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April 2004


A Patient’s Gift:
Do You Value It?

By Richard P. Mills, MD, MPH

Trust has always captivated my right brain. Fundamentally, to trust is an act of faith; it is an expectation of integrity, veracity or some other sound principle of another person or thing. At times, it is given without any prior personal experience on which to base an opinion, and in other cases, it is earned over many encounters. It is in that latter vein, and in no small part because of my fascination with trust, that it became EyeNet’s tagline, “The trusted source for clinical insights.”

In medicine, one of the key components of the physician-patient relationship is trust. In every case, a patient evidences trust by presenting for care. For new ophthalmic patients, the trust relates to the implicit belief that, as a professional, the ophthalmologist holds the interests of the patient above all other interests and will act in the patient’s best interest. For established patients, there is some track record on which to base trust. But make no mistake, patients are continually validating their trust against the evidence. Usually, patients have insufficient knowledge about medical conditions to judge in that sphere, but they are often surprisingly perspicacious in evaluating the therapeutic encounter.

Nowhere is this more evident than in an informed consent discussion. When I was still doing neuro-ophthalmology, a 60-year-old man presented with a chronic sixth nerve palsy due to a cavernous sinus meningioma. I sent him to a neurosurgeon to discuss surgical options. Several months later the patient returned, untreated. He said that the neurosurgeon was a “nice fella” and had advised surgical removal. But when the surgeon started talking about possible complications, he broke eye contact and looked at the floor while talking. “Right then and there I decided I didn’t want no operation.” His trust had evaporated in a blink of the surgeon’s eye. This episode taught me why it is important for me to have an informed consent dialogue personally with the patient.

While I was thumbing through last year’s issues of Medical Care, the journal of the American Public Health Association (ah, what I go through for the readers of EyeNet), I noticed a few papers on physician trust. One paper1 reported that communities with a higher prevalence of gatekeeping activity (when patients are required to play “Mother, may I” with their primary care practitioner) had a significantly lower level of trust that their doctor would put their medical needs above all other considerations. In another paper,2 physician trust was sensitive to the amount of contact the patient had with the physician and to their perceived adequacy of choice in selecting that physician.

Before I left Seattle for Kentucky (and before I moved back), I had a chance to outline my impending departure to my chronic glaucoma patients. Many accepted the suggested transfer of care to a colleague with, “If you have chosen him to practice with you, I’ll trust your judgment.” But a few openly wept. One woman was bold enough to say what the others were thinking, “Doctor, I know I won’t be able to transfer to another doctor the trust I have given you.”

That’s when I started thinking of trust as a gift. With my right brain.
1 Haas, J. S. et al. Med Care 2003;41:660–668.
2 Balkrishnan, R. et al. Med Care 2003;41: 1058–1064.