Tag: Building Trust Essay Contest

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

“So, do I not need to start the Metformin?” Mr. Smith¹ asked a few minutes into our visit.

The question should have raised a red flag, but in my initial confusion, I asked, “What do you mean?”

“Well, I’ve been taking GlucoBal² for four weeks, so I shouldn’t need to start Metformin, right?”

Mr. Smith explained that he’d gone home after his last visit and, naturally, had Googled “type 2 diabetes”—the disease he’d been told he had. Just as his doctor had told him, he read that diabetes was a disease in which his body could not process sugar correctly. He remembered the doctor saying that while he needed to start Metformin to get his blood sugar under control, it would not cure his diabetes.

But there had to be a cure, right? He remembered hearing something about a cure for diabetes on the news. “Cure for diabetes,” he searched. On the first page of results, he found what he was looking for: “Best Natural Blood Sugar Cure? – New Study Says ‘Try GlucoBal.’”

The website was slick, with high-quality, scientific-appearing diagrams and links to real scientific studies. It said that the blend of “earth-grown herbs and natural compounds work together to restore healthy blood sugar levels.” A natural cure for diabetes had to be better than taking Metformin forever, right? Reviews on the website near-universally said that GlucoBal had balanced people’s blood sugar. He even clicked on one of the linked studies. It seemed to support what the website was claiming. There wasn’t any need to pick up the Metformin from the pharmacy.

As Mr. Smith recounted this story, I looked up GlucoBal and its ingredients. Bitter gourd extract? Clinical trials didn’t seem to support its use.³ Cinnamon? There was some evidence it would lower blood sugar, but certainly not cure diabetes (and the dose was too low anyway).⁴ The rest of the ingredients fit the same bill.

“Where am I even going to start?” I thought.

I wish I could say I had some magical approach to answering Mr. Smith’s question that conveyed all my doubts after a few quick searches.

I tried to imagine what he was thinking. He had spent a significant amount of time reading about this supplement. And he had spent money too: almost $50 for a month’s supply. What could I say?

I started with a confession: “I’ll admit haven’t heard of GlucoBal, but I am skeptical of some of the claims. Lots of people have been trying to find a cure for diabetes, but nothing I’ve heard of has come close. It would be big news if something did. Would you be willing to search for some answers together right now?”

Mr. Smith agreed, and we spent 15 minutes going through the ingredients and data together. As a medical student, I had the luxury of time, with no patients in the lobby waiting for me to get to them.

In the end, Mr. Smith said he understood that Metformin was “probably” a better choice and told me that he would pick up his prescription from the pharmacy. He did.

I’ve since wondered why Mr. Smith came to trust me enough to fill his prescription. I think the time that I spent with him factors into it. After all, it’s much easier to combat two hours’ worth of internet misinformation in 15 minutes than it is in five. These days, many primary care doctors are lucky to get 15 minutes for an entire appointment.

But I think the more important element is the fact that I expressed my lack of certainty to Mr. Smith.

At the end of my medicine clerkship, one of my physician mentors gifted me some light reading: a 500-page biography of William Osler.⁵ I often find myself returning to this book and the writings of the eternally quotable Osler.

Reflecting on my time with Mr. Smith, one quote comes to mind: “To confess ignorance is often wiser than to beat about the bush with a hypothetical diagnosis.”⁶ Or, distilled: Be honest, even if it requires the vulnerability of saying “I don’t know, but let’s find out.”

As uncomfortable as it may feel to internalize this concept, it is vital for our medical training. We will all have our Mr. Smith, and we all must eventually learn to confess ignorance just as readily as we confess expertise. Honesty is the only cure for misinformation.

That only leaves us the challenge of finding the time. 

Ian S. Jaffe is an MD/MS student at New York University. He currently works with the NYU Transplant Institute and is passionate about improving the health and wellness of transplant recipients. Outside of medicine, Ian enjoys cycling, writing, and exploring the museums and theaters of NYC.

¹ Mr. Smith is a pseudonym.

² GlucoBal is a fictional name for a real-life product used by Mr. Smith. There are multiple supplements on the market with similar ingredients that make similar claims and show up in similar internet searches.

