“Mistrust in Science –A Threat to the Patient-Physician Relationship”

A recent commentary, “Mistrust in Science –A Threat to the Patient-Physician Relationship” (RJ Baron, AJ Berinsky. NEJM 2019; 381: 182-5), addresses the deterioration of trust in the patient-physician relationship and potential ways to improve this.

Shortly before reading this, I read a newspaper article titled “Newtown Parents Fight Back” in Sunday’s AJC (related article online: Newton Parents Score a Win…). In this article, some of the parents of the 20 children who were killed in Newton, Connecticut have brought successful lawsuits against ‘hoaxers’ who claimed that the “rampage had been staged, with crisis actors.” Some of the parents have received death threats subsequently.

In this ‘misinformation’ age, it would be naive to expect that medicine and science would be spared. The alluded commentary makes the following points:

  • “Clinicians enter patient encounters with the reasonable presumption that they will be trusted. After all, they have powerful knowledge and good intentions…But, medicine is changing.”
  • “The legitimacy of the medical community rests on the the credibility of medical science…Physicians rely on that foundation in every interaction they have with their patients.” And on “the intimate and personal nature of each individual doctor-patient relationship”
  • “Medical practice is becoming increasingly corporate…In 2016, for the first time, less than half of practicing physicians owned their own practice…Less attention has been paid to how corporatization changes patients’ experience and …trust.”
  • “Gallup polling has revealed that confidence in almost all institutions in the United States…has deteriorated greatly…confidence in the medical system fell from 80% in 1975 to 37% in 2015.”
  • “Alternative sources of ‘authority’ have emerged to fill gap” including social media platforms, friends and relatives.

“Given the decline in trust in the institution of medicine, simply asserting medical authority or citing evidence is unlikely to win adherents…Skepticism…is a widespread phenomenon…appealing to a neutral or independent ‘referee’ of the truth…on a given subject–does not actually change minds…attempts by experts to correct misinformation may further entrench erroneous beliefs.”

Pathways to Trust

  • “Feeling recognized is a precondition for trust.”  Having to repeat stories over and over again can be ‘trust-destroying’ as the individual feels as a stranger in the health care system
  • “Explicitly acknowledging the role…of other members of the health care team may be another way…Speak positively about the staff [and colleagues]…This practice …increased patients’ trust and satisfaction.”

My take: The authors note that in this age, science s devalued and relationships are more influential.  Thus, creating trust goes back to Peabody’s 1927 admonition: “The secret of the care of the patient is in caring for the patient.”

In the newspaper article, a book publisher involved in the promoting the Sandy Hook conspiracy had to meet one of the parents as part of a lawsuit.  “At the end of the day, Gahary shook Pozner’s hand and apologized. He offered condolences for Noah’s death.”  As in medicine, getting to know each other is the surest way to garner trust.

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NYT: Do You Trust the Medical Profession?

An interesting commentary from NY Times: Do You Trust the Medical Profession?

This article explains how lack of trust in medical leaders can effect response to epidemics (eg. ebola), participation in clinical trials, and influence acceptance of vaccines. In addition, on a personal level, individuals who trust their physician are more likely to continue treatment important for their health.

An excerpt:

Trust, in each other and in American institutions, is vital for our social and economic well-being: It allows us to work, buy, sell and vote with some reasonable expectation that our behavior will be met with fairness and good will.

But trust has been declining for decades, and the most tangible and immediate damage may be to public health and safety. Mistrust in the medical profession — particularly during emergencies like epidemics — can have deadly consequences…

Trust is the cornerstone of the doctor-patient relationship, and patients who trust their doctors are more likely to follow treatment plans…

Another study found that trust is one of the best predictors of whether patients follow a doctor’s advice about things like exercise, smoking cessation and condom use. Mistrust can lead people to skip the flu shot or forgo the measles vaccine for their children — with potentially serious consequences for individual patients and the broader population…

A degree of skepticism is inevitable and important. But when doubt becomes pervasive, it can erode the glue that binds society together, and the medicine that keeps us healthy.

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Public Health Casualties: Collateral Damage in the War on Terror

This week there is a fascinating editorial that I almost skipped because the title didn’t grab my attention: “Ensuring Public Health Neutrality” (NEJM 2013; 368: 1073-1075).

This commentary provides background by recollecting Red Cross relief flights to Biafra being shot down by the Nigerian government. “In the minds of some people, ..these attacks were justified by another clear violation of humanitarian neutrality: on at least one occasion, a plane painted with the Red Cross insignia was actually carrying weapons.”

Fast-forward to January 6, 2013.  12 deans of U.S. schools of public health sent a letter to President Obama protesting the conduct of a sham vaccination campaign as part of the hunt for Osama bin Laden.  Apparently, the CIA hired a Pakistani surgeon to go house to house vaccinating children but also drawing back a little blood in the syringe in order to analyze the DNA.  This ploy was not effective in the bin Laden compound as the surgeon’s team was kicked out.

So what are the consequences?

  • Pakistan has expelled foreign staff of the international aid agency Save the Children (Sept 2012)
  • Eight polio vaccination workers were killed (Dec 2012)
  • U.N. has suspended its polio-eradication efforts in Pakistan.  Pakistan is one of three countries where polio has not been eradicated (Nigeria and Afghanistan are the other two).
  • This undermines vaccination in Pakistan where 150,000 children die of vaccine-preventable illness each year.

Using physicians in this manner violates the Hippocratic Oath: “Whatever house I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice.”

The authors note that “although some U.S. policymakers consider immediate national security concerns a higher priority than long-term global health efforts, the CIA’s false vaccination campaign in Pakistan may cause collateral damage with profound long-term implications for national security.  If every aid worker..is suspected of being a spy, the children..of the world will no longer have protection against our greatest killers.”

Public health neutrality –a different twist to think about while you are watching “Zero Dark Thirty.”

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