Tag: Building Trust Essay Contest

“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.

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.