³ Ooi, C. P., Yassin, Z., & Hamid, T. A. (2012). Momordica charantia for type 2 diabetes mellitus. Cochrane database of systematic reviews, (8).

⁴ Allen, R. W., Schwartzman, E., Baker, W. L., Coleman, C. I., & Phung, O. J. (2013). Cinnamon use in type 2 diabetes: an updated systematic review and meta-analysis. The Annals of Family Medicine, 11(5), 452-459.

⁵ Bliss, M. (1999). William Osler: A life in medicine. Oxford University Press.

⁶ Osler, W., & Camac, C. N. B. (1905). Counsels and ideals from the writings of William Osler. Oxford: H. Frowde.

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

I set the microwaved cup of instant coffee on the table so hard that it sloshes. He looks at me with guarded eyes. Despite trying to stay positive, this is not exactly an ideal start.

Working with refugees seeking asylum has taught me that trust is not easily won, and nor should it be. For someone who has lost so much to tell you their stories, it requires the willingness to try establishing a connection over and over again.

“David,* you need a root canal due to the deterioration of your teeth,” I explain the procedure to him and its importance to his health, but he shakes his head vigorously to make me understand.

“They will sell my teeth to the government. They will use it to track me down or frame me for a crime.”

David’s fears are far from unfounded. His deep mistrust of the medical system is borne from experiences in his home country, where the government arrested people for crimes they did not commit, and health care providers turned over patients to the police. His misinformed beliefs are rooted in conversations with other refugees that have warned him that people may pretend to help him only to send him back to his home country.

He has little reason to trust me after our few hours of meetings over the past few weeks. My eyes settle on his knuckles glowing white as he clutches the coffee cup.

I soften my voice. “I know it is scary. This procedure is completely safe. All they will do is…”

He cuts me off, exclaiming in frustration. “No! Too many words! I don’t want it, I told you.”

Instead of immediately responding, I take a moment. My mind wanders to my niece, remembering her eyes brimming with tears as she screamed that she didn’t want to go to the dentist because it would hurt. We showed her a video, explaining what each tool did until her tears subsided. Maybe combating misinformation isn’t just the information itself but finding the best way to communicate it to the other person.

I pull up a video on YouTube that explains the procedure. I watch as his tense shoulders relax, smoothing into gentle curves just as the frown of his lips settles.

I ask a little too cheerfully, “So… what do you think?”

He looks at me for a moment. He is still unsure, but I can see his grip on the Styrofoam cup loosening. I allow myself a moment to hope.

“Not today, I think.” He hitches his jacket over his shoulder as he prepares to leave the appointment. I feel the familiar stone of disappointment settle in my stomach as I shuffle the stack of papers stained with coffee.

He pauses at the door. “Next week? Next week we can watch the video again?” he asks.

I smile wider. Nod. “We can watch again next week. Maybe I’ll even write a song to convince you.” David nods back at me. Not exactly a smile, but an affirmation we will try again next week. And the week after. And as many weeks as he will let me try to earn his trust.

Misinformation is a door that offers a peek into the corners of another person’s mind. Although these conversations may be fraught with tension and disagreement, they are also an opportunity to understand more deeply. Building trust is a series of small steps that do not always arrive at a solution. Although it may not have the outcome I hope for, it is still as valuable as an appointment where mutual trust comes quickly.

I believe the most difficult piece is accepting that agreement is not always promised. My first months of medical school were energized with idealism and the belief I could win over every patient. Now, I have a more subdued approach. I sit beside the patients. I listen without judgment. I wonder about the amalgamation of life experiences that have led them to their beliefs, ingrained value systems, and this very conversation.

I do not pretend to have all the answers. Perhaps this is ultimately what draws us together. Even at odds, reaching out to each other across a vast divide, we can all acknowledge that we are doing our best to find meaning amidst the messy beats of life. So that even if our conversation does not end with agreement and a handshake, there is a promise to keep reaching across the divide, listening and sharing thoughts over a lukewarm cup of coffee.

Meher Kalkat is a third-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.

*Note that name and any identifying information have been changed.

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

“Are you sure?” The question was to my preceptor, but his gaze was on me, like he was searching for a second, differing opinion.

