The concept wasn’t new to me: “The most basic lesson in medicine, medicine 101, that you should have learned in your first week: don’t trust your patients.”
I was reading a story in the Wall Street Journal, published earlier this week, about how a culture of doctors distrusting patients, and distrusting female patients, allowed Dr. Larry Nassar to abuse athletes in his care over many years. The quote came from Dr. William Strampel, Nassar’s boss and the former dean of the Michigan State University College of Osteopathic Medicine, and it is something he said in a meeting about an unrelated male student accused of abuse.
As I read, paragraph after paragraph, the thing that kept popping into my mind was this: The way that Strampel is applying that “basic lesson” is wrong. Trust is fundamental to the doctor-patient relationship, but it isn’t always straightforward. Patients can get their facts wrong, and sometimes they mislead us purposefully. But, we can’t just dismiss our patients’ stories outright — we need to carefully consider what they say.
What’s profound was Strampel’s refusal to give those athletes the benefit of the doubt, and to dig deeper. This is what we mean when we say “don’t trust your patients” — hear what they are saying, and then clarify, or verify. Doing so is how we provide the right — and the safest — care to our patients, and it’s something that I started learning early on in my career.
When I was in medical school, I asked a new patient if he had ever had surgery, and he told me that he had not. Later, when I told this to the attending surgeon, I was frustrated when we examined the man together and saw the scar on his chest from open-heart surgery.
That day, I learned that I can’t always trust what my patients tell me as objective truth. What patients tell me guides how I treat them. Even if what they say isn’t accurate, it’s still my fault if something goes wrong. No matter what that patient told me, I alone was responsible for my clinical decisions.
So, I quickly changed how I interviewed the people in my care. I started asking my patients extra questions like, “Has a doctor ever cut you open with a scalpel?” or, “Are you sure you have all the organs and body parts you were born with?” to help capture that forgotten appendectomy, tonsillectomy, or transplant.
And while my trusting (but not verifying) the patient who had open-heart surgery didn’t impact his clinical care, as I’ve assumed more advanced patient care responsibilities, I’ve seen that bad intel is bad for patient care. Blind trust might undermine our promise, as medical experts, to do no harm.
When I was an intern, I asked a patient in the hospital whether he was taking his medications, as directed, every day. This was important because he was taking something that needed to be increased very slowly over several weeks to reduce the chance of dangerous side effects, like large areas of his skin sloughing off. He said he was.
We checked his blood to verify — the levels of the medication should have been higher than they were —they were undetectable. Had we taken his word for it, and started on the high dose he was supposed to be taking, the results could have been disastrous and even deadly.
“[Ronald] Reagan said trust, but verify” my resident said, reflecting on our patient’s misinformation, “but in medicine, we verify and then trust.”
Medical distrust is discerning. It is cautious compassion used to pursue good health and good practice. And, in fact, such distrust helps us promote public health.
As part of the effort to curb the opioid crisis in Massachusetts, state law says we have to verify, via a state database, whether or when a patient has been prescribed opioids before writing another script. We do this to prevent overdoses or diversion of drugs into the black market.
But to be clear, distrust isn’t dismiss — Strampel was effectively calling the girls and women Nassar abused liars. That distrust is hostile, and it serves to absolve us of our duty to care.
This is especially true, given what Nassar was accused of. Even if we cannot be sure that what the patient is saying is true, when the potential for harm is so great, we can’t be liberal in how we treat the incident. This is why, in most states, including Michigan, doctors are mandated reporters. At the slightest hint that a child is being harmed, even if we aren’t 100 percent sure, we are obligated to report.
Strampel needed to take action on behalf of the patients and take Nasser out of practice willingly, even while verifying. His gross misjudgment and dismissal of dozens of young women — all telling the same concerning story — aided Nassar’s sexual assault of dozens of people during his time at MSU.
As a university leader and a teacher, this is how he failed his profession, his colleagues, and these patients, and this is why his statement about not trusting what patients say is causing such an uproar.
This is atrocious on many levels — how NOT to handle patient complaints: “This just goes to show that none of you learned the most basic lesson in medicine, medicine 101, that you should have learned in your first week: don’t trust your patients,” https://t.co/rR8kGjEE71
— Rogue Dad, M.D. (@RogueDadMD) March 19, 2018
Patients may be what we call “unreliable historians,” because they mistakenly mislead us. Other times, it’s because they lie to manipulate their care. While these possibilities always exist, it’s wildly inappropriate to approach patients as adversaries.
Care is collaborative, in the sense that doctors and patients are working toward a common goal. But, as doctors, we can neither blindly trust nor distrust. As we see with MSU, having no will to act — to investigate — can be catastrophic.
I need to be reasonably confident in my patient care decisions. My patients put their trust in me, and, in turn, I trust their suffering, even if I can’t take every single detail at face value.
And I hope, with each, “Are you sure?” or, “We’ll need to check,” my patients will understand I’m being thorough so that I will do no harm.