A unique dimension of trust in doctors

 “Your medicines just don’t work. Are they really medicines, or are you just giving me some dummy pills? My shoulders, hips, knees, feet, everything aches. I don’t know why I keep coming here to see you repeatedly!” Every encounter with Mr. Kuppan (name changed) starts like this. Mr. Kuppan came to us 6 years ago with loss of sensations, numbness and pins and needle sensations over his hands, especially his fingers. Detailed evaluation led to a diagnosis of lepromatous leprosy. We referred him to Central Leprosy Training and Research Institute (CLTRI) in Chengalpet for evaluation and treatment. He completed 9 months of tablets, and it was extended further to complete a full year. Mr. Kuppan had a rather stormy course of treatment. He developed many side effects of the drugs. It took a lot of empathetic hand holding and comfort care to lead him through the treatment. We expected that completing the treatment for leprosy would feel like a great relief and freedom from an illness. However, it ended up feeling like a great relief from the arduous treatment, the toxic pills and their horrible side effects. When you go through so much together, a special kind of bond develops between the patient and the physician. Mr. Kuppan and I share an intimate friendship. We discuss issues from mosquito menace in our village all the way to Tamil Nadu politics and governance. But when it comes to treatment of his ailments like musculoskeletal pains, he would never hesitate to express his immense dissatisfaction with our treatments. He would say that our treatments are useless. But he would return to the clinic the very next week with a fresh set of complaints. 

 

“Yenga…(deep sigh) onnum sari aagala…” (Where?...(deep sigh) nothing is becoming better…) would be the first comment from Mrs. Mangalam (name changed). Her comment would be soaked in frustration and anger. She has diabetes and hypertension, and age related degenerative joint pains. I am treating her with high doses of paracetamol, but it doesn’t help her, and she keeps demanding stronger pain medications. Her kidney functions are borderline abnormal and so I am using pain killers very carefully. She shows her frustration by giving me the angry look, scolding me now and then and sometimes even snapping at me rudely. Despite this, she returns to the clinic regularly for the paracetamol. 

 

Mr. Kuppan and Mrs. Mangalam are only two examples. There are many patients who are dissatisfied with the outcomes of their treatment. But their dissatisfaction does not lead to mistrust. Like most of the patients in our villages, both Mr. Kuppan and Mrs. Mangalam have visited several other private doctors as well as doctors in the public health system before they ended up in our clinic. They continue to receive services from other doctors. Despite their dissatisfaction with our treatment, they choose our clinic to all the other options that they have. And many of these patients are also regular and frequent visitors to our clinic. 

 

Published scholarship on doctor-patient relationships claim that outcomes of treatment, competence of the doctor and satisfaction with clinical encounters promote trust. However, patients like Mr. Kuppan and Mrs. Mangalam and all others like them have this strange combination of clinical dissatisfaction with our treatment nevertheless with a deep trust in the clinic. This makes me believe that trust might not actually be a transactional and strategic choice made by a patient. Trust is probably relational. Mr. Kuppan and Mrs. Mangalam have a trusting relationship with us and our clinic. They know that ours is a small low resource clinic, with limited range of medicines and services. They understand that we do not have any cutting-edge cures to offer. But they have a trusting relationship with us. So, they would keep coming back to us. They have very low expectations from us for a cure. But they know they are safe in our hands. That feeling of safety gives them reassurance. That reassurance probably gives them a sense of wellbeing. They probably come back to us repeatedly for a shot of that wellbeing. 

 

I worked for 4+ years on my doctoral research on trust in the doctor-patient relationship. I spoke to many people in rural Tamil Nadu about their trusted doctors. One thing one of my interviewees told me stands out in my mind now as I write this blog. “Visiting my PHC doctor is like going home for a home-cooked meal.” This statement encapsulates what is trust. The analogy to home-cooked meal refers to comfort, safety, security, and reassurance. For Mr. Kuppan and Mrs. Mangalam our clinic is probably home and our treatment the home-cooked meal. Even when the home-cooked meal is not very tasty, we go back to it and crave it, and it gives us comfort at the end of a very hectic day of work. Our clinic treatment may not be stellar and cutting edge, but for Kuppans and Mangalams it gives reassurance and a sense of security of home. We are happy that we can provide that to a few.