I speak about antibiotic resistance and alteration of gut microbiome. He asks about the risks associated with tonsillectomy. I tell him about the recovery period, pain control, and the risk of bleeding. He wonders why they took so long to suggest surgery if this is the best option. I review with him the American Academy of Pediatrics recommendation for recurrent strep throat and criteria for tonsillectomy. He asks if I think having Max’s tonsils out is a good idea. I tell him I do. He asks if I think Max will be safe. I tell him I do. I help him develop a list of questions to discuss with the ENT, and I tell him his concerns are valid. Then I take off my medical student hat, return my aunt hat to its rightful place, and I watch cartoons with my nephew.

Trust is integral to successful medicine, and as a student, my responsibility to build trust does not end when I leave the hospital. One’s lived experiences often take precedence over rationality and knowledge when trust is at stake – even though my brother-in-law is a highly educated, logical individual, he does not automatically trust the recommendations of a physician simply because they are rooted in science. As health care professionals we must listen and strive to understand in order to build communication that facilitates trust.

W was able to discuss his concerns over Max’s surgery with the ENT. The physician sat down, took her time, and addressed his questions thoroughly. Though still nervous, W agreed to proceed with the surgery, and Max is now successfully tonsil – and strep – free.

Meg Sorg will be starting her second year of medical school at the University of Kentucky College of Medicine this August. She is a nontraditional student with a background in pediatric nursing, and she loves spending time with her husband and four young children.

I rearranged the consult documents on my desk for the hundredth time as I waited for a call from an unknown number. When it rang, I took a deep breath and answered, greeting my first consult as an abortion doula. We were both nervous to be speaking to one another, yet in our vulnerability we found solace. I was a 21-year-old medical student, and she was a 40-year-old single mother of two facing an impossible decision. 

I could sense her fear from the very beginning. Her current pregnancy was unplanned, and although unexpected, she decided to carry it to term because she couldn’t bear the idea of a termination. Yet, on her fourth prenatal visit she was informed of a genetic defect that would result in the demise of her fetus. After countless doctor visits in search of a second opinion and enduring isolating sly remarks of some family members, she reached out to our team of doulas.

At its core, the role of an abortion doula is to offer support in a way that honors a patient’s experience and preserves their dignity. I have had the privilege of working in the field of reproductive health, which has allowed me to understand what an abortion implies. Nevertheless, I know that is not the experience for most Puerto Rican women. Therefore, ensuring a safe space for her to entrust in me what is surely one of her most difficult life experiences demanded insurmountable sensitivity, patience, and comprehension. 

Establishing a rapport with patients is difficult, and having to do this over the phone during a pandemic made it even harder. To me, an abortion offers security, control, and freedom but to her the concept of abortion was riddled with shame and fear. Most of these negative emotions stem from the secrecy that surrounds reproductive health and the lack of agency she has had over her own body throughout her life. 

So, as a means of preserving her autonomy during our conversation I adopted the language she used to describe her situation. Throughout our calls we spoke about the “baby” instead of a “fetus” and a “procedure” or “God’s will” instead of an “abortion” or “termination.” This simple adjustment to my selection of words created a space for her to share her experience without tainting it with my personal beliefs. 

Forty-five minutes into the phone call I knew we had transcended past the trepidation of our initial greeting when she asked if she could read me a poem she wrote after her last doctor’s appointment. What followed was proof of the power of thoughtful listening. After her reading I confessed that I also write poetry and so we spent the last fifteen minutes of our call sharing our poems with one another. It is not often that we get to witness the sheer vulnerability of another human being, yet if we are willing to learn and be receptive to the experiences of others, we find ourselves able to achieve extraordinary connections.

It is difficult to overcome the stigmatization and misinformation that holds reproductive and sexual health care hostage. For this reason, cultivating a multifaceted approach that is founded on a genuine selfless interest for our patient’s wellbeing can make a difference in every interaction. I’m grateful for the opportunity of being a doula, as it has given me the chance to deconstruct the barriers people face when seeking such health care services and improving the ways in which I can connect with others to provide excellent care to those that need it most.

Claudia Sofía Rivera Barbeito is a third-year medical student at the University of Puerto Rico School of Medicine. Her interests include reproductive justice, maternal fetal medicine, and health care policy. In her free time, she enjoys hiking, painting, taking photographs, and playing tennis.

Last year, my mom was diagnosed with Stage 4 ameloblastic carcinoma, an exceedingly rare form of cancer. This diagnosis instilled profound fear in my immigrant parents, who harbored a deep-seated distrust of medical institutions due to their past experiences with inadequate health care in their home country. 

