January 1, 2017
Editor’s note: Dr. Pellegrini presented the John J. Conley Ethics and Philosophy Lecture at Clinical Congress 2016 in Washington, DC. Dr. Pellegrini was invited to submit the following column, which highlights the key points he made in that lecture. The address was published online in October 2016 in the Journal of the American College of Surgeons.
John J. Conley, MD, FACS, an otolaryngologist, felt that in order to provide the best care to patients, surgeons should be trained in skills that extend beyond the technical aspects of surgery. With this objective in mind, he established the Ethics and Philosophy Lecture at the Clinical Congress of the American College of Surgeons, which now bears his name.
During my years as a surgeon, I realized that my ability to heal and provide comfort to my patients was substantially enhanced when I developed a bond of trust and a strong relationship with them. As I started working on ways to achieve that goal, I recognized the impact that those enhanced relationships had on me as a person and on my colleagues.
I envision the patient-physician relationship, and by extension the relationship that surgeons develop with other members of the team and with themselves, as an arch; the surgeon represents one pillar, and the other party represents the other pillar. Trust is that stone at the top of the arch—the so-called keystone on which the stability and the integrity of the arch is dependent. Indeed, I am convinced that trust is to a relationship like a keystone is to an arch—essential for its integrity.
Trust is defined as “assured reliance on the character, ability, strength, or truth of someone or something.”1 Trust does not usually result from a single interaction, but instead it is built over time, with repeated interactions through which expectations about a person’s trustworthiness can be tested.
In medicine, our patients expect that we, as physicians, will behave in a certain way. In this relationship, the patient is the trusting party and must have confidence that we will act for their benefit.2 This intrinsic trust in the physician is expressed in the discretionary latitude that patients give their physicians to do what is necessary to, hopefully, benefit their well-being.
In the world of medicine, trust results from a number of interactions and the patient’s perception of the physician’s technical competency, interpersonal attributes, and values, as well as the patient’s impression of how the system works, including the reputation of the institution. In addition, medicine emphasizes the affective nature of trust, identifying patient trust as reliance on the physician and the physician’s intent.3 In surgery, our power to heal extends far beyond our technical prowess and is directly influenced by the relationship we establish with our patients. Indeed, studies show that patient trust in a physician increases the likelihood of adherence to treatment recommendations and satisfaction with the physician’s care.
It is important to consider our patients’ vulnerability in the relationship. For physicians to fulfill their commitment to trust, they must protect, rather than exploit, this vulnerability. To do so, the physician must place the medical good in the context of the patient’s assessment of what is good. More specifically, the physician must recognize that although he or she has expert knowledge of the medical facts, the patient is the expert when it comes to determining what is best for him or her given his or her values, beliefs, and aspirations.2 Hence, the physician is obligated to present clinical data as free as possible of personal or professional bias and to assist patients in understanding the rationale, effectiveness, benefits, and potential risks of a treatment plan without manipulation or coercion.
Just as the patient must be able to trust the physician, the physician needs to have trust in the patient. Mutual trust is an important aspect of the patient-physician relationship with potential benefits for each party. Trust improves cooperation and reduces the need for monitoring.4 A physician’s trust in the patient enhances the relationship and contributes significantly to the physician’s sense of well-being and professional satisfaction.
Another form of trust plays an important role in medicine—the “social trust,” which has to do with the patient’s trust in the institutions where they receive care. Every individual enters a consultation with a certain element of trust in the institution or site of practice. The patient’s interaction with the system as well as the physician will reinforce or undermine both social and interpersonal trust. For example, when physicians make positive comments about staff and other members of the medical profession, social and interpersonal trust are enhanced. On the other hand, if a patient perceives a lack of continuity in the system, it likely will undermine social and interpersonal trust. It is my advice to you that in your interactions with patients, always keep in mind the power that you have with your words and behaviors to enhance both social and interpersonal trust.
Trust is the keystone of a patient-physician relationship. It is an indispensable virtue of a good physician. Without this virtue, the relationship disintegrates, just as happens to an arch when the keystone is removed. With it, we enhance our ability to heal the body and the soul of the patient, the physician, and the patient care team.
