Latest / Health Ethics Podcast / "Trust Me, I'm a Clinician": Medical Expertise, Trust, and the Patient Experience

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"Trust Me, I'm a Clinician": Medical Expertise, Trust, and the Patient Experience · Health Ethics Podcast

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Welcome to the COVID Ethics Series podcast, a conversation with leading experts about bioethical
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issues that have been exacerbated due to the COVID nineteen pandemic. On Brian Pilkington
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and I teach bioethics at Seatonhall University and at the Hackensack Marinian School of Medicine.
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I moderate the COVID Ethics Series in cooperation with the IHS Library and IHS
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Student Life. This podcast is a spin off collaboration with the IHS Library where
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we'll have the opportunity to go deep with the experts from our series. Thanks
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for joining our conversation. Welcome everyone to the COVID Ethics Series. I am
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Brian Pilkington, and it is my great pleasure to be speaking with Jamie Watson.
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Jamie Watson is a clinical ethicist at the Cleveland Clinics Center for Bioethics.
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Professor Watson studies primarily considerations of expertise, the nature of expertise, and the
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extent of expert authority. In addition to his work on expertise, he also
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does work in health literacy and moral distress. And Jamie and I met at
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a conference and gave a wonderful talk on trust, and I've been thinking a
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lot about trust in terms of the healthcare system, and so he was kind
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enough to join us on this on the COVID Ethics series podcast to talk through
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some considerations of trust. So, Jamie, thank you so much for taking
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the time. I'm glad you're here. Thanks Brian, appreciate the opportunity to
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talk with you. Thanks for the invite, of course, of course,
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and so before we jump into some of the arguments, sort of the detailed
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considerations of trust, what sort of big picture what brought you to bioethics generally
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and in particular what sort of motivated you to start thinking about the host of
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projects you have around expertise and trust. Yeah, so bioethics was, you
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know, an entryway from philosophy. For me, I've always been interested in
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the ways in which philosophy can be applied in the real world. I did
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some work in business ethics a while back, but then I started learning about
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the impact of clinical ethicist in real clinical spaces, the sorts of education they
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do, the sort of consultation they do, and and got really excited about
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it. And for me, expertise has always been sort of this, you
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know, front runner question when we talk about what do we know? How
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can we know? I'm an epistemologist by training, which means a study of
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knowledge, and you know, with expert authority comes this question of how do
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we know that someone's an expert? How do we know that someone is trustworthy?
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Under what circumstances should we trust someone? And you know, trust is
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everywhere. It's from political decisions to you know how many times the weather channel
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access is my location. You know, we're putting trust in people at every
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stage of our lives these days because the world's too big and complex not to
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we can't get by without it. But I think it's nowhere more intimate and
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personal than in clinical spaces. In the medical environment. You know, we've
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got people who are vulnerable because of health needs, who are talking with people
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who are ostensibly experts, who are literally gatekeepers to the medicines that they need,
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the treatments that they need, all of which are integral in some cases
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in some ways to their their well being. And so you know, the
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ability for providers to benefit and harm is huge, and so trust in those
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spaces is so critical. It's I mean, yeah, I think having well,
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having thought a bit about some of this at a lower level, and
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having been a patient not too long ago. It's sort of very eye opening
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in terms of the amount of trust that I placed in lots of folks,
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both health care practitioners and also the system in general. So there's yeah,
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oh, there's there's so much there. So what are the primary concerns around
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trust with healthcare? What do patients face daily? I mean to talk us
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through sort of what's going on in some of the ethical implications that you've been
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thinking about in your work. Yeah, you know, I think there's an
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easy way to divide the landscape. We can think about big concerns with trust
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that get a lot of attention. So things like COVID social restrictions, you
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know, under what circumstances are they justified and who's making these decisions and are
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there political influences? And then there are questions about opioid prescribing. Is it
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too much? Is it not? With the certain kinds of guardrails. So
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are lots of big questions, and they raise questions about well, who counts
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as an expert because there's lots of dissenting voices in these spaces, and how
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would novices know whether they were dealing with an expert? And I think these
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are these are big hard questions, no, no, no doubt about But
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I think in most of our daily lives, well, we're not concerned with
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whether someone's an expert. We're really concerned with what I call small concerns with
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a big impact, which are we recognize that the doctor in front of us
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is an expert in some sense. We recognize that the specialist that we've been
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sent to is an expert in some sense. The question is are they the
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expert that's going to meet our needs. There's this problem with a misalignment of
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values, where you've got physicians making different risk assessments than patients, and so
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we'll make recommendations based on their own risk assessment, patients will say no,
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and the conversation will end. Don't really recognize the reasons that a patient might
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be saying no, or that there's a difference in how a risk is assessed.
