Should You Trust Your Physician?

As far as I can tell there are two basic considerations in whether or not you trust your physician. The first is combination of personality and cultural factors and the resulting expectations you have when you see a physician. That may have something to do with your actual experience, but also may have more to do with observations from the care of other people. As an example, you saw your father was cared for and thought it was excellent care and expect the same care for yourself. That can also backfire in the case where you believe the observed care was substandard and led you to be more skeptical of medical care administered by physicians. From a cultural standpoint, you may be from a culture that does not trust authority figures or even physicians.  These are all very complicated issues, that I will illustrate with personal examples of treatment I have received over the years.

The second approach to whether or not you trust your physician, is to adopt a very performance-based approach. That approach is the answer to the question: “What has this doctor done for me and do I like those results?” Medicine is a complex field made more complicated by subjective assessment of the patient in their experience of care and treatment. As a psychiatrist, I see people who are very satisfied with their care from physicians and surgeons and many who are dissatisfied. I see people who have had the exact same procedure – let’s say a hip replacement with identical functional results.  One of these patients will tell me, that they are doing very well and the other will describe disappointment.  The disappointed patient will often tell me they are only slightly improved than when their joint was “bone on bone”.

My own experience with physicians is mixed at best. When I was a teenager, was in a doctor’s office and developed acute facial swelling, wheezing, and my eyelids were swollen to the point I could barely see. The explanation was given to my parents at the time was it was “psychosomatic” I was not treated with anything. The next several years, the only treatment I got was to get up at night go out into the cool night air and drink caffeinated soda. Needless to say that was suboptimal. When I finally saw an allergist about six years later I was “allergic to everything” and finally started taking antihistamines. But eight years later when I was intern, I saw an allergy specialist who spent the entire interview demanding to know what I wanted to try immunotherapy. I guess it was his form of motivational interviewing.  I never went back.

In medical school, I started to get gout attacks. With the first attack I went the emergency department and spent six hours there.  I was discharged with acetaminophen and codeine – a medication that is essentially worthless for gout pain. During a follow-up appointment in the orthopedic clinic, I was told that I probably sprained my ankle in bed and they put a cast on it. Gout pain gradually resolves after about two weeks and that is what happened. But the gout saga does not end there. During residency I started to get acute wrist pain. I went to a primary care clinic where the physician learned my history and then tried to aspirate my wrist joint with a large needle. That was a skill set that he did not have, but he did end up aspirating some tissue into the syringe that was eventually identified as synovium from the joint.  At some point, I also had a left inguinal lymph node biopsy that went awry. I went back to work and started gushing blood all over my khakis. The surgeon advised me to come to his office right away and by then my shoes were full of blood. I left bloody footprints all over his carpeting.  He cut open the incision and tied off the artery in the office while two nurses held me down.

That is a sampling of my negative experience. There is actually a lot more, but despite these fiascoes I have been able to find physicians that I trust and routinely go back to see. I have been seeing the same primary care physician for the past 30 years - recommended by psychiatric colleague who worked with him.

From a cultural standpoint, I was taught to be skeptical of everyone. My father was a blue-collar worker who routinely talked about the abuses of the administrative class and how working people were taken advantage of. He was in a union and would routinely show me the house that the president of the union lived in compared to our house.  That perspective is still ingrained at some level, but it does not prove very useful when it comes to medical care. The reason is that at some point almost everybody needs medical care and that typically includes care that involves doing something that you would rather not do. That might be surgical procedure or taking medication for a long time or even getting an immunization. But the choices are often fairly dire and that is continue to be miserable or die or accept the recommended treatment. Despite my medical misadventures, I continue to accept doctor’s recommendations even when they have significant risk.

I also come at this from the perspective of interacting with thousands of patients, many of whom don’t trust doctors at all. In most extreme circumstances, I had to interact productively with people who not only did not trust doctors but were simultaneously being coerced into treatment by the probate court system. In other words they were on involuntary holds, probate court holds, or civil commitment. That was the best possible experience to conceptualize the physician trust issue. A typical exchange follows:

MD:  “Hi – I’m George Dawson and I’m the psychiatrist here. It looks like I am seeing you because you were admitted to this unit on a 72-hour hold.”

Pt: “I don’t trust psychiatrists. I just want to be discharged.”

MD: “In order to do that, I have to make an assessment of the situation and determine if you can be released or not.”

Pt: “Why should I trust you?”

