The Missing Ingredient in Medicine: TRUST

A friend of mine is interested in trust. Not the kind that lawyers and bankers deal with, but the strong intermolecular force that makes human interaction possible. If you catch a lawyer or banker at the end of the day and stand him a couple of drinks, he will admit that no matter how well he does his job, without risk there would be no contracts. No loans, no corporations; no deals. The hardest-headed negotiator must take a leap of faith. And the best deals put everybody to work when unpleasant surprises occur. I think my friend has a point: maybe we should all be interested in trust.

It follows from any necessity of trust that when it dries up, things that depend on people agreeing stop working. And maybe, says my friend, that’s what’s gone wrong with health care.

Say she’s right. Imagine that an unspoken contract has to exist for healing to work its magic. Contemplate for a moment that without that contract (whatever it is) the only thing we get from the doctor and the pharmacist is the material click clack of chemotherapy molecules and cell walls. Satisfactory professional performance criteria met, but in case the bad stuff hits the fan the professionals are some distance off not to get any on their white coats.

Let’s for purposes of argument presume that technical intervention alone doesn’t meet human needs, both of the “givers” and the “receivers”, and that something extra is required in the healthcare… what… setting? Interaction? Contract? And let’s also say that part of what’s broken in health care is that this extra piece has been lost. I have to confess I’m a little scared of the next question if we were interested in trying to recover it, which is What is it?

My usual strategy facing questions I don’t think I can answer is to confess I don’t know. And I don’t. But one afternoon I sat with this same friend and heard her describe her husband dying in hospital and how much of the horror of it came not from the tragic events, but afterwards, from the doctors and administrators frankly not telling the truth, not accepting their role in the piece, not sharing the burden. Suddenly I was starting to cry in front of someone I (at that time) didn’t know very well.

I knew the trust she was talking about. As a child in the 1950s I had felt my parents’ relief as an old-fashioned pediatrician told them not to worry, the little boy was going to be okay. It wasn’t the doctor’s technical understanding they trusted so much as knowing that we mattered to him. Even if he was wrong, they knew he would be back to reassess, rethink, explain, admit uncertainty, and try again. And I think my parents understood that if in that most unthinkable of all possible worlds somehow the little boy died, it would break the doctor’s heart too.

I went into this business partly to participate in that exchange. I wanted to be able to give and receive that wonderful trust. Over the years I’ve figured out that you can only do that by promising to take responsibility, and keeping the promise. That trust means a great deal to a person with a health problem, but it is also by far the most satisfying experience someone doing healthcare can have. It can only happen when the professional person has something visceral invested in how effective his help is.

But something has gone wrong, and I found myself grieving in front of my friend, sorry for we doctors’ having shortchanged the world, including ourselves, by not keeping our old human promise. We’ve diminished the gift we give and receive by limiting it to delivering technical and statistical goods. You’re the unlucky statistic with a bad outcome? It happens. Tough. Why does the doctor go home at the end of the day not quite understanding why he feels empty and frustrated? He abandoned his trust, reneged on his contract, and forsook his patient when she needed him most.

Still trying to name what is missing, what the thing the doctor was supposed to do looks like, I went online. Sure enough, trust itself is a subject that’s been studied, and we know this because there is a literature, experts, acronyms, classification, and controversy available to anybody with a computer. For example we have CBT and IBT: “Content Based Trust” and “Intuition Based Trust”.  I would say this disjunction represents a superficial right and left in the healthcare trust dilemma: “Let’s trust one another because the doctor knows his business” versus “Let’s trust one another because we both feel the other is trustworthy.”

I wonder if we are all being invited by trust academics to take sides. Side One (CBT): silly ill-informed people superficially agreeing to feel good about one another equals bad, evidence-based information people can rely on equals good. Or Side Two (IBT): all-knowing expert dictating to ignorant subject equals bad, two people talking things over equals good. Take your pick of the two points of view about “what trust is”. But neither of them is satisfying.  Blind trust in authorized “fact” is scary and dangerous, but thoughtlessly agreeing that everything is okay because two people get along well doesn’t take account of personal realities either.

I think there is a solution.  For me the magnet that can pull CBT and IBT together is mutual investment in the outcome: shared responsibility.  Call it “RBT”.

If I had to decide, I’d be inclined toward an intuitive rather than cognitive basis for trust because I think we put too much emphasis on science. My pediatrician from the 1950s would have been doing “scientific” things that would horrify us today. But neither cognition nor intuition is worth much unless we feel and carry responsibility toward one another. Just dispensing information or just giving somebody a hug are both pretty thin excuses for taking our share of the blame or credit.

We may look the other guy in the eye and shake his hand as we agree to do a risky operation or close a business deal, but what if things go wrong? Even though we meant well, it’s hard to predict the future. Science’s methods of predicting the future aren’t perfect. The best intentions don’t matter unless in the end we both have to deal with the upside and the downside. Life’s risky. My friend is right when she tells me the only safety net beneath us on obligatory leaps of faith is making sure we’re in it together.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 40 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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