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There's differences in how providers respond to disability. Some people think that it's
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going to be like inherently a lower quality of life depending on the disability,
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and they may make medical recommendations based on that assumption. Same with the end
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of life we talk about quality of life assessments. Some physicians will push for
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certain paths over others based on their own assumption of quality of life. And
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so if there's any mismatch or misalignment between experts and their patients, or experts
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and non experts with respective values, even if an expert is well intentioned,
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even if they really are an expert in their field, we can get non
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experts not getting what they need from experts. That's I mean, the framing
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is really helpful. It so we have these large questions who counts as an
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expert? And I'll do this throughout our chat for folks listening in. You
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probably remember if you've stayed tuned to all of our episodes. General Leva of
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seton Hall Law School sort of highlighted this early on in one of our conversations
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in the Pandemic, about folks who appeared to be experts and they truly were
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in certain contexts, but sort of not staying in their lane and broadening out
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and starting to comment on other kinds of things. So we've got that in
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the background, sort of big questions what the policies are and all that,
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and COVID's nice, no challenging example, and then to Jamie the but we've
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got this other concern which maybe is discussed less outside of your work, which
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is smaller concerns with a huge impact, like risk assessment. So throw your
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clinical ethics head on just to give a practical case for our students, and
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of course we give medical students at the Hackensack Marine School of Medicine and nursing
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students and health sciences students at Setonhole University who are all interested in this from
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a variety of perspectives. Any sort of identification of particular problems beyond risk assessment,
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any recommendations for navigating values conflicts, especially if excellent practitioners who are trying
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hard don't pick up on them. Yeah, so you know, you imagine
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you go to the doctor and you've got, you know, not a common
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condition, but not a especially rare condition. There's a little bit of data
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on it, and the clinician is trying to provide you with their expertise and
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a recommendation about how to go forward with a treatment plan. And they say,
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you know, there's an eighty percent likelihood that you're going to do very,
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very well with this treatment. And you can imagine the same conversation with
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the same with a different clinician who says, you know what, there's a
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twenty percent chance you're gonna have some very serious complications with this treatment plan,
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and just the framing the eighty verses twenty the same numbers, right, But
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if you're leading with what you're most concerned about, like based on your value
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system, then someone might be biased. We call this a framing bias,
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and this can be very subtle. And that's just a very blatant example.
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There are lots of others, but there's a very blatant example of how you're
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going to lead with the statistic or the number that makes sense to you and
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a lot of your values. And I think, you know, if I
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heard patients say, oh, twenty percent, well you know I got a
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twenty percent chance of getting hurt going down the highway, right, and so
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their risk assessment like twenty percents, no big deal. Other patients, it
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might be a very big deal. And the question is twenty percent of what
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can we deal with any complications? Like the conversation tends to stop at the
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initials and they say, well, twenty percent that X and you know what,
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we can treat X. We have We have X all the time and
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that's no problem. Or we might say, oh, twenty percent chance of
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X, and you know X is going to mean these changes to your life.
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Is that acceptable to you? Right? So these sort of deeper questions
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that go beyond the sort of loaded assumptions that go into the numbers themselves.
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And so I think when you're navigating these in the clinical spaces, the best
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thing to do is ask questions. And so if I'm a clinical ethicist,
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I'm in the room, I'll make sure I'll I'll if I'm a clinical ethicist
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and I'm in the room, i will play the medical outsider. I'll say,
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Doc, tell me what this means is twenty percent? What does this
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mean for this patient? What does that look like? They'll start talking,
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So, is there something that we can handle with X that is in that
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twenty percent range? What does this eighty percent look like? You're saying eighty
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percent chance of that you're going to do very well? What does very well
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mean for this patient? And so we can start diving in. So we
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could turn to the patient and say, well, what are you hearing When
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the doctor says twenty percent chance of X. And in some cases the answer
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will blow you away because it comes out of nowhere. It's like, oh,
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well, my sister had X, and like she was miserable and I
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would never ever want to X. I wouldn't live with X. And you're
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like, oh wait, let's talk about your sister for a second, because
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your case may be very different, all right, And if so, you've
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not engaged with the patient about their values and what's what they're hearing when those
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numbers come out, then you can't formulate a care plan that's going to again
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line up with the clinicians values and the patient's values. I mean, so
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this sounds exactly right, right, But the response that we're going to get
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right, so I'll play the person doesn't know what's going on here. Finding
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your example. The response that many of my students mentioned when I talk about
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all the kinds of things you can talk through to help values alignment, well,
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I only have twelve minutes to see this patient, so there are other
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kinds of constraints and other sorts of things that impact what they would like to
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do, right of course, and they don't want to get out there to
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go you know, home. They want to just see the next patient be
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able to provide care within a stress system with you know, a sort of
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waning workforce. So what do you do then help help? I mean,
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how do we have these conversations effectively more quickly optimally? Yeah, I mean,
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so it's a big challenge, right, there's a structural challenge here.