In their eyes, a medical diagnosis as intimidating as “cancer” meant: “death.” Witnessing my mom’s apprehension during countless doctor visits and engaging in meaningful dialogues with her emphasized the paramount importance of fostering genuine human connections between health care providers and patients. This experience provided me with invaluable insights into effective methods of building trust, prompting me to reflect on my own interactions with patients. I aspire to share and expand upon these lessons throughout my career as a physician.

My mom’s diagnostic odyssey was characterized by many misdiagnoses, with doctors attributing her symptoms to the stresses of a working mother. Eventually, her worsening symptoms prompted them to label her condition as periodontal disease, despite her gums being perfectly healthy. Through our conversations, I observed the impact of cultural nuances on patient care, as my mom, feeling dismissed by doctors she once trusted, internalized her pain, and suffered in silence as women typically do in South Asian culture. 

While she was eventually diagnosed with ameloblastic carcinoma, she explained that her lack of faith and cultural biases had influenced her conservative decision for only the surgical removal of cancer, denying other treatments. Witnessing the harmful manifestations in my mom’s physical and psychological health, I encouraged her to seek doctors that prioritize active listening and cultural competency. 

Rather than leading patients astray with false assurances and misinformation that can be compounded by past traumas and unreliable sources online, I explained the value of physicians acknowledging the limits of medical information. My contrasting suggestion was to accept the radiation and reconstruction treatments. This dialogue with my mother, who was battling uncertainty as a rare condition patient, not only fostered trust but also empowered her to actively participate in her own care, following through with the appropriate treatments from doctors who could understand her story.

From this experience, I learned that nurturing patients’ trust requires viewing them as individuals with unique stories, fears, and aspirations, rather than as mere cases to be solved. Furthermore, the quality of patient-provider relationships relies on doctors’ promotion of cultural competence and health equity.¹ 

I recall a particularly poignant, different encounter during my time as part of a medical team in Haiti. Amidst the backdrop of poverty and limited access to health care, I witnessed the profound impact of bonding with patients to provide comfort.

One instance stands out vividly. I encountered a patient named Marie, a middle-aged woman, who was seeking relief from chronic back pain. Her pain was not just physical but also emotional, stemming from years of laborious work carrying heavy baskets on her head for long distances, without access to proper medical care. As I examined her, I recognized the fear in her eyes, mirroring the same emotions I had seen in my own family during my mother’s illness. As she shared her daily struggles, I could sense her apprehension towards my broken Creole, which was similar to the interactions I witnessed with my parents.

However, I couldn’t help but empathize with her plight. Living and working alongside the community allowed me to experience their daily struggles firsthand. Having set up camp in an isolated mountain village, I pulled water from a well, slept on the floor in homes without electricity, and adapted to the local conditions. I understood the unspoken reality of how Marie’s cultural environment exacerbated her condition. These implicit experiences allowed me to ease Marie’s doubts about whether a foreigner could understand her pain. 

As I continued my verbal and non-verbal engagement with Marie and her community, a sense of camaraderie began to form. Her shift in perspective regarding my cultural competence allowed me to no longer be an outsider but instead an ally working to address her health care needs. My conversations with Marie became more meaningful, considering not just her physical symptoms but also the underlying social determinants affecting her well-being.

By attentively acknowledging patients’ cultural environments through open conversations, physicians’ bonds with patients can flourish, transcending language and cultural barriers and uniting us in a shared commitment to patient well-being.²

I learned building trust with patients is not confined to the walls of a hospital or clinic. It is a universal language of compassion and empathy that transcends surface-level dialogues to a deeper understanding of our patients’ diverse backgrounds.

Nitya Devisetti is a medical student at Rutgers New Jersey Medical School (in the Combined BS/MD Program) in Newark, NJ. She is passionate about promoting accessible health care to underserved populations. Pursuing this passion, she has interned at the Penn Injury Science Center and Centers for Disease Control and Prevention (CDC) where she did research on the social determinants of health. Recently, Nitya won $20,000 in a business plan competition, detailing her business idea for affordable health care inspired by the current state of the health care system and recent Price Transparency Laws. In her free time, Nitya likes to experiment with nail art, cook plant-based meals, and exercise with her dog, Cookie.

