• Contrarian

“If you are listening to find out, then your mind is free”, the poet Krishnamoorthi advised, but most providers are not listening to find out, rather, they are reacting to guidelines, protocols that we call standards of care, that manifest as biases in actual encounters. Because providers train their minds to revert to what they know, what they studied, the oasis of medical knowledge in the desert of medical uncertainty.

In the litigious world of modern healthcare, it may appear that trusting a patient puts the provider at greater risk than not trusting. But without trust, the essence of the patient encounter is gone. Which means a certain amount of risk is necessary, as the thought patterns should not focus on whether to trust or not, but how to optimize the trust. Risk is a natural part of healthcare as the famed physicians whose oaths providers swear under were natural risk takers.

Hippocrates challenged many of the conventionally held medical practices of his day. Maimonides challenges the physicians of his day to be as much philosophers as clinical practitioners and advocate social issues as much as individual clinical care. Galen built his name off of surgical experiments on Roman gladiators. Each of these three intellectual giants of health care were keenly aware of their medical responsibilities and balanced their practice with medically appropriate levels of risk accordingly. But in today’s litigious healthcare the artist has been replaced with the industry of critics, or more specifically, the art of medicine has been replaced with the industry of litigation.

Providers need to be comfortable trusting their patients, but if the threat of criminalizing the patient encounter changes or becomes far more consequential, providers will change their behavior – at the cost of patient care. Legal oversight to should instead on maintaining the balance, ensuring that trust is appropriately meted out with the verification of that trust, instead of redefining the specific decisions that should take place over the course of a patient encounter.

Healthcare should be regulated by, not directed by the law, with the difference coming from the influence of the thought patterns. The threat of legal ramifications should not create thought patterns that lead to medically inappropriate decisions, thereby putting providers in a position to make decisions that are adverse to patient care, more focused more around self-protection.

Healthcare, characteristically, has always been more science than law, and science requires experimentation, which is founded upon controlled risk. Risk, that when undertaken, producing positive outcomes, is widely celebrated, as when Dr. Jonas Salk developed the polio vaccine. But when producing negative outcomes, the same risk can lead down a rabbit hole of litigation and regulation. In other words, the price of errors, even well-intentioned ones, is high. High enough for many providers to avoid any clinical risk. As a result, risk has been sanctioned and controlled to the point that even legally sanctioned medical experiments, clinical research, is wound under a tight web of regulatory oversight and review leading researchers to incur significant costs and years’ worth of delays.

An issue economists have warned against in recent years, starting with no other than Milton Friedman, who warned of the additional financial burdens on healthcare as a whole from excessive regulatory oversight can cause. But the burden extends to even individual decision-making, as many physicians often order extra studies, tests, drug screens, far beyond what is medical necessary, because of the legal risks. This imbalance of excessive costs can be addressed by contextualizing trust as instrumental to the decision-making process.

We know trust is important, and essential to good patient care. But we know this in implicit terms, as a general assumption that we acknowledge and move on from, focusing most of our time and data and clinical guidelines that dictate decision-making. Like the structure of the atom, trust is all the space around the nucleus, that we ignore, focusing on the nucleus of data and clinical evidence.

But we now know that the figurative empty space is what determines the behavior of the atom, just like the trust and thought patterns determine how providers and patients respond to clinical data and facts. And if trust is lacking, providers will make decisions based on the lack of trust, over the clinical data and facts. We see this when providers refuse to continue treating patients with conditions or medication needs that put the providers at risk, if the providers believe the risk too great; or when providers prescribe anxiety medications for back pain simply to reduce the quantity of opioids prescribed; or when providers self-prescribe antimalaria medication during the coronavirus pandemic.

Time and time again we see the effects of prevailing interpretations overcoming the clinical data or standard guidelines, leading to medically inappropriate decisions.

In 2018, the New England Journal of Medicine published a study that found 20-30% of overdoses were suicides. But in 2019, the Journal of American Medical Association conducted a similar study that tound 4% of overdoses were suicides. Both similar studies, with widely disparate results, that arise from the different interpretations of the data, and to determine which study you agree with more, you would review the study design and the assumptions underlying each design.

But likely not – as most people would blindly accept whichever study appears to them first since we are conditioned to implicitly trust data when it is presented to us. But blindly trusting the data does not mean we blindly implement the study, as accepting data as fact is different from integrating data into our decision-making.

The interpretations of the data dictate the decision-making during a patient encounter. But the interpretations that form, and of the ones that form, the ones we become consciously aware of, change – not just over the course of multiple encounters, but within each encounter itself. And change in ways often we are not aware of.

Becoming aware of which interpretations form, and how they form, requires a framework to provide structure to our thought patterns. And to develop medically appropriate interpretations that lead to medical decisions that optimize patient care, such a framework needs to be structured around thought patterns that emphasize mutual trust. Mutual trust is inherently a balance between trust and verification, experimentation with standardization, the science of healthcare with the law of healthcare.

In Kentucky, an interventional Cardiologist was convicted and imprisoned for apparently performing unnecessary heart valve stent procedures, a procedure in which a stent is placed in certain blood vessels, called arteries, to keep the blood vessels open, allowing for blood flow to pass. The basis of the conviction was different interpretations of what constituted medical necessity – which subsequently was overturned after a different set of interpretations verified that the procedures performed were in fact medically necessary. Underlying the legal pretenses in this case is the implicit assumption that prosecutors can verify criminal intent based on an interpretation of one specific clinical decision within a series of clinical decisions.

That criminal intent can be discerned out of a complex set of actions within the continuum of patient care. An issue we discussed before, in which interpretations of the law become the legal arguments, whether its for prescribing opioids or performing procedures, which appears repeatedly because the legal world interprets medical decisions and the ensuing actions, which have some correlation, through the lens of cause and effect – a lens which changes depending on the perspective taken and the interpretation assumed.

Trust exposes providers to risk, but can be used to mitigate risk if trust is explicitly defined as part of the decision-making. Gladwell describes the thought patterns that naturally predispose us to trust as a tendency to default to trust. And this default to trust predisposes us to give the benefit of the doubt first and initially trust people. In fact, our cognitive functions are better equipped to perceive truths than detect lies, so unless we have an overt reason not to trust, we default to trust.

Which most providers will tell you, is good medicine. But when the legal pressures influence providers, by increasing the risk of trust to where it alters clinical decision-making, we have to identify ways to return the balance of trust so providers and patients behave in medically appropriate ways.

Trust, then, becomes a virtue to aspire for, like the virtue we described in medically appropriate behavior, and something we should reinforce with thought patterns that actively promote trust. But a more practical approach is to look at trust like a skill, to be developed over time. If all the trust in healthcare miraculously vanished, then healthcare would instantly collapse in a crisis of trust under the burden of litigation and suspicion. By building trust, by explicitly defining how trust goes into making key decisions, and by establishing a framework of trust that influences patient, provider communication, and subsequently the thought patterns.

Trust, in this manner, is like a habit to cultivate, a skill author Charles Duggal defines in his motivational books. He stresses the importance of an internal local of control in building habits, a term which means that those who develop new habits begin with the desire to develop those new habits. Trust should similarly be cultivated by actively promoting and practicing it over the course of patient encounters.

And by choosing to trust, making clinical decisions explicitly through that rationale, both the patient and provider think along those terms – and eventually, become aware that they are thinking in terms of trust. An awareness necessary to build a framework to standardize trust in all patient encounters.