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We know that if we had infinite time and infinite space, we could we
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could be the good providers that that we want to be. We recognize that
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there are ways of um, you know that that is sort of truncated and
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hastened. I think what we're learning is we listen to more patients that they're
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less concerned with a lot of the sort of medically jargon that we give them.
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They're more concerned that they're heard. So I think there are two things
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that we can do. I think we can do more in the time that
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we have, So if you've got that twelve to fifteen minutes, still,
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patients respond better when they're listened to more and talked at less. The other
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thing is to make use of the resources that are now expanded in our clinical
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spaces. The way that the medical chart works, the way that your virtual
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communication can go the way that you can have telephone calls and virtual calls,
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I think we can make more use of those, better use of those for
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dealing with specific technical issues outside of that space. Because when you're in that
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clinical space, space to face, that's when the trust is built, that's
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when the body language matters, that's when the listening occurs, because you're not
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going to get that through your virtual portal. But if they have questions that
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they can ask on the virtual portal about the technical stuff and you could provide
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it, that's great. So I think it's hard, and this is not
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a perfect solution by any stretch of the imagination, but I think if we're
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in those clinical spaces and we lead with you know what I'm going to call
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a trust first knowledge economy, hopefully in a few minutes, and then and
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then use the technology that we have to kind of expand some opportunities. But
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it's tough when you're in you've only got fifteen minutes with a patient, it's
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tough to build the trust you need, especially for critical medical care. Yeah,
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I mean, the challenges are real, and the move right to listen
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first sound just like very helpful advice. Well, I got some other questions
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we might come back to around disability, but let's jump to what you just
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mentioned. Talk to us about this trust first, sorry, knowledge evidence yea,
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go yeah now yeah. So you know the way that we typically respond
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to these the big questions that I talked about, the big questions about trust
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that to get a lot of attention. The typical response is to, you
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know, push competence, push credentials, push experience, push professionalism, will
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push the follow the science mantra. The problem with that sort of approach is
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again it misses the smaller clinical space relevant question. People aren't questioning their doctor's
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expertise, They're wondering if their doctor has thought about their specific needs right.
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And so when we say follow the science, in some cases, science hasn't
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caught up. You know, when we're talking about COVID, especially in the
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early stages, we didn't have the science behind us, and so there were
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lots of talking heads, there were lots of experts who again very well intentioned
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and clearly experts in their field, but the science just hadn't caught up.
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Also, science is valuating. We saw this with the pandemic. We have
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certain risk assessments. So when we're making a public health risk assessment, we're
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automatically going to risk on the conservative side because we don't have the information yet,
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because it's happening too fast, And people respond negatively to that because they're
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like, oh, you're overreactive and nobody knows right, and so you're in
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that weird space. So when you push competence first knowledge economy, you can
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get caught in an odd sort of trap, you know, and you can
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fall into your patterns. So, for example, if you're trying to appeal
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to the masses, you're trying to say, well, look, we're the
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experts, and we're saying that, you know, breastfeeding is natural. So
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this was a very big, common, you know, common sort of framing
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of encouraging breastfeeding for women, millions and millions of women. Right, But
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then we get to the vaccines and that they're clearly not natural, right in
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a in a specific sort of sense. They're scientifically created in a lab.