References

1. Saha S, Beach MC, Cooper LA. Patient Centeredness, Cultural Competence and Healthcare Quality. Journal of the National Medical Association. 2018;100(11):1275-1285. doi:https://doi.org/10.1016/s0027-9684(15)31505-4
2. Stubbe DE. Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients. Focus. 2020;18(1):49-51. doi:https://doi.org/10.1176/appi.focus.20190041

“You cannot tell him,” my mom repeated as we stood outside the hospital, the summer heat radiating off the sidewalk. I was always apprehensive about traveling to China, surrounded by an unfamiliar environment that should feel like home, a language I can haphazardly understand, and never-ending smiles to barely-known family members. However, on this trip, I had a different reason to be nervous.  

It had been four years since I last saw waigong, my grandfather. Although distanced by language and cultural barriers, he always inundated us with freshly cut fruit, homemade chicken soup, and xiaolongbao from the best market in town. Although not a man of many words, his warmth melted my anxiety and replaced it with a full, satiated stomach. 

“What do you mean I can’t tell him? He doesn’t know?” I asked in disbelief. 

“It is for his own good,” my mom said.

Over the past few months, she exhausted herself flying back and forth to China, taking care of waigong. He had been losing a battle to pancreatic cancer. However, he did not know cancer was killing his body. 

Growing up in America, I learned to value autonomy, one of the four principles of ethics drilled into us during medical school. Above all else, the patient has the right to make their own decisions.

I could not fathom lying to a family member about their illness. Stoically, I pushed back and advocated for my values. I urged my mom that withholding his diagnosis is wrong, and he deserves to know the truth about his condition. If you were him, wouldn’t you want to know?

“It’s not that simple, this is what’s best for him,” my mom stated, as we entered the building. 

We maneuvered the crowded and labyrinth hospital halls, reaching waigong’s bed. The man who once had such a large presence now looked small, both literally and figuratively. He had not been able to enjoy the food he once loved, and loved to share with us. 

Once he saw us, his face lit up with the warm smile I remember from years ago, though now with a 

touch of jaundice and an abundance of exhaustion. I sat with him while my mom talked to the doctors. We shared very few words owing to my mediocre mandarin, but I understood what he wanted to say to me that day, and I believe he understood what I should have said to him. We sat in a shared silence of appreciation, my hand never letting go of his. 

I wondered then if he knew he was dying. I wondered if he knew this was the last time he was going to see me. I wondered if I should tell him the truth. 

After leaving the hospital, my mom said that was the first time she had seen waigong smile in weeks. 

“Here, it is common to withhold a cancer diagnosis. Why do you think we have not told him?” she asked, but I could not imagine why.

“Hope,” my mom described. “If he does not know, he can still hold onto hope.” She explained that hope is thought to be a crucial ingredient to any treatment or cure. 

“You can still have hope even if you know the truth?” I replied. 

“Yes, but we are also protecting him from unnecessary distress and worry,” she said. 

My family believed they were carrying the burden of illness so my waigong did not have to. They endured sleepless nights and immeasurable anxiety, then assumed a smiling face and optimistic demeanor for my grandfather, helping preserve his own energy to recover. Rather than valuing autonomy, my family nourished a collective beneficence for him.

Naively, I had insisted my mom do the “right” thing without understanding the context. The significance of autonomy is unfailingly emphasized in American culture that I believed it to be necessarily true. I learned from my family that the unwavering values cultivated in us are not absolute. Each culture, each society, each family, and each individual lives in different contexts. 

As a physician in training, it is imperative to me to be conscious of my biases and realize when the “right” answer we are taught is not right for everyone. I should have trusted my mom’s decision and exercised curiosity about cultural practices, rather than imposing my own views. To provide true compassionate care to patients, I must appreciate and respect our differences, fostering our trust in each other to make the right decisions.

Shannon Fang is a third-year medical student at Case Western Reserve University School of Medicine and received her undergraduate degree from Duke University. Shannon is interested in pursuing a career in medical education, health humanities, and health care advocacy. Outside the hospital, she enjoys playing with her cats, crocheting, and watching college basketball.

It was 11PM on my Internal Medicine sub-internship when a new admission was paged out from the ED.  

“67-year-old male, history of alcohol use disorder, presenting after a fall. He had a pint shortly before the incident.” My resident and I sigh. “Watch him, give him the vitamins––same deal as when he was here a few weeks ago. Probably just the classic ‘alcohol-induced ambulatory dysfunction.’”  

I trudge to the exam room, prematurely irritated by the Sisyphean plan of a vitamin cocktail rolling down the mountain of substance use.  

