Medical professionals haven’t just relied on long-standing respect; they have also evolved with the times. In the past generation, the practice of medicine has undergone a sea change—from the old-school approach in which the doctor knew everything, made decisions, and told the patient little, to a new model that emphasizes patient understanding and choice. Medical schools added compulsory courses on communication and ethics, and the medical-licensing exam now includes an entire segment on doctor-patient interaction.
As patients began to question their doctors, doctors responded by welcoming that back-and-forth. They are more likely than before to explain the downsides of a treatment, share the honest odds of success, and honor a patient’s choice that might differ from their own. “The medical profession has absorbed some of those influences, because patients are, in fact, better informed,” says Dr. Albert Wu, a professor and the director of the Center for Health Services and Outcomes Research at Johns Hopkins Bloomberg School of Public Health. “The Internet and other sources of information are resulting in the need to team up more with patients.”
For Morse-Dwelley, Pellegrini’s honesty about the limits of her medical knowledge didn’t weaken her stature; it enhanced it. Pellegrini professed confidence but admitted that she was new and that she hadn’t specialized in intestinal repair. When Morse-Dwelley’s fistula persisted after multiple operations, Pellegrini called gastrointestinal surgeons for advice and attended every session about fistula repair at a national conference. She read up on new wound-closure techniques. She told the family that Morse-Dwelley’s chance of surviving a particular bowel-repair procedure was only 5 percent. “To me, nobody knows all the answers,” Morse-Dwelley says. “Anyone who’s willing and secure enough to be out asking for input—what have you heard?—[that] inspired me to no end. If she’d come across like some surgeons, like, ‘I know best,’ I would have left.”
Doctors and liability insurers are slowly learning this lesson. The traditional response to medical error was for a doctor to admit nothing and make it as hard as possible for patients to sue. But new research shows that even in situations where mistakes (not just bad luck) have harmed patients, it’s possible to preserve trust. Patients, it turns out, frequently accept a provider’s honest apology. “I’ve seen that over and over again,” says Dr. Steve Kraman, a professor of pulmonary critical care and sleep medicine at the University of Kentucky College of Medicine.
As the chief of staff at the Lexington Veterans Affairs Medical Center in the 1990s, Kraman implemented a policy of disclosure and apology any time something went wrong. It was his job to personally deliver the bad news to patients who had been harmed by poor care. The results—lower liability costs and less bad will—led the VA to implement the policy nationwide. It is now (slowly) becoming the standard of care in medicine. “It is, at its foundation, a human relationship, and the patient wants very much to trust their doctor,” Kraman says. It’s also a lesson that politicians, and others who err on the job, could stand to learn: People forgive honest mistakes but not denials and cover-ups.
Unlike choosing a car (which has a crash-test rating) or retaining a lawyer (who has a win rate), picking a medical practitioner is not really a fact-based process. It’s hard to find a meaningful metric that shows whether a doctor is great or mediocre. Although advocates and policymakers are trying to improve measures of quality and patient access to ratings, most patients still make decisions blind. “How does a patient know anything about me?” asks Pellegrini, wondering how she would select a surgeon if she got sick. “Maybe I’m just a personable doctor, and my outcomes suck,” she says.
And here’s the crazy part: Despite the leap of faith required to trust a doctor, data show that patients who do so have better health care outcomes. Studies find that patients with the most trust are likelier to take their medications, engage in healthy behaviors such as quitting smoking, and return for follow-up care. Medicine may be one of the only markets where a skeptical consumer is likely to end up with a worse product.
FACING IT TOGETHER
As Morse-Dwelley prepares for her next surgery, she’s trying to think of everything. She’ll bring signs to remind the staff in her wing that she’s allergic to betadine, a common antiseptic, and the adhesive in medical tape. (“Don’t screw with me! Read that sign, because otherwise my skin falls out.”) She made sure that her medical record notes the bad reaction she had to an older anesthesia drug. She has updated her advanced directive so it says, in effect, “Do everything to save me.”
She asks Pellegrini about scary, antibiotic-resistant bacteria she has read about. She has already had a dangerous infection known as MRSA, but what about another sometimes fatal one known as C.diff? She asks about the surgical materials Pellegrini might use, reminding the doctor that her body has rejected others, leading to more surgery.
But, in the end, she knows that if she’s going to go through with it, she’ll have to give up control and trust Pellegrini to take care of her. “It’s a big step,” Pellegrini says somberly.
“We’ll get drugs for the family,” Morse-Dwelley jokes. She knows they’re skittish, too.
Then they laugh, and talk about the kids, and hug good-bye.
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This story is part of a yearlong series that examines America’s crumbling foundations and how to rebuild them. Find more on the Web at nationaljournal.com/restoration-calls.
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