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And so you've got, you know, breastfeeding women who are saying you've been
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pushing natural all this time, and now you're telling me to get this vaccine
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that's not natural. So you've put yourself by being the expert. But trying
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to appeal to the masses with your competence and your framing, you put yourself
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in this weird position. So what I think the change is, and again
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this is to focus on these small concerns that have this big impact. Is
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to focus on the trust building first. If you trust someone you're you're less
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concerned with how it's framed. You're not going to perseverate on the fact that
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they're you know, using natural in one sense and you know, pushing something
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that's not natural in another. And so if we're focused on the trust economy,
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the competence is still necessary. You still have to be the expert in
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the field, you have to have the science that you have to offer.
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But what the trust first economy allows you to add is those things that count
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as social capital, like listening, more like asking more questions, more than
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making more statements. In contrast to the competence first knowledge economy, I think
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that we should focus on a trust first knowledge economy. Again, assuming that
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the competence question has been answered, that the person in front of us,
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we really have good reasons to believe they're an expert. We know that trust
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is not established by rehearsing the reasons that they're an expert. That doesn't increase
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trust. What increased trust is personal relationships and the roles that you develop in
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relationship with one another. And so once we've presumed that the competence question can
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be answered, we can look for things like responsiveness, How did you respond
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to my specific question? How well did you demonstrate that you listened to me?
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Is the information you're giving me values based? You know, patients care
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very much less about whether it's a treatment as sixty five percent successful or seventy
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five percent successful because they can't conceptualize that in terms of their individual lives.
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If you tell them that this is what it would mean for you if X
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were to happen, that helps them build a sense of whether they're going to
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accept a treatment or not, or whether it's right for them or not.
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And so if you're looking for the responsiveness, you're looking for the values based
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framing. If you're the way that it lines up with their lives, then
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you've got an opportunity to make recommendations that people find appealing, that they find
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reasonable. And so I think the trust first version is what works for these
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smaller clinical spaces. And then I think that has an impact on the bigger
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question. Once we've established the trust with the people that we already recognized as
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experts, then when we hear similar statements outside that context, in the broader
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public or institutional context, that we have a tie in, we have a
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connection to some personal relationship that we already find trustworthy, that is saying something
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similar, and so we find it confirming rather than having the sense that we
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need to react to it. I find attractive this idea of trust first and
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sort of can see sort of very easily and obviously the benefits of this move
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And I imagine, and I don't know the literature well enough, I don't
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know if folks have done empirical studies on reduction of medical errors in light of
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this kind of move, right, because I imagine the sort of enhanced communication
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here and potential values alignments of and the increase of trust avoids a lot of
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potential mistakes, both because the clininician in a way knows the patient better and
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they're just i mean, just more on the same page, to use a
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boring cliche. So that's is their empirical workout here around that's a total off
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the Cuugh question. Any empirical work to suggest this reduces medical error, maximizes
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outcomes, those kinds of things. I think what it does is it reduces
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the perception that the decision happened too fast, reduces the perception that the decision
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was pressured, and it reduces error in the sense that perceived error is less.
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And so, for example, we have lots and lots of cases as
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an ethicist, we see lots and lots of cases at the end of life
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where families are making decisions about loved ones and how they know how their medical
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care is going to go, whether they're going to go with an aggressive treatment
19:45
plan, whether they're going to go with a palliative treatment plan. And we
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have lots of empirical evidence that surrogate decision makers experience PTSD like symptoms after making
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a decision or say comfort care you know to or withdraw life sustaining treatment,
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for example. And so I think that the better that they get the sense
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that we're oriented to what the patient would want and they feel supported by the
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clinical team and a decision that is benefiting the patient, I think they feel
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like it's less likely to have those sort of symptoms like the PTSD symptoms the
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sort of traumatic symptoms. And we also have empirical evidence that people are happier
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with their care when doctors are sensitive to those trust relevant issues. So people
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are happier when their care when their doctors are on time, which is a
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weird one, right, because doctors are always sort of running behind. But
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if a doctor is on time and they listen more than they talk, patients
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are happier with their visit. Does that mean that the doctor was more or
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less competent, No, but they were exhibiting again, more of that social
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capital, the respect for the person, the sense that I'm concerned about your
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interests enough to take you seriously as a person's I mean, that's really help
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when I can imagine as a patient that's going to you know, sort of
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all be more inclined to do the kinds of things which would result from any
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competent doctor if I have this trusting relationship with a physician, healthcare practition,
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whoever that might be. So I want to think a bit or push you
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a little bit and think about the small wonderful response. And I really appreciate
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you both the framing and the sort of trust first economy. I see how
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that works on the individual or even maybe group of patient level. Can this
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be taken up to systems levels, because I'm thinking about health systems who have
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wonderful sets in the best case scenario of healthcare practitioners, maybe so much so
21:45
that they think about you visit I'm not going to name anything, but you
21:48
visit the health system, you don't visit doctor Watson. I'm interested in that
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kind of thing, how trust economies get played out, or how the trust
21:55
economy gets played out there. And also in the background is sort of systems
22:00
of oppression, systemic bias, and other kinds of what I think are sort
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of big challenges, large structural challenges which might impact then the smaller interactions.