He lay in bed, somnolent, his downcast eyelids like lampshades masking provider scrutiny. His diffuse tremors work through Ativan’s sedating effects. 

“Mr. Hutson!” I yell, trying to get his attention. His eyelids droop further shut.  

I haphazardly solicit a history from his mumbles, ultimately deciding to just consult his chart. After all, would this encounter truly be any different from the last five?      

When presenting all of his electrolyte derangements, cardiac arrhythmias, and nutritional deficiencies to my attending, I let Mr. Hutson’s bottle count drench his entire problem list and, in effect, his personhood. The problem is alcohol, the solution is sobriety, and the perceived infeasibility of the latter leaves me ill motivated to probe any deeper.  

Later in his room, I watch my attending lower herself to his eye level. She sits back on her heels, takes his tremulous hand in hers, and stares earnestly into his eyes. She asks him who he likes to drink with and why. He replies that he drinks alone, that it is the one-year anniversary of his son’s death, that the alcohol soothes his hurt. She asks if he would be open to quitting, to which he says that yes, yes he would but no, no he would not wait in the hospital for rehab placement. She gently presses further, citing her concerns about relapse and invoking the worries of his daughter, who lives too far away to act upon the falls recorded on her self-installed home monitors. With several more minutes of teary-eyed conversation, he acquiesces, agreeing to stay inpatient as a bridge to rehab.  

I am internally slack jawed, awed by the power of a clinician’s authentic care to guide a patient toward a decision that will benefit their health. Over the next few days, I practice getting down on one knee, speaking to the person and not the pathology, and creating space for vulnerability. We talk about March Madness brackets, he agrees to starting Vivitrol injections, and I watch his eyes light up as he tells me about his daughter. The trust between us builds, and I start to write a happy ending. 

And then, over 80 hours since his last drink and in the absence of any signs of worsening withdrawal, he seizes.  

With a multi-day Ativan taper, he emerges from the grip of complicated withdrawal, still set on pursuing rehab, although now with steadfast intent to first return home. The precise timeline of rehab center referral, interview, and acceptance remain uncertain; we fear that each minute spent alone in his home would compound his vulnerability to relapse.   

I kneel at his bedside, I call his daughter, I voice our concerns about the electrolyte-related ventricular arrhythmias captured on telemetry, imprudently grasping at fear tactics to catalyze a change of heart. But he refuses, adamant about returning home to have his living will be notarized. He is fixated on this affair, almost eerily so, as though he knows that life itself now delicately hangs in the balance.  

And ultimately, who am I to deny this grown man the right to part from this life on his preset terms? To refute his desire to pack clean clothes for the courageous journey ahead? To question his wish to visit his son’s grave for fear of whatever sadness it might stir?  

In the success story of patient trust, I had naively expected the patient to ultimately accede to provider recommendations. But trust is neither a thing to be “won” or an active “winning” of patient compliance. Trust is to meet a patient halfway, to walk alongside them, and to encourage them forward while never abandoning them should that journey grow circuitous.  

And so I stop trying to persuade, again kneeling by his bed as I had done every day. 

“Don’t worry about me. I’m a tough one,” he smiles. 

I take his now-steady hand in my own and look into his now-open, mournful, yet hopeful, eyes.  

“You are.” 

Ella Eisinger is a fourth-year medical student at the University of Pennsylvania Perelman School of Medicine who is applying into Internal Medicine with plans to specialize in Pulmonary and Critical Care. She holds a bachelor’s in biology from Stanford University, and her interests span both translational and policy-facing academic research, medical education, and effective science communication. In her free time, she enjoys running, cycling on her road bike affectionately named “Olive,” and backpacking.

The 2023 Building Trust Essay Contest, sponsored by The American Medical Student Association and the ABIM Foundation, asked medical students to engage in a reflective writing exercise about their experiences where they or someone they know received, shared, or acted upon misinformation in a health care setting

A sneeze issued from the tent as we approached.

“Anybody home? Street medicine outreach,” my preceptor called out.

The tent’s mouth unzipped, the canvas falling inward to reveal our patient, a young man. Our street medicine team frequented these community campsites on a biweekly basis, providing medical care to individuals experiencing homelessness.

I knelt down, offering a cup of coffee.

“How are you today?”

Our patient shook his head.

“Not so good,” he coughed, cheeks flushed. He’d become ill yesterday; fever, malaise, sore throat, cough. Four days ago he’d had a meal at a soup kitchen–one our team knew was the site of a recent COVID-19 outbreak.

