Skepticism in medicine can be dangerous

NEW DELHI: I arrived at the hospital one recent morning to find a team of doctors gathered just outside a patient room. The patient was struggling — his breaths too fast and too shallow. For days we had been trying to walk the line between treating the pain caused by his rapidly growing cancer and prolonging his life. Overnight he had worsened. His family, wrestling with the inevitability of his death, had come to a tentative plan, and I needed to make sure that his wife understood what was ahead. I explained that if we inserted a breathing tube, as she had decided overnight, her husband would be sedated. When the rest of their family arrived in Boston, we would take out the tube and he would die. We would not be able to wake him up — to do so would only cause him to suffer.

At this, his wife stiffened. Why wouldn’t he be able to wake up? I explained that his cancer was so advanced that to wake him would be to give him the conscious awareness of drowning. I watched as she took me in, this doctor she had never met before, telling her something she did not want to hear. Her expression shifted. “Why should I believe you?” she asked me. And then, her voice toughening: “I don’t think that I do.”

The room was silent. My patient’s wife looked into her bag, rooting around for a tissue. I glanced down at my feet. Why should she believe me? I was wearing sneakers, and I found myself wondering whether she would have trusted me without question if I appeared more professional, or if I were older or male. Perhaps, but there was so much more at play in that moment. This was not just about one doctor and one family member, but instead, about a public for whom the medical system is no longer an institution to be trusted.

We are at a crossroads in medicine when it comes to public trust. After a pandemic that twisted science for political gain, it is not surprising that confidence in medicine is eroding. In fact, trust in medical scientists has fallen to its lowest levels since January 2019. As a result, more people are seeking out less conventional voices of “authority” that hew closer to their beliefs. Robert F. Kennedy Jr., a longtime vaccine skeptic campaigning for the presidency, is finding double-digit support in some polls and has made medical freedom a recurring theme of his candidacy.

But our medical system relies on trust — in face-to-face meetings as well as public health bulletins. Distrust can lead doctors to burnout and can encourage avoidable negative outcomes for our patients. This is partly what is driving increasing rates of measles among unvaccinated children, failure to follow recommended cancer screening and refusal to take lifesaving preventive medications. There are no easy solutions here.

But if we do not find ways to restore and strengthen trust with our patients, more lives will be lost. This is relatively new terrain for American physicians. When I was in medical training, we did not talk much about trust. During my early years as a doctor, I barely trusted myself and in fact felt uncomfortable with the responsibility I had to keep my patients alive. Only recently have I found myself thinking what happens when this ephemeral ingredient in the doctor-patient relationship is lost.

Medical skepticism is not the same as medical nihilism. The data behind the drugs doctors prescribe and the decisions we make need not be the purview of us alone; the public has the right to review the numbers and to make their own decisions about risk and benefit. But when that skepticism shifts into abject and irreparable disbelief, we see some patients make dangerous decisions. And when doctors respond with frustration, that only further separates us from those patients. Trust can sometimes be repaired by clearly presenting facts and figures, but it is about more than explaining numbers. We tell patients things about the body that are unseen. We recommend lifestyle changes and medication to treat or to prevent problems that may not be felt. Surgeons refer to a profound version of trust called the surgical contract: the idea that when people go under the knife, they are allowing their surgeon to make them sicker — to cut them open — in order to make them better. That trust must be earned. In emergencies, patients don’t have the luxury to choose whom to trust, and medical decisions must happen hastily, in minutes even. So part of our job is to build rapport quickly. That becomes harder, impossible even, when we enter into the climax of a medical crisis to find that whatever trust our patient may have once had long ago has been eroded. Many of our patients started their medical journeys wanting to believe in their doctors. But then the medical system that they wanted to trust failed them, in small ways and large, from haphazardly rescheduled appointments to real medical error. How do we begin the process of repair, both as a profession and as individuals, when time is short?

In medicine, we talk about the idea of shared decision-making, in which medical decisions are arrived at jointly by doctor and patient, in contrast to the paternalistic tone of years gone by. As doctors, we do not tell our patients what to do — instead we offer them the information necessary for them to choose the path that is right for them. For all our training, our medical knowledge is useless if our patients are unwilling or unable to believe what we have to offer. And that isn’t a fault of our patients, no matter how bothered we might become. This is a fault of a system that does not deserve our patients’ blind faith, of a surrounding political milieu that has turned scientific fact into fiction in many people’s minds.

That is how I found myself in that room, early that one morning, with my patient’s wife, her disbelief and the weight of the decision hanging between us. I knew so little about her. I did not know her history or her interactions with the medical system. I did not know the story of her husband’s diagnosis and treatment, or whether he had struggled to find care for his cancer. In our fractured system, I was just meeting her that day. I had no way to make her trust me, except to sit with her, to give her what little time with her husband we could. And to hope that regardless of what came before, she would choose to believe what I was telling her. I am not certain what she believed, but she chose against intubation. Her husband lived until the rest of his family came anyway. And when he died, they left without a word, carrying with them his bags of belongings and — I can only hope — faith that we had done the best we could.

Dr. Lamas, a contributing Opinion writer, is a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston The New York Times