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So two huge questions. Anything on either one would be super helpful. Yeah,
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you know, health institutions have some power. They don't have all the
22:25
powers. So when we're talking about the amount of time that you get with
22:27
a patient, those are typically billable hours. So an insurance may only pay
22:32
for a fifteen minute visit, and so there may be very little bit a
22:34
health system can do to change that. I think what a health system can
22:38
do, though, is to help support providers in those spaces with tools that
22:44
will improve trust based relationships. So, for example, you know, one
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of the things that I've learned through some of the stuff that I've done with
22:52
health literacy is improving communication styles, improving communications skills and the sort of tools
23:00
that are available can make patients feel more comfortable with the decisions and so using
23:07
plain language. And this sounds so simple because it's been around for so long,
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but one of the things that we do, and when we get into
23:11
critical care situations and all providers do this, I as a clinical ethicis do
23:15
this, and you just have to practice. But the moment that there is
23:19
a potential for conflict or a potential for some sort of difficult thing to communicate,
23:25
like you're at the end of life, we fall back into jargon.
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We fall back into the medical lange because that's our safe space. That's what
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we know. Like I can fall back into ethics language about non maleficens.
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Right, It's just very easy to go to that place where you feel safe.
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And if we practice you speaking to people and language that they understand,
23:45
and not only language that they understand, but language that can apply to their
23:47
life. So one of the things that we learned from health literacy research is
23:51
that a lot of notes in the chart that say a patient is non adherent
23:56
to their medications because they didn't know how to take their medication. What's on
24:00
the bottle is inscrutable to them, and so they struggle with how to take
24:06
medication. So they go back they're like, are you're taking your medication?
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Like, yeah, I'm taking a medication. Look, well, your blood
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work doesn't show that you're taking your medication. And so there are lots of
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plain language templates out there for medication prescribing that can benefit patients in those moments
24:19
and empower them to do the things that they're being asked to do. They
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avoid those stigmas. Right, Because you get a patient that comes into your
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space that says non adherent with medication, right, then they're going to be
24:30
treated differently by that provider, even if it wasn't their fault, right,
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And there are lots lots of lights of ways to handle this. One is
24:36
to stop putting that in the chart the way it is. We can say
24:38
patient struggles with medication, but cause like they're on seven medications and they have
24:44
to take it four times a day and it's very complicated. Please provide information
24:48
to help this patient. Right, that's a way to put a chart note
24:51
in to help stop that kind of stigma. But then patients don't feel weird
24:53
when they go to the doctor because they know that they're not going to be
24:56
stigmatized for struggling when they realize is that it really is difficult. And the
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other thing that we can do is support our clinicians with decision aids, making
25:04
sure that they have access to things that will help patients make hard decisions.
25:10
When I was working at the University of Arkansas for Medical Sciences and the Center
25:14
for Health Literacy, we're trying to put together a decision aid for mammograms at
25:18
what age and how frequently should women get mammograms? And the decision aid was
25:25
actually a calculus that was trying to put in age and risk factors and to
25:30
try to empower people to understand just how complicated a decision is, because if
25:33
you get too frequent or too early of mammograms, you may end up with
25:37
a false positive that leads to a lot of negative treatments. And there are
25:41
lots of big problems with this in a lot of areas. But that's just
25:45
one example. So I think that's one way an institution can support practitioners.
25:51
I think the other way is even before that and the health system, in
25:56
the training and medical schools and colleges of health professions. You know, we
26:00
do a lot of really cool things with simulation, Like I love I love
26:04
simulations, And if you've got a sim center, like I would encourage you
26:08
to use it, not just for the clinical stuff. I mean, we
26:11
know from expertise literature how important sims are when we look at medical training and
26:15
we look at didactics versus simulations, Like people don't get better that people don't
26:19
become better doctors or better surgeons from lectures and from conferences where they're passively engaged.