After hearing his history, I asked, “Can we get you a COVID test today?” Our patient looked up sharply. I was aware of him taking in my N-95, the pro-vaccination pin on my lanyard.

“Nah,” he said, “that COVID thing is a hoax.”

Immediately, my heart began to beat with agitation. I couldn’t ignore his provocation: the presentation of false facts, my own knowledge questioned, and, of course, the public health ramifications of his belief.

How dare he claim COVID-19 was a hoax?

A recent Kaiser Family Foundation report found that 78% of those surveyed “believed or were unsure about at least one false statement,” related to COVID-19.¹ COVID-19 misinformation has created a second pandemic; loss of trust in scientific institutions, failure to evaluate credible information, and a lack of agreement among neighbors on even the most basic set of facts. COVID-19 misinformation is “a powerfully destructive force…one false idea can spread instantly to many vulnerable ears.”²

But while it is true that misinformation is a tremendous burden to our collective public health, so too is the way we speak of those who espouse it. We shake our heads at the “ignorance,” and lament the “selfishness,” of those who eschew medical recommendations, effectively creating silos of “us” versus “them,” that pit clinicians against patients. Infrequently, however, do we attempt to understand the lure of misinformation. It is not often that we stop to consider how misinformation may make sense to those for whom our health care system has not traditionally worked well.

Our patients experiencing homelessness have good reason to mistrust health care; unhoused patients contend with profound bias, stigma, and mistreatment in medical institutions.³ So too do our patients of color; we have yet to demonstrate, in health care or society, that we value the lives of Black, Indigenous, or Latinx Americans.⁴

Misinformation results from a lack of trust in one another, a fundamental breach in our ability to communicate respectfully. Mitigating misinformation can only begin when we endeavor to understand its origins.

In her book, I Never Thought About It That Way, Mónica Guzmán makes the case for changing our approach toward those with whom we disagree. She argues for curiosity as an antidote to the partisan isolation of our current discourse. Instead of attacking one another on the merits, or perceived lack-there-of, of our arguments, our inability to communicate with one another must be the starting point to engagement.⁵

We must approach misinformation the same way.

In my own life, I have witnessed the destructive power of false belief. A close family member refused to be vaccinated for COVID-19, subsequently failing to meet my son until more than a year after his birth. I have a parent who struggles with the neurologic sequelae of long COVID-19, frequently tasked with convincing others their symptoms are real. As I try to navigate how to keep my children safe, in a world ready to move on, I meet unvaccinated patients, in clinic and on the streets, who assert that COVID-19 is fake, overblown, or a conspiracy. I am usually frustrated, occasionally devastated, and often terrified by the hold misinformation has on our communities.

But I have learned enough, from my mentors and my time working with unhoused patients, to know that building bridges back to health care and community is hard. Building trust, both within our hospital walls and at our dinner tables, on the curb or in the clinic, requires patience, grace, and yes, curiosity. Guzmán offers this advice: “When you want to stop listening so you can react or respond or judge…mind that gap between what you know and what you most certainly don’t and ask one more curious question.”⁵

We must attempt to see one another, before we try to change one another. I faced my patient and took a deep breath.

“Tell me more,” I said.

Molly is an incoming PGY-0 in the Psychiatry department at Duke University. She studied sociology and peace studies at Bryn Mawr College before serving as a Peace Corps Volunteer in Belize from 2014 to 2016. She is the co-founder of Auxocardia Journal, a creative space for health professional students, and previously served on the board of the University of Michigan Medical School’s Wolverine Street Medicine, leading foot care efforts for persons experiencing homelessness and medical education initiatives. She is a 2022-2023 Albert Schweitzer Fellow in the Detroit cohort, member of the Gold Humanism Honor Society, and AOA.

1. Hamel L, Lopes L, Kirzinger A, Sparks G, Strokes M, Bridle M. Kaiser Family Foundation COVID-19 vaccine monitor: media & misinformation. KFF Reports. 2021. Accessed March 2, 2023.

2. Nelson T, Kagan N, Critchlow C, Hillard A, Hsu A. The danger of misinformation in the COVID-19 crisis. Mo Med. 2020;117(6):510-512.

