I cannot think of a factor more important in the doctor-patient relationship than trust. In my 23 years of practice as an oncologist, I also cannot think of a time when that trust has been tested by so many outside pressures. First is the ongoing pandemic, which has resulted in numerous restrictions and still-mounting deaths. Second is a struggling economy, along with historic job losses. Third is a political climate that has polarized our nation. Together, these issues have tested our resolve to provide optimal health care—especially cancer care—for our patients. It is in this context that I have experienced recent challenges that many of you will relate to.
Regarding the pandemic, which has been particularly devastating for our elderly patients, I have noted the increase in fear among my patients as the incidence of COVID-19 and the number of associated deaths have skyrocketed. Patients who just a few months earlier were happy to see me in clinic and come into my office for routine care have begun rescheduling their visits or arranging for follow-up care by telemedicine. This is fine for those of my patients who are cancer survivors and see me for follow-up care, but it is highly problematic for the ones who are undergoing active treatment or are between treatment cycles. In these cases, postponing a visit or scheduling a visit via telemedicine may lead to a delay in treatment or in the diagnosis of a complication. Each time I explain these risks to a patient, the interaction becomes a test of trust. Does the patient trust me enough to believe that the benefits of optimal cancer treatment outweigh the risks of coming to our clinic? Or is the patient fearful enough of the virus to push back against my advice? Another brewing crisis pertains to the many people who have deferred cancer screening for the past year because of the pandemic or because they have lost their jobs, and therefore their health care coverage, and will likely present in the future with disease at a more advanced stage.
Our patients’ trust in us was tested again in the early days of the vaccine rollout, when community and academic health care institutions were focused on vaccinating their extensive health care staff and first responders. Patients, by contrast, were asked to be—well—patient. The delays in population-based vaccinations that are occurring across the country are only heightening the anxiety of our patients. Although I never experienced any animosity from patients because I received my vaccine before they received theirs, I breathed a tremendous sigh of relief when patients started to receive their shots several weeks after I had received mine. Although we still have a long way to go, I am thankful to see that more and more of my patients are undergoing vaccination.
Economic disparity is another stressor on health care delivery that has increased, adding further opportunity for mistrust. For example, our oncology pharmacist normally focuses on monitoring active treatments and educating our patients with cancer. Now, much of her day is spent addressing the concerns of patients who need financial assistance, especially to pay for the growing number of expensive oral cancer therapies. Patients are relying on our resources more than ever to navigate the labyrinthine processes that are a prerequisite for receiving support. In other cases, patients have expressed their dismay at the exorbitant costs of oncology treatments, and the inability of physicians to rationalize these prices.
Lastly, the political climate in this country has created tension in our relationships and tested our humanity. Although I have my own political views, I try my best to keep them to myself when dealing with patients. I find that the doctor-patient relationship can be strained when patients express their political opinions, even if they and the doctor agree. As physicians, it is part of our ethical code to treat all patients with dignity, regardless of gender, race, creed, or age. Our discussions with one patient, however private they may be, should be representative of how we speak to all patients.
All of this is to acknowledge the increasing pressure that these times have brought to a profession that was already stressful. Recognizing these factors and managing them within ourselves, as well as with our patients, colleagues, and staff, is just one more task for us as physicians.
Daniel J. George, MD