26:25
They get better when they're in simulations. What we can do is include
26:29
more psychosocial simulations to get physicians and providers practice handling difficult conversations, practice handling
26:37
ethical issues, practice handling conflict. Because once they've developed a set of schools
26:42
that can adapt to different conversations like that, then they're more empowered to make
26:47
patients fee old patients in their families feel more involved in the process. That's
26:52
great, and I think a sort of really helpful twofold response to the first
26:57
part, maybe bleeding into the second part of the question. So let me
27:00
jump back to the second part because they threw so much at you for the
27:07
trust first economy and sort of from the totality of your work on expertise,
27:11
any recommendations for folks who are trying to address systemic racism at least in the
27:18
US or systemic bias you mentioned sort of different considerations of disability from practitioners and
27:26
patients previously. I mean, some of these big structural challenges. Values alignment
27:32
sounds like a good move if you have time for the conversation, But some
27:37
of these I know, you know, some of these challenges. There's a
27:40
heck of a lot of really terrible things that happened historically. What's the move?
27:47
I mean, what can the trust first economy do. Not that it's
27:49
going to solve the problem, but sort of how do you think about addressing
27:55
these sort of big background challenges. Yeah, you know, a lot of
28:00
the biases that we're trying to address now in healthcare are implicit and implicit biases,
28:07
Implicit racial biases, implicit sex based biases. They work just like things
28:14
like confirmation bias. They have the same sorts of mental structures as things like
28:18
the availability heuristic. They're operating at a level that's unconscious and they're coming really
28:22
fast. And the ways that we handle things like the availability heuristic and confirmation
28:27
bias in research is to put in structures that limit or prevent those things from
28:36
happening. So we put in the double blind experiment to help stop confirmation bias.
28:40
I think the same thing happens in the clinic. We need to put
28:42
in some structures that prevent the biases from manifesting themselves. And so for I
28:48
mean a very simple example is we often put race in the demographic section of
28:53
a patient, and we know that implicitly whether you're a black provider white provider,
29:00
Like we have evidence that black patients receive less pain medication than white patients
29:06
for similar similar claims to pain. If we take the race out of demographics
29:11
and put it in say social determinants health, where it might actually have some
29:15
causal efficacy if needed, then we can sort of stop the bias before it
29:19
starts, before we have the you know, engage the patient. There are
29:25
lots of little structural things that I think we can do that can help mitigate
29:30
a lot of these biases. So understanding how they work and why they work
29:33
is important to understanding what structures are going to be needed in order to mitigate
29:37
them. You know, having certain reviews making sure that we're not you know,
29:42
chart reviews to make sure that we're not disproportionately disadvantaging certain populations owe to
29:48
others excellent. And again, I mean I love the small, specific practical
29:55
changes that lead to big ethical impacts. So I mean this is I think
29:57
a really helpful theme. So we've only got so much time today. But
30:02
before I'll let you go, I want to or sort of I was gonna
30:04
say shift, but sort of pick up on some of the educational features of
30:10
our conversation. So, any big takeaways for students both sort of medical students,
30:18
nursing students, ot s at s pts, sort of folks interested in
30:22
healthcare who come to care for others and are facing and will increasingly face sort
30:27
of trust challenges. So what can the trust first economy? What can a
30:32
good epistemologist? Sort of what's the takeaway for students? Yeah, I think
30:37
I think there are a couple of things. I think one is when you're
30:40
starting critical care conversations and if it's something as simple as a broken bone.
30:45
These are less important than when it's how to manage your diabetes long term.
