Tips for Handling Patient Distrust

Patients can express distrust in their care provider for any number of reasons, with differences in age, race, ethnicity, or gender identity being among the top. Most doctors will encounter a biased patient at some point in their career, and navigating around the patient’s distrust to provide the necessary care can be a challenge. Here, three retina specialists share their stories of patient bias and how they addressed the patient’s concerns. Their words of wisdom can help you navigate similar situations in the future.

A Full-Circle Moment

By Christina Y. Weng, MD, MBA

A few years ago, I was staffing a resident clinic when a new elderly male patient presented for evaluation. While he was very pleasant to the female staff, his demeanor changed once a female resident walked into the room and introduced herself as his physician. He stated that he wanted a male doctor and pointed to some of our male residents in the hallway.

Shocked, embarrassed, and unsure of how to respond, the resident came to seek my advice. I accompanied her back to the patient’s room, introduced myself, and told him, “I understand from Dr. X* that you have requested to see a male physician today. Unfortunately, all of our male physicians are unavailable and I am the only supervising doctor today. But if you do not want to see Dr. X, it is not a problem at all. We are happy to reschedule you for another day so that you can see the type of doctor with whom you feel comfortable. However, I do want to take a moment to tell you that Dr. X is one of the best clinicians and surgeons in her class, and I know she will take great care of you.”

I am not sure if my words were so convincing or whether it was the sheer thought of another 1-hour wait in our busy clinic, but it only took a few moments for him to have a change of heart, and he agreed to see us both that day. Interestingly, when it came time for his cataract surgery, he requested Dr. X to be his surgeon, and he is doing well years later.

This was a true déjà vu moment for me because I had experienced a similar incident when I was in residency. At that time, one of my male attendings came to advocate for me in exactly the same way, and I am extremely grateful to this day. We are all role models, and our actions in these critical moments can have perpetual effects long after the clinic day ends.

*Name withheld.

AGE IS ONLY A NUMBER

By Vlad Matei, MD

Patient distrust based on perceived physician inexperience is one of the many challenges that young retina specialists face in the clinic. Fortunately, a fundamental understanding of age-based distrust paves the way for successfully navigating most scenarios.

A practitioner’s youth is naturally associated with inexperience, implying underdeveloped skills and potentially subpar results. When patients doubt our skill, they are merely trying to ensure a good medical outcome for themselves, not to personally offend us. Patient anxiety about medical outcomes is amplified by a lack of medical knowledge and the inherent unpredictability of disease. The choice of physician may be one of the few variables within a patient’s control.

Hence, to earn the patient’s confidence and trust, focus on conveying your ability to provide an optimal outcome and allaying the patient’s overall anxiety about the disease.

Developing a good rapport with the patient goes a long way toward accomplishing these objectives. Good rapport may even obviate the question of experience. Thoroughly explaining conditions and procedures—including steps that we might take to ensure patient comfort and optimal outcomes—strengthens perceived expertise. The patient who is well-informed about the logistics, risks, benefits, and alternatives of a treatment may also be less likely to blame the physician’s supposed inexperience for an unexpected outcome.

Patients who question our experience may ask about the number of patients with that diagnosis that we have seen, or the number of relevant surgeries we have performed. Never overstate your experience, because once the truth surfaces, the patient’s distrust will only deepen. Overstating is also unnecessary, since we will have already performed at least 100 to 200 surgeries, even fresh out of fellowship, and most patients often perceive “a couple hundred” to be sufficient experience. If you have done very few of a particular type of surgery, you can usually still state that the surgery in question is merely a variation of a surgery that you perform regularly. For example, pars plana vitrectomy with autologous retinal transplant for macular hole repair builds upon steps common in standard vitrectomy for macular hole. Placing an occasional humorous twist on your answers can further put the patient at ease: “You’ve done this surgery before, right?” “Yes, on a pig, who then learned how to use a computer just to give me a five-star review!”

MISCOMMUNICATION MISHAP

By Basil K. Williams Jr, MD

I had a patient with wet AMD in one eye and dry AMD in the other eye who returned to the clinic 1 month after his initial anti-VEGF injection. When I walked into the examination room, his frustration was palpable. He explained that he felt completely mislead and that I had told him that he would only need a few injections in his “affected” eye and that everything was “OK” in his other eye. He was even more angry that he had discovered that his “OK” eye also had a problem only when the photographer was describing to him what she saw on his OCT images. He asked the photographer how often most people need injections, and she told him that many patients needed injections for years if not for the rest of their lives. He demanded an explanation of the situation and wanted me to demonstrate why he shouldn’t switch to another retina specialist.

I was completely shocked because I had never had a patient so angry with me before. It made even less sense knowing I would never tell a patient with wet AMD that they only require a few injections. It also did not sound like me to say that his other eye was “OK.”

After the initial shock wore off, I was overcome with frustration with the patient for misinterpreting or mishearing what I had actually told him. I was also frustrated with the photographer for discussing the images and potential treatment plan with the patient.

I took a few moments to compose myself, knowing that those emotions would only escalate the tension. I first apologized to the patient for the miscommunication and used facial expressions and body language to show the patient that I understood his frustration. I then asked him to allow me an opportunity to explain how dry and wet AMD work and my usual treatment process for each.

For wet AMD, I usually do a few injections monthly before deciding if the treatment interval could be extended or if a switch in medication is needed. I suggested that this initial assessment period may have been poorly explained at his last visit, which is why he took away that he would only need a few injections.

I then asked him if he had started taking Age-Related Eye Disease Study vitamins (Preservision, Bausch + Lomb) , and when he said yes, I explained that those were to reduce the risk of his eye with dry AMD developing wet AMD. I then offered to refer him to another retina specialist because I didn’t think it was in his best interest to see someone he didn’t trust.

Fortunately, the discussion about the vitamins indicated that I was paying attention to both eyes, even if I did not communicate that well in his viewpoint.

This situation stemmed from an underlying miscommunication. I avoided an aggressive approach and the patient decided not to switch providers. We ultimately developed a very good relationship.