Trust


Like time, trust is a difficult concept –easy enough to conceptualize, perhaps, but hard to define. To categorize. To understand. It is slippery, and slides through the fingers like water. As St. Thomas Aquinas said of time, you know what it is until someone asks you to be more specific. It is something, however, that seems to be essential  in many of our interactions –arguably none more so than in Medicine.

As a doctor, I could be accused of a confirmation bias I suppose –after all there are other relationships that require a high degree of whatever we understand to be involved in the concept of trust that might seem too numerous to list. That is true enough; trust pervades all levels of our daily lives, but I suspect we are likely more fastidious in entrusting our very existence –or the quality thereof- to an unknown person, especially since the interaction involves an unequal power relationship.

But it is a necessary trap, isn’t it? Sickness can be incapacitating and so we usually seek to alleviate it if possible, or mitigate the effects if not. Patients –the etymology of the word derives from the present participle of the Latin word suggesting ‘undergo’, or ‘suffer’- understandably seek what power they can exercise beforehand. If they have to place themselves in the hands of someone else, often a stranger, they can avail themselves of  information about the doctor beforehand. There are rating systems online that canvas opinions of interactions and results from the doctor in question to help with the decision. They may pre-engender that elusive trust -or at least, facilitate it in what are often constrained and inadequate time limits of a consultation visit.

My reputation –or lack of it- is therefore already packaged for a patient to open or discard as she sees fit. I am a sort of book already read and critiqued by someone else, dependent on the rating, even though I am –as is everybody else- a work in progress. The last chapters are yet to be written. But I have no such prescient knowledge about my patients –no way of knowing them beforehand. I must take what I get and write the next page…

And yet, that is not always the case: some, you get to know and enjoy; Sonia was one of those. I had seen her on and off for years, albeit at intervals that verged on epochs –often so long, in fact, that I sometimes assumed she was dividing her loyalty amongst several doctors. Sonia, I had realized long ago, saw medical opinions as bouquets from which she felt quite comfortable in selecting the most appealing flower.

She is a short, large woman, with a smile that says relax. Her hair has greyed over the years, but is invariably bunched on the top of her head and artfully fastened with a brightly coloured ribbon no doubt contrived to contrast with her clothes. It is probably a fashion statement; I see it as an idiosyncrasy, but I’m sure that my Rate-Your-Doctor file does not comment favorably on my own tastes in that area. My receptionists certainly don’t.

I have always liked Sonia. She seems to have that rare talent of being able to summarize her concerns succinctly and intelligently –almost as if she had written them down beforehand, memorized the salient features, and then practiced them over and over again until she was satisfied they made sense. Satisfied I would understand how important they were to her. Almost as if she had reused them many times…

But today, her referral letter suggested nothing new: fibroids -benign growths of the muscles of the uterus- with a past history of occasionally heavy periods. I had seen her for this a few years before and she had decided not to do anything about it, confident, as she had said, that the problems would go away with her menopause. I saw her watching me as I scrolled through the letter and the accompanying ultrasound on the computer screen.

I looked up at her from the monitor. She was dressed in a beautiful green, velvety dress like she was about to head for a cocktail party after the consultation. And, true to form, had fastened her long, unruly hair on her head with a neon bright, thick orange ribbon –like a trail marker tied to a bush in a forest… I buried the thought as soon as I noticed her smiling at my glance. “So..?”

“So, I’ve decided I want you to check my fibroids again,” she said as if I’d just canvassed her opinion the week before and was still trying to make up her mind about what to do. “Just my fibroids, that’s all.”

It was so like Sonia to want to help me to focus on the reason for her visit. I pulled up a comparison ultrasound done at her last visit three and a half years ago. She was 52 then and I had encouraged her decision at that time. Fortunately the fibroid –there was only one then and now- had not grown in the interval. But the lining cells of the uterus –the ones that are shed during a period- were now quite remarkably thickened. That had changed! I scanned the blood tests her family doctor had done a few weeks ago and they seemed to indicate that she had probably already gone through her menopause. So any bleeding now would be both unusual as well as worrisome –uterine cancer can present like that. I looked at what she’d told me on her last visit: heavy, but only sporadic bleeding. She’d refused to allow me to sample the cells in the uterus –an often painful but necessary procedure we commonly perform in the office but which could be done in the operating room under an anaesthetic if necessary. She’d promised to decide and come back on another day… But hadn’t.

“What about the bleeding, you had?” I said, mindful of her concerns about the biopsy I had suggested last time.

“You want to do a biopsy, don’t you?” she said with an almost flirtatious smile.

“Well, I’d like to make sure there are no abnormal cells in the uterus. The fibroid hasn’t grown, since we last met, but we never did that biopsy I’d suggested.”

She turned on another sweet smile and shrugged. “I’m sorry about that, but business took me out of town right after I saw you. Anyway, I had one done down in the United States and it was normal.”

I looked through the data her doctor had included with the referral, but I couldn’t find any pathology report or mention of the biopsy. “I can’t find any record of it here,” I said, busily scanning the screen to see if I’d missed anything.

“You won’t find it in there, I don’t think,” she said with a little toss of her head. I looked up. “The doctor down there just phoned me and said everything was okay, but never asked me where to send the results.”

That seemed a little unusual –if only for medicolegal purposes, doctors like to make sure results of tests are sent to the patient’s personal physician. “When was that?” I said, ready to enter it into her notes.

Another shrug. “I don’t know. Three years ago maybe?”

“Are you still bleeding, Sonia?” A simple question, I thought. But her face suddenly hardened. “Because a lot can change in three years…”

Her eyes tightened slightly and she looked at me suspiciously. “No, wait. I’m sure it was more recent…” She closed her eyes for a moment, obviously trying to decide what might be a better answer. She was now angry and her whole body stiffened.

I thought perhaps I could diffuse the situation. “Well, do you think you could ask that American doctor to send me the report of his or her biopsy at least?”

“You don’t trust me, do you doctor?”  She stood up and started to put on her coat. “And after all these years!”

“Sonia, let me just have a look at that report and see what it says…”

“I told you what it said,” she said through tense lips.

“And anyway, if you’re worried about another biopsy, if we have to do one, why don’t we do it in the hospital under a general anaesthetic..?”

Suddenly, her coat was on and she hurried to the door stopping only briefly to face me. Her face was an angry mask as it stared at me with a mixture of indignation and disbelief. “I’ve trusted you all these years to do what was best for me,” it said with a slow, almost sad shake of the head underneath. “But without trust…” She sighed loudly and walked stiffly but determinedly through the door without a backward glance.

Maybe she was right about the trust we shared, but I am still waiting for that report.

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