30:49
But when you're starting with critical conversations about medical care, start with values and
30:55
interests. Start with who the patient is, Start with the things that matter
30:57
to them and things that they like. Document these things because these can have
31:02
an impact over time as the patient's medical condition changes, as their needs change,
31:07
as your recommendations for treatments that will affect their lifestyle changes. You can
31:11
refer back to say, look, you said that this really matters to you,
31:15
but it's going to mean you can't do this anymore. And so I
31:18
think starting every conversation with values and interests who the patient is, regardless of
31:22
how much clinical time you have, because that little nugget is going to carry
31:26
through. It's going to pay dividends and trust, and it's going to pay
31:29
dividends for information for future healthcare. I think the next thing is learning these
31:34
communication skills, this plain language, decision aids, action steps that fit patient's
31:41
lifestyle. Learning how to frame your recommendations in ways that make sense in light
31:45
of a particular patient's lifestyle. If a patient can't if you're recommending a treatment
31:49
for a patient that involves the means that they can't go up and downstairs,
31:52
but their bedrooms on the second floor and they don't have any other means of
31:56
getting upstairs. That might not be the best treatment plan, and then they
31:59
might end up being not adherent. Right, things like that that can compound
32:04
a patient's care for the negative. Being very sensitive to what you put in
32:07
the chart, making sure that if there are barriers to care, barriers to
32:10
access, that those are documented rather than simply noted here or noncompliant. That
32:15
can facilitate better care conversations with the next person. It'll make the patient feel
32:20
less isolated, ostracized, and empower them in their own care. I think,
32:27
you know, the other thing that we need to be sensitive to is
32:29
that we're often caught in the middle of the expertise battles. Right. We're
32:34
not the lay public who you know, don't have access to experts in say,
32:38
epidemiology, but neither are we the epidemiologists. Right, we're sort of
32:43
caught in the middle. We're hearing the patients say things about, you know,
32:45
all the national policy on this, or you know, the surgeon General
32:51
said that, and that's nonsense. But we don't know what the Surgeon General
32:53
knows either, right, and so making sure that we're recognized that we're sort
32:58
of stuck in the middle, and that we can point them to places that
33:02
that can empower them to make better decisions to come to stronger beliefs, just
33:07
the way we would do for ourselves, knowing who to turn to and what
33:10
sort of information is beneficial for them. So I think those those three practices
33:17
can can benefit patient care. Excellent, excellent, super heafl And the last
33:24
question I'll get you out on this one is you've already wrenched simulation and folks
33:29
seton Hall is super lug, my colleague Jennifer McCarthy A phenomenal simulation is So
33:32
there's a robust both at Seaton Hall and Hagensack Merinary School medicine, really robust
33:37
work going on with a bunch of folks around or sort of involving simulation,
33:44
anything else that healthcare education institutions can do, given the importance of trust,
33:51
to foster trust, to foster sort of student inclination to really think about the
33:55
importance of trust, What do you tell the folks in the dean's office when
34:00
sort of the big curriculum questions make their way all the way to the top.
34:07
Yeah, from the big curriculum questions. You know, anything interactive that
34:09
allows clinicians to have better insights into who patients are and the decisions they make,
34:17
any sort of case studies that are directly from patients, any kind of
34:22
role play that's directly that's centered around real patient experiences, Because what we find
34:29
is physicians saying like, I can't imagine living that way, right, or
34:35
I can't imagine not making this decision, choosing this, and so just take
34:39
something as simple as vaccine hesitancy. There's a phenomenal book called Vaccine Hesitancy by
34:45
doctor Maya Goldenberg. Highly recommend it. She talks about the crisis of trust
34:49
rather than the crisis of expertise, which is really what I think is critical
34:52
here. And she said, there are lots of empirical evidence suggesting that mothers
34:58
who are vaccine hesitant, there's a large population of them. It's not that
35:01
they don't believe in vaccines. It's not that they don't believe vaccines work,
35:06
and it's not that they have some conspiratorial beliefs. If they believe that there's
35:08
something specific about their child's constitution or medical needs that make them not a good
35:14
candidate for getting a vaccine. That's very different, Right, You're going to
35:19
treat that person once you know that narrative, You're going to treat that person
35:22
very different from the conspiracy theorist anti vaccer, right, And so to lump
35:27
everyone together as if all stories are homogeneous in that sense, that's going to
35:31
cause a problem for patient care. That's going to cause a lack of trust.
35:35
And so think anything you can do to humanize patient's decisions and no matter
35:39
how strange they may seem to your clinical mind, can enhance the opportunity to
35:45
ask the right sort of questions and build that trust in clinical spaces. Excellent,
35:52
super helpul And how I read that last question, given the importance of
35:54
critical thinking, is just we need institutions need to hire more philosophers. I
35:59
think that's the that's the move right Glass and ethicis Jamie. Thank you so
36:05
much. Thanks everyone for tuning in. I've been speaking with Jamie Watson of
36:08
the Cleveland Clinic. Check out the website, the Companion website as well.
36:14
We're world list a number of Jamie's really helpful publications on expertise and trust.
36:20
Thanks again, Jamie, it was great to have you. Thanks for having
36:22
me really enjoyed being here. Thank you for listening to this episode of the
36:27
covid Ethics series podcast. Be sure to check out video versions of our episodes
36:31
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