MD: “I can’t think of a reason why you should. You just met me. I would suggest that we proceed with the evaluation and see how that goes. At the end of the evaluation I will let you know what my impression and recommendations are. You can decide whether or not you trust me based on what happens. If you decide to follow my recommendations you can also base your decision on whether or not those recommendations work for you. Does that seem reasonable?”

That is the basic framework that I tried to outline for people are focused on trust. The focus is on actual performance as well as subjectivity. The subjective elements are a number of factors on the patient’s side.  They include all of the conscious and unconscious factors involved in interpersonal assessments as well as any overriding psychopathology. The most important element of the patient’s conscious state is whether or not they can incorporate the information that they are receiving from the physician into their responses and adapt a different framework for the interaction. Not everybody is able to do that, but the great majority of people are to some degree.

The above example is from what is probably the most contentious situation.  I think the approach works even better in outpatient settings where people have had adverse experiences in psychiatric care like my experiences with medical care.  In some of those situations a description of the therapeutic alliance is useful. That might go something like this:

“It might be useful to discuss how these interviews work.  You and I are both focused on the problems that you identify.  We discuss them and at some point, my job is to give you the best possible medical advice on how to address them.  Your job at that point is to think about that advice and whether or not you find it useful and want to use it.  It is also possible that your problems are not medical or psychiatric in nature. I will let you know if I think so.”

That clarifies a few points.  The interview is not a unilateral “analysis”.  Many people have the psychiatric stereotype that a psychiatrist can just look at you and figure out the problem. To this day, many people that I casually meet still ask me if I am “analyzing them.”  It also points out that I am interested in what they identify as problems – not somebody else’s idea of the problem. Unless that is explicit, many people go out of their way to tell me that it was their idea to see me or go to treatment.  Most importantly – it emphasizes that this is a cooperative effort.  I have no preconceived idea about their problem or diagnosis.  My ideas develop from the discussion and there has to be agreement that I am on track.

That is my basic approach to the trust issue in interactions with patients.  There are many variations on that theme.  Although what I have written here is from the physician perspective – I can add that from the patient perspective the performance dimension is very important.  My personal internist always takes enough time to assess my problems and do an adequate evaluation.  He has made some remarkable diagnoses based on those evaluations.  That performance over time builds trust as well.  It also highlights another important aspect from the patient perspective and that is empathy towards the physician.  Is there an understanding of how the physician’s cognitive ability and emotional capacity can be affected by outside factors? Is there any allowance for even minor physician errors or lapses in etiquette – like being very late for an appointment?  People vary greatly in that capacity and often it is necessary to keep a productive relationship going.

Most medicine these days is run by corporations rather than physicians. That makes it harder to establish long term relationships with physicians. In the above narrative I hope that I outlined the advantages of that relationship as opposed to one that may be more like being asked 20 questions about a medical condition by different people every time you go into a clinic.

George Dawson, MD, DFAPA

Therapeutic Alliance - A Better Diagram

I posted on the therapeutic alliance about 5 years ago.  The goal of that post was to point out how psychiatric treatment occurs - specifically the idea that the physician and the patient need to collaborate and define a set of diagnoses and/or problems to work on.  They have to agree on the problems and also the plans to resolve (or not) resolve them.  In the case of a chronic illness  with no clear resolution, the goals are focused on optimizing function.  The is basically the ideal treatment model for any physician and any treatment - the only difference is that psychiatrists are trained to attend to the relationship between the patient and the physician in very specific ways.  That includes the concept of transference and countertransference or the emotional reaction and associated thoughts of the patient to the physician and and the physician to the patient based on their past experiences.  By attending to those patterns psychiatrists can develop insights into what is unfolding in the relationship and in some cases use defensive patterns to assist in the diagnosis and treatment process.

I had a few ideas about how I wanted this diagram to differ from the diagram in my previous post.  First, I wanted it to reflect treatment continuity.  Ongoing treatment is a dynamic process of multiple events across time in the case of ongoing care. It can also involve single cross sectional interventions that require a patient to complete a prescribed treatment and contact the physician if the problem is not resolved as expected.   There are several hard stops to a medical treatment process - cure, improved function without cure, increasing disability, care refusal, and death to name a few.  I decided to leave those implicit and not alter the basic diagram.  Second, I thought that triangles demarcating the physician-patient decision space would be a good idea because they are more open structures and were used in a recent example of how graph theory may be useful in neuroscience.  Third, I wanted to avoid jargon.  There are numerous conceptualizations of the conscious state of the patient and the physician and what that implies for the communication - but I distilled it down to the communication and collaboration parameters as noted above.  There is implicit informed consent in this model. There are far too may people who see physicians and adopt a passive role.  In some cases they request that the physician make important decisions for them: "What would you do if you were me?" The role of the physician is to communicate the information that the patient acts on with all of the attendant risks.

