Why Do Patients Trust their Doctor? Because He or She is a Competent Mensch

(Written during the pandemic)

Trust is equal parts character and competence. — Stephen M R Covey

Because of the well documented science behind nocebo and placebo effects, we now know that patients’ trust in their clinicians can affect outcomes as much as their prescribed medications can. We also, obviously, know that physicians don’t get paid by their patients, but directly by their employers and indirectly by the Government or by the insurance companies. Treatment outcomes are inherently affected by the demands such non-patient entities place on physicians’ decision making.

So, what does it take to be trusted by our patients? And, truthfully, is that always something we strive for above anything else?

Trust in the realm of medicine involves not only the belief that a medical provider has the necessary technical skill to help a patient. More and more, it also must mean that the clinician doesn’t have conflicts of interest that could keep them from delivering care that is truly in the patient’s best interest.

From productivity demands that serve corporate financial interests to physician compensation algorithms, patients rightfully sometimes wonder if they get enough time with their provider to get the care they expect. Examples of this include not listening well to patients but instead ordering expensive or unnecessary testing or enforcing “rules” like only addressing one problem per visit.

When patients have medical conditions with quantifiable “quality” indicators that are helpful for a majority of patients, do medical providers always consider that individual patients with unique situations don’t always fit the mold and could be harmed if “guidelines” are followed too blindly? An example of this is increasing blood pressure medications for people with “white coat hypertension” who actually have symptoms at home from low blood pressure.

When resources are scarce, do physicians unfairly ration care? Are there situations when the doctor is thinking more of “the common good” than what the patient in front of him or her is asking for? Who gets the last intensive care unit bed or respirator, as the debate about Covid-19 now goes?

The Covey quote at the beginning of this reflection is both succinct and broad. Competence is fairly straightforward, but character is a difficult quality to define and quantify.

What is the character of a physician? How do we develop, hone and maintain it? And, perhaps more important than we had thought it to be, how do we show it?

In my mind, all kinds of other words cluster around the word character: Humility, Kindness, Empathy, Honesty and Righteousness.

I think you need to cultivate relationship in order to demonstrate your character. You can’t be distant or aloof and show your true character at the same time. You have to reveal the inner workings of your mind, show that you are constantly assessing, weighing and processing information.

It isn’t enough to imply that you will always do the right thing, because every situation is unique and just like we were told in medical school that what we learned was how to learn and not a fixed encyclopedia of medical knowledge, we need to embody the wisdom that our life and our work involve the capacity and willingness to process problems in an ethical and patient centered way not once and for all, but continually as life and medicine are ever-changing.

My high school German allowed me to understand some of the Yiddish I encountered in my Jewish host family when I first visited this country (Hi, Bob!), and I really liked the use of the word Mensch. In German, it just means human being and says nothing about individual character, just like a dog can be big or small, cuddly or vicious. But Mensch in Yiddish is a beautiful characterization of a kind of human being that all of us, and especially doctors in these complicated times, need to always strive to become.