3. Reilly J, Ho I, Williamson A. A systematic review of the effect of stigma on the health of people experiencing homelessness. Health Soc Care Community. 2022;30(6):2128-2141. 4. Manning KD. More than medical mistrust. Lancet. 2020;396(10261):1481-1482. doi:10.1016/S0140-6736(20)32286-8

5. Guzmán M. I Never Thought of It That Way. 1st ed. BenBella Books; March 8, 2022.

The 2023 Building Trust Essay Contest, sponsored by The American Medical Student Association and the ABIM Foundation, asked medical students to engage in a reflective writing exercise about their experiences where they or someone they know received, shared, or acted upon misinformation in a health care setting

As patient advocates, physicians are in unique positions to address their patients’ concerns while also learning the belief systems that govern their lifestyle choices. To achieve this, establishing trust and reliability is an integral part of a successful therapeutic relationship. Some patients may not feel comfortable disclosing their viewpoints or collaborating with a provider who appears unapproachable and callous. If a patient is not invited to engage, indicate understanding, or provide context, there is the risk of incorrect adherence or fulfillment of the treatment plan that was developed. Misinformation can be easily overlooked if there is no opportunity to discuss it.

A particular experience comes to mind when reflecting on misinformation in health care settings. During my third year of medical school, I spent some time in a geriatric primary care clinic. One patient in her 80s, Ms. Marshall, was being seen for a routine checkup.  Together she and the attending physician discussed her hypertension, diabetes, and cholesterol. The conversation then approached mental wellbeing. The physician inquired about her mood.

Ms. Marshall looked momentarily taken aback before saying, “Actually, I just feel so anxious all the time. I don’t feel myself. I worry about everything. It’s constant.”

The physician paused her documentation to turn to Ms. Marshall. “Tell me more.”

Ms. Marshall revealed that lately, she had been worrying about her children and grandchildren more than usual for no apparent reason. She felt as though she was the caretaker of the family and always owed them her undivided attention.

“It sounds like you’ve been struggling. There are options we can talk about,” said the physician. “Therapy, medication…“

“No. I don’t want medication,” she interrupted. Her response was firm and immediate, and I saw the attending’s head tilt in concern.

“Why don’t you want medication?”

“I read on Facebook that it changes your personality,” Ms. Marshall replied. Her hands trembled in her lap. My attending gently reached over to pry Ms. Marshall’s hands apart and hold them in her own. “And makes you crazy. I don’t want to mess with anything. I’m not weak. I can handle it. I don’t need meds.”

I watched my attending pause to digest this information. This was a delicate moment. It was clear that Ms. Marshall trusted her physician enough to disclose personal matters about her mental health, but not enough to permit the physician’s recommendations to overtake her belief systems. The path forward hinged on whether or not my attending chose to acknowledge her patient’s beliefs about anxiolytic medications.

She did. “Let me ask you something,” said the physician. She was still holding the patient’s hands. “Do you take medication for your high blood pressure and diabetes?”

A bewildered pause. “Yes, of course.”

“Do you believe those medications are helping you get better?”

“I do…”

“Did you hesitate to start medication for those issues?”

Ms. Marshall was silent, as if she began to understand the direction. “No, I suppose I didn’t.”

“Then why,” asked my attending, “should your mental health be any different? Why should you treat it differently, less urgently, than your diabetes or blood pressure?”

What followed was one of the most impactful moments I can remember in my third year. I can still vividly recall the change in Ms. Marshall’s expression as she registered those words. It was as if a veil had physically lifted and understanding dawned on her face. She began to cry.

“You’re right,” she whispered. “I don’t know why I thought that. It won’t make me weak.”

In this instance, the physician was able to combat both stigma as well as misinformation. To me, this represented the importance of shared decision-making as a tool for addressing misinformation. It is important that healthcare providers present multiple options to patients to elicit their preferences as well as hesitations. Sometimes, it can be as simple as reframing patients’ priorities (“Is anxiety any different from hypertension as a medical concern?”) or probing deeper into patients’ views to create space for education (“What’s your understanding of what antidepressants do to the body?”).

Clinicians can unknowingly contribute to the spread of misinformation by not allowing space to have these critical discussions, by keeping treatment options monochromatic and inflexible, and by choosing not to explore patients’ inner lives and what helps them make decisions.

It was heartwarming to see that not only did Ms. Marshall elect to receive care for an important issue, but she may eventually correct someone else in her life who shared her former perspectives. Meaningful conversations with individual patients can make a large, perpetual impact on the health of large populations.

Isra Hasnain is currently a third-year medical student at the University of Chicago Pritzker School of Medicine. Her interests include primary care, maternal health equity, and rural health disparities. When she’s not championing her unbiased love for Chicago pizza, Isra enjoys practicing yoga and snuggling with her oreo-colored cat Nova.