If trust is a defining element in any interpersonal relationship, then communication is the most effective and efficient means of engendering trust. I am of course talking about communication in a much broader sense than the traditional concept. Most of the communication I refer to is, in fact, nonverbal. To create rich relationships with our patients, team members, and, indeed, ourselves, we must use all communication tools available to us.
Human beings use a wealth of methods to communicate with one another, and the process is remarkably complex. Communication is a science and an art that requires substantial skill. It is not just about what we say, but rather far more about how we say it, and then how it is interpreted. It is how we behave, the way we listen, the manner in which we deliver on what we say, how we treat others, and how others perceive our treatment. It is the way we perceive the patient’s feelings beyond their words and the way we ask questions based on that perception. It is the way we relate to the patient’s family, clinic staff, and the organization in which we work. All the ways we communicate have a tremendous impact on developing, building, and reinforcing trust.
And let us never forget that for every message we intend to give, the values, beliefs, and previous experiences of those on the receiving end will play a key role in how the message is interpreted. Effective communication, the kind that enhances the relationship, should be based on a patient-centered approach that elicits, understands, and validates the patient’s experience within his or her own cultural and psychological context; reaches a shared understanding of the patient’s problem and treatment; and empowers the patient by offering meaningful involvement in choices about their care.5
One of the greatest challenges of this era in health care is to preserve the interpersonal relationship with our patients in an environment that is driven by business, standardization, and large systems of care that focus on population health rather than individual patients. To uphold the human connection with our patients, surgeons must improve their communication skills.
Although there is substantial evidence in the literature regarding the effects that a positive physician-patient relationship has on patients, very little has been written on the great influence that this bond has on physician well-being. Those of us who chose to become health care professionals are exposed to emotional turmoil repeatedly throughout our careers. Patient tragedies of all kinds—due to violence, trauma, cancer, and so on—can affect the most resilient among us. Indeed, studies that have examined physician well-being have concluded that approximately 30 percent of all practicing physicians in this country are suffering from burnout.6,7 To avoid this emotional rollercoaster, some have suggested that physicians should remain personally and emotionally detached from their patients. On the contrary, I would argue that establishing a meaningful connection with patients and colleagues in the organization is one of the most powerful deterrents to physician burnout, and the satisfaction derived from these relationships provides context, meaning, and purpose to our lives.
Similarly, these improved relationships will have a positive impact across the organization. The members of our teams are always watching our actions. When they see someone who leads by example—delivering on promises, caring for patients, being approachable, listening—they develop a sense of inner peace and satisfaction and a desire to contribute to the excellent work of the group. This facilitates the development of high performing teams—teams that share a common purpose and that pursue lofty goals in the care of their patients.
Most of us don’t view surgical practice as a job. We view it as a calling. The passion and sense of purpose that drives physicians connects us with our patients in a way that reassures and inspires them. At the same time, it is important to emphasize that clinician well-being and self-awareness have a powerful effect on our ability to communicate better, which in turn will improve the interpersonal relationships that drive patient satisfaction and behavior. A clinician’s mental well-being is a precondition for being effective in the delivery of care and in recognizing and valuing the patient’s perspective as distinct from one’s own.8
I have described the importance of building trust through communications, primarily in the context of the practice of medicine. In every encounter with our patients, our teams, or for that matter, with ourselves, our own souls, we have a unique opportunity to do good—to make someone feel better or to improve the image of our workplace—and allow us to build trust, no matter how small or how big the opportunity or the result may be. I invite you to reflect on this simple statement, and if you believe it, if you see yourself using each encounter to affix that keystone that ensures the integrity of the arch described earlier, then I say to you: do it. Be present. Seize each opportunity to do what your heart tells you is the right thing to do at every turn of that long, winding road that we call life. That way when you reach the sunset of your career, you will feel as if you lived and as if your life mattered—to you, to your patients, to your team, and to humanity at large.