Lessons in Trust

1959

As a youngster I was terribly self-conscious about my size. In tenth grade I weighed about 85 pounds. My build resembled that of the guy on the back of the comic book who was getting sand kicked in his face. The one thing I could be proud of was my intelligence, which I wasn't shy about showing off. With the exception of gym, all my teachers seemed only to know the first letter of the alphabet when it came to marking my report card. So when I came home with a B in algebra, my father naturally startled. "What happened?" I explained sheepishly that I didn't know why. I'd aced the mid-term and gotten a perfect score on all the quizzes. "We're going to go talk to the teacher!" he announced.

Sure enough, a couple days later, he marched into the algebra class where my teacher and I waited. This being a Navy town, the teacher read my father's rank from his uniform and greeted him as Commander Rienstra. On being asked what was wrong with my work, he told my father that I was an excellent math student with just one fault. The problem was, he explained, that just as he was about to nail an algebra concept home to the class, I would sometimes raise my hand and helpfully add that there was a better solution two chapters ahead in the textbook. (I realize I am blowing my own horn here, but then my father had begun us boys on simple sums as soon as we could talk). My father, also involved in education (he was then working at the Naval Academy), understood the situation. I wasn't surprised that he made no appeal on my behalf. He turned to me and said, "That's why you got a B." He paused. "Don't let it happen again."

My father drove me home from school with no further word on the subject of algebra. While he was not shy of letting me know when I had failed to reach my potential, that afternoon he spoke in a kind way about other things. He was letting me know that he trusted me. He wouldn't always be around to protect me--he'd let me stand on my own feet.

Trusting the Patient: Part 1

Bill had hurt his back lifting something at work. The crankcase hadn't been particularly heavy, but no matter. People can get bad back pain from just bending over. So, exam, evaluation, initial treatment, time off work, recheck in a week.

One week, two weeks, no better. Getting worse in fact. The physical therapy exercises made him feel worse. Time for an Xray. Normal. Three, four, five weeks. Workman's Compensation starts wondering why he isn't back at work yet. I order an MRI, but denied by the insurance company. Back injuries at work are notorious for delayed recovery, which is often enhanced after full or partial disability is approved. After further delay and some convincing, Workman's Comp approves an MRI.

To everyone's surprise, he has an abscess in his spinal column. He didn't have inject drugs, have diabetes, and never showed signs of immune system problems, so, a rare bird.

So often people fear that we doctors will not believe that they are ill. Sometimes they apologize. "I hope I'm not being a hypochondriac."

Medicine is a dance. Most likely in this man was a normal backache, perhaps made worse by ordinary wear and tear, emotional stress or even unhappiness at work. Often unimaginable is the rare bird. It's easier to catch all the rare birds without breaking the bank with unnecessary tests when doctor and patient trust each other. We docs need to know that we won't be blamed when we miss some rare birds, which we will. You want to know that your doc is in it for you body and soul, and not there for the money or anything else.

Trusting the Patient: Part 2

A more subtle medical error is this. Sometimes, we doctors may think the patient doesn't want to get well.

Put yourself in the doctor's shoes when she hears...

1. "I guess I forgot to fill that prescription."
2. "Doc, sometimes I drink too much, but that's not the problem."
3. "Doc, I'm just too busy to do my back pain exercises."
4. "Doc, just a few pain pills, I'm not addicted."
5. "Yes, doc, I suppose that might work, but... " (spin, rinse, repeat)

And yet, each of these people almost certainly really wants to get well. They are just stuck. Examples of how a doctor might approach these situations include...

1. People don't fill prescriptions for several reasons. They may find they cost too much, or they read the side effect list and got freaked out, or don't understand why taking the medication is better than not taking it, or have a friend who had a problem with that particular med. The doctor's job is to find out what the situation is, to trust that they do care about their health, and help them move forward. The patient is not in the office that day by accident.
2. People drink excessively for a reason. They may not see it as a problem, or may not see any other way to live a bearable life, or not believe themselves capable of moderation or sobriety, or have previously tried and failed, or-you can list a hundred similar reasons. In such a situation, the doctor might say something like this: "Let's see if we can figure out what might work for you. If that pathway doesn't bring success, we can think again. Remember this, though. However it turns out along the way, I am not going to give up on you."

And so on for the other kinds of "stuck-ness."

We ran a cash-only practice. So I knew, when listening to people who seemed to reject every suggestion I made, that they wouldn't be sitting in that chair across from me if they didn't want to get well.

Mutual Trust

When doctor and patient have enough history together that trust is absolute, health is better and money is saved.

New Year's Wish

My father gave me a tremendous gift. He trusted and loved me. A career Naval officer, completely dedicated to his military mission, he perhaps never understood my decision to abort a very short military career based on my objection to the war in Vietnam. Yet he trusted me and always remained kind and supportive.

May there be people in your life who give you that same gift.