The general model is a good one for all medical specialties.  Psychiatrists are be trained to attend more the the relationship and overcome obstacles to treatment. A basic example would be the person who consults with a physician but who is skeptical of the physician's motivations or intentions.  In many cases this results in a disagreement and the relationship is terminated without the patient receiving treatment.  A psychiatrist should be capable of recognizing what is occurring in the interview and at least being able to point out the reality of the situation to the patient.  That reality is depicted in the diagram at the top.  I frequently tell people that I have no interest in telling them what to do or even prescribing a medication that they do not want to take.  My appropriate role in the model is to give them the best possible medical advice about resolving problems the we both agree on and that might benefit from treatment.  It is their role to decide among the options and consent to treatment.  Not consenting to any treatment is always an option.

The model also implies that both parties are competent to interact and make decisions.  In the case of physicians, states have a vetting and licensing process that is focused on public safety and it does a good job of removing most unsafe or incompetent physicians.  In the case of the patient, there are various contexts in which substitute decision-makers are engaged in the process including guardians, conservators, and judges.  The legal process to make that determination varies widely from state-to-state and even county-to-county within the same state.


George Dawson, MD, DFAPA
    

The Therapeutic Alliance

You + Me -> working on your problems.

That is the basic paradigm for treatment.  It assumes that the psychiatrists is competent and professional.  Assumptions about the patient are less clear.  In the ideal situation, the patient is aware of the therapeutic alliance and focused on examining and solving problems.  There are a wide array of problems that can be the focus of treatment.

The approach generally works very well but there are things that can derail it.  In the course of treatment, emotionally loaded topics are discussed.  In some cases the emotions of patients and psychiatrists impinge on the alliance and need to be clarified.  There are boundary issues that often bias treatment in a particular direction.  A common example is a friend or family member referring a person into treatment.  These days there are important factors outside of treatment that bias treatment as indicated in the following diagram.

In this case, the patient and psychiatrist can have an excellent working alliance.  They can be focused on solving problems by applying the best possible evidence based medicine or consensus guidelines, but the best course of treatment that they agree on is not funded by the managed care company or pharmaceutical benefit manager.  A common example these days would be a patient with depression and back pain.  I frequently recommend duloxetine, especially in the case of failed treatment with SSRI type antidepressants.  Even in the case where this treatment is effective for both depression and back pain,  the PBM can either refuse to pay for the medication or make the copay so high that the patient cannot afford it.  On the inpatient side, a common scenario is the manic patient who is not able to function unsupervised at home or in transitional care.  The managed care  company can say that the patient is "not a danger to self or others" and insist that they be discharged form the hospital.  That is probably one of the most frequent reasons for readmission.  In other cases, managed care companies declare that the patient is no longer at risk for suicide.  Their reviewers make this decision based on reading chart notes or talking to the doctor who thinks that the suicide risk is still high.  In the majority of cases they decide against the attending physician - probably the most egregious breach of the therapeutic alliance especially when the patient is as concerned as the psychiatrist.

The government also intrudes at multiple levels.  The biggest intrusion has been by facilitating the development of both managed care and PBMs.  These are businesses that were essentially invented by the government in order to reduce the cost of health acre.  After two decades it is clear that health care inflation is as high as ever, that mental health services have been cut to the bone, and that public mental health services that have adapted managed care strategies have a also dramatically reduced services.  In almost all cases, the government advances a purely political experiment that results in numerous inefficiencies that fails to produce results.  Some common example include failed pay for performance initiatives and a failure to reduce Medicare readmissions based on financial incentives and disincentives.  Practically all of these experiments use the administrators assumption that physicians don't know what they are doing in the first place.  That is probably not the best place to start.

There are many political influences that  are not on the diagram.  Direct to consumer advertising, the media, and various advocacy groups are additional examples.  Psychiatry is unique in that there are a number of causes dedicated to the most negative characterizations or destruction of the field.  That orientation not only precludes any therapeutic alliance but also may lead to intrusions on existing or initial alliances.

George Dawson, MD, DFAPA