If we’re being honest, I’m usually not sure. The abundance of information available at our fingertips can be overwhelming. As a first-year medical student, I often struggle to trust myself, but I trust the process of my training. Since starting my pre-clinical years, my knowledge base has been tested, stretched, and built upon at an exceeding rate. Every other Tuesday, I get to see real patients, practice interview skills, and apply new material through a clinical preceptorship program. It’s in these clinical encounters that I learn about more than the organ system of the block. It’s in these clinical encounters that I witness fear and vulnerability turn into trust. It was also in one of these clinical encounters that I met Sergio.

Sergio was a year younger than me. A week prior he was helping a neighbor with a construction project where he inhaled some dust and debris. The exposure was brief and limited, but he was nonetheless concerned. He read online that vigorous exercise was the best thing he could do to “clean out his lungs following exposure.” Not only did it not help, but for the first time in years, it exacerbated his asthma. The next day, he noticed a new pain in his back right where his lung would be. He came to us anxious and convinced that lung scarring from the exposure would lead to a serious disease. As my preceptor worked through his list of concerns, reassuring him along the way, he’d push back.

“Yes, I understand, but…” he’d circle back to something else he read. It’s pulled up on his phone. He can show us.

The issue with online information is that it’s often out of context. Internet searches tend to identify rare or worst-case outcomes. Misinformation and misinterpretation often go hand-in-hand, and it’s hard to navigate this space alone. Caring for vulnerable patients requires trust, comfort, and thoughtful communication to help alleviate the anxiety often experienced by patients in these settings. Teachable moments in the clinic are an opportunity for these values to shine.

My preceptor is good at teachable moments. I’ve watched her pull up diagrams on her computer to show patients exactly what she is talking about when referring to anatomy. With Sergio, I watched her do what his online searches couldn’t. I followed along as she connected his medical history, experience, and story to his current symptoms. I listened as she walked us through her line of thinking.

We found out that he’s not usually that active and swinging a hammer in that manner was a new motion for his body. Most importantly, we were able to pinpoint a muscle group that aligned with where he felt the pain. To his relief, it wasn’t his lung.

We no longer have a stronghold on medical information, but we have the skills of empathy, connection, and context. The ability to assess, interpret, and contextualize signs and symptoms is a gift. For Sergio, it provided the reassurance he desperately needed in that moment. The amount of information available online can be overwhelming, but teachable moments can build trust for medical students and patients alike. It’s moments like this that engage patients in their own care and rebuild the foundation of trust and partnership.

Elina Kurkurina is a first-year medical student at the Frank H. Netter MD School of Medicine at Quinnipiac University. She is interested in the intersection between emergency medicine, geriatrics, and primary care. Prior to medical school, she worked in quality measurement and holds an MPH degree in Social and Behavioral Sciences from the Yale School of Public Health. In her free time, she can be found on a hiking trail with her husband and rescue dog. 

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 the tip of the syringe moved toward his shoulder, I witnessed an ever-expanding fear grow in the eyes of Teddy, a 6’ 6”, 260-pound Police Officer at New York City Health + Hospitals (NYC H+H), in Harlem.

Teddy, a Harlem native, was supported, loved, and grew up in the surrounding community, and he now returns the favor every day, taking care of his community in a space meant to be safe. As the needle pierced his skin, its protective contents pushed into his body, he immediately looked at me. Teddy asked me to be with him for his first COVID-19 vaccination. Seeing doubt and fear in his eyes, questioning what he had just done, was, for lack of a better word, painful. However, Teddy receiving that life-saving (for many) vaccine, trusting what he was taught, and relying on the information he learned, was motivating.

When I reflect on this moment, I feel somewhat selfish and uncomfortable with what I describe as a feeling of personal victory. I convinced Teddy to get his first COVID-19 vaccine! But then I remember who Teddy is, and why his decision to get vaccinated is so important to me.

Teddy was born and raised in Harlem, a permanent resident of the “Black Mecca,” a loving husband, and a proud father. During COVID-19 first wave, he was a transporter of lives lost, stored in refrigerated containers due to a lack of space in the morgue. Throughout the pandemic, Teddy was steadfast in protecting his community, a pillar in his post, often unmasked due to the limited availability of N-95’s. As a health care worker (HCW), his risk of testing positive for COVID-19 is 11.6 times higher than the general community, and as a Black male, he is 2.1 times more likely to be hospitalized due to COVID, and 1.6 times more likely to die from COVID-19 compared to white, non-Hispanic persons. Teddy was also one of 542 HCW’s at NYC H+H/Harlem who took part in the Community Activation Model: COVID-19 Vaccine Educational Seminar (CAM). Teddy getting that vaccine was a victory!

On August 16^th, 2021, New York Governor Andrew Cuomo announced that all HCW’s in the state must be vaccinated against COVID-19 by September 27^th, 2021. This preventative measure was needed due to a growing deficit in HCW availability, combined with hospitals being overwhelmed by the influx of non-COVID-19 patients due to delayed care, compounded by the Delta Variant spreading across the City. For systems like NYC H+H, where approximately 20% of its 42,000 employees had yet to receive their first vaccine, meeting this requirement would be no small task.

After my third year of medical school, I took a gap year to work at NYC H+H, and was part of a team responsible for reducing the potential downstream impacts of this mandate on the care we provide. A majority of my work was completed at NYC H+H/Harlem, where 22% of the workforce was unvaccinated.

Alongside other efforts I developed the CAM as an intervention to retain employees and to increase vaccination rates among the workforce. The foundation of the CAM is centered on respecting the individuality and unique needs of the population you seek to serve. Therefore, as part of designing the CAM, we conducted key informant interviews with hospital staff, in order to identify key drivers of vaccine hesitancy at NYC H+H/Harlem, which included:

1. Lack of trust in the vaccine due to difficulty in accessing information that is easy to understand.
2. COVID-19 no longer being a threat – “we lived through the first two waves without a vaccine.”
3. The importance of personal agency – disregard for autonomous decision making.

Respecting the unique needs of the Harlem community, I designed a teaching curriculum to answer the questions and concerns related to the population, and provide accurate knowledge to enable informed decision making. Simplifying immunology, virology, and vaccine history and development to a middle school reading level, and requiring every unvaccinated employee to take part in the seminar over a 3-week period.

The results were tremendous, with a reduction in unvaccinated employees by September 27 from 22% to 4.4% (NYC H+H average of 7.8%).

While I recognize the mandate as a critical driver of vaccine adherence, the efforts of the CAM played a major role in vaccine understanding, comfortability, and acceptance. While misinformation will always have an enormous impact on healthy and informed decision making, we learned through this experience that it is just as important to increase accessibility to understandable and accurate information that anyone can use to combat misinformation.

Dr. Christopher R. B. Montgomery’s professional journey has spanned various roles and responsibilities. After serving as Assistant Health Care Program Planner and Analyst at NYC Health + Hospitals, he is now an intern at the UCLA Reagan/Olive View Emergency Medicine Residency. His academic journey began in Germany, where he received a Baccalaureate of Science from the University of Mainz and a Bachelor’s degree in Biology from the Technical University of Kaiserslautern. He then pursued an MD with distinction from the University of California, San Francisco, preceded by a Master’s in Public Health with a focus on Global Health, Epidemiology, and Biostatistics at Loma Linda University. His experience extends to the San Bernardino Department of Public Health, where he worked as an epidemiologist, contributing to systems improvement, resource optimization and community engagement.

• Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG, Ma W, Mehta RS, Warner ET, Sikavi DR, Lo CH, Kwon S, Song M, Mucci LA, Stampfer MJ, Willett WC, Eliassen AH, Hart JE, Chavarro JE, Rich-Edwards JW, Davies R, Capdevila J, Lee KA, Lochlainn MN, Varsavsky T, Sudre CH, Cardoso MJ, Wolf J, Spector TD, Ourselin S, Steves CJ, Chan AT; COronavirus Pandemic Epidemiology Consortium. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Public Health. 2020 Sep;5(9):e475-e483. doi: 10.1016/S2468-2667(20)30164-X. Epub 2020 Jul 31. PMID: 32745512; PMCID: PMC7491202.
• CDC (2022, December 28). Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity. CDC Center for Disease Control and Prevention. Retrieved March 1, 2023, from https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html

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.