For each area of trust experienced by the patient, the health professional has done his or her part by being trustworthy.

Competence and Trust

Competence is:

 knowing what you know and are skilled to do,

 a commitment to diligently stay current on the research and management of conditions within your scope of practice,

 being aware of your professional and personal shortcomings, and

 applying the communication skills discussed in the previous section of this book.

You have learned that a patient’s request for your services is usually generated by the presence of a sign or symptom that manifests itself in the form of pain, lack of ability to function, or some other discomfort. The patient counts on you and your colleagues, all strangers to the patient, to learn his or her diagnosis, what it means for his or her everyday life, and what he or she needs to do to initiate and follow a treatment process. People also seek your counsel about how to stay healthy and prevent health-related difficulties.

In each instance patients come to you having to decide whether or not to trust that your professional training prepares you to competently address pertinent health-related needs and questions. Your role in the relationship is to be trustworthy through actions that demonstrate you are there to meet their reasonable expectations in ways you are professionally prepared to do. Their trust grows as you interact with them. At the same time, for genuine trust to take root in the relationship the patient also must be convinced that he or she is viewed as something more than a symptom or an interesting medical case or a body part (Figure 10-2). Unfortunately, health professionals and institutions are sometimes insensitive to the messages they are conveying in this regard. For example, the “bone clinic,” the “allergy clinic,” the “heart specialist,” and the “obstetrics nurse” all convey images of body parts or symptoms rather than living, breathing human beings. Some have called this phenomenon “thinging.” In it the patient is made to feel more valued for the “interesting thing” that he or she is bringing to the health professions setting than because of being a person with a human need.

Common sense suggests that patients should not trust you if you seem more interested in their diagnosis or symptom than in what these mean to their well-being as persons. To the extent that you recognize the mistake of “thinging,” you will have taken a giant step in engendering a genuine bond of trust as the bond between you and the patient.

Sometimes being judged as trustworthy by patients is not completely in your control no matter how well intentioned you are. You are a part of a system. For example, government or institutional policies determining your course of intervention may shortchange a patient or discriminate against a group, resulting in their understandable lack of trust in the system or in you personally. This does not relieve you of responsibility. Being trustworthy requires that, as you learned in Chapter 2, you participate in the change of deleterious or unjust policies whenever possible.³ Rogers and Ballantyne found in their study of women patients that when they felt themselves to be among the safe, privileged variety (e.g., white, economically well off, younger) they may develop a distorted trust in the health professional to make policies work on their behalf when that is not the case. The result can be care that is no more suited to this patient than to the one in a socially disadvantaged position.⁴

In most cases you are also one member of an interprofessional health care team, and this, too can have an impact on whether the patient will believe you are trustworthy to deliver competent care. Being trustworthy requires some things you can do, such as:

 be an alert and active participant in team decisions appropriate to your expertise,

 communicate throughout your relationship with what you judge the challenges are in the patient’s situation and what you are doing to address them, and

 let the patient know when you are going to tap the expertise of others more expert than you.

Occasionally, health professionals find themselves in awkward situations knowing that the patient’s trust might be based on unreasonable expectations. For example, consider the case of Mrs. Gleason, her family, and the team:

Mrs. Gleason, a 70-year-old homemaker, has had amyotrophic lateral sclerosis (ALS) for just over a year. Mrs. Gleason and her family have gone on the Internet and learned that ALS, also known as Lou Gehrig’s disease, is a progressive neurological disease affecting all voluntary muscles of her body. Most patients become weaker and weaker until they die, usually of respiratory arrest. Mrs. Gleason has only a small amount of movement left in her legs but can get around in a wheelchair. She is in the hospital for treatment of pneumonia that is probably due to weakness of her swallowing muscles, allowing aspiration of her mouth contents into her lungs. Her weakness has accelerated since hospitalization, even though her pneumonia is responding to antibiotics. She is discouraged, knowing that the aspiration will continue and that in her present state it is unlikely she will go home. Her family realizes she is probably past the point of her ability to live independently. They feel unable to care for her in any of their own homes but are afraid of the terrible effect it will have on her when she learns this news. They ask the physician, Jaime Sills, to do anything she can to reassure their mother that she will be OK.

Jaime decides to request a reevaluation by speech therapy and occupational therapy with the goal of determining the maximum swallowing function she has necessary for eating and any possible way she might be able to function well enough in her activities of daily living to manage in her own home with home health care assistance and the family’s periodic help. Both therapists are extremely guarded in their conclusions, believing that her potential for a return home is minimal.

Jaime Sills calls a family meeting with Mrs. Gleason, the children, the nurses primarily responsible for her care, and the therapists. As the family feared, Mrs. Gleason is devastated, saying that she trusted them to help her and now they have let her down. The family, too, becomes assertive, telling the team that increasing her therapy at least would have given her some chance of a longer stay at home. No amount of reasoning about other alternatives open to all of them seems acceptable at this moment in time. Jaime Sills tells them that a social worker will be glad to work with them to further explore their options.

This situation was uncomfortable for the health professionals who felt they had Mrs. Gleason’s interests at heart but could not meet her and the family’s expectations. In the end all you can do in such situations is to continue to search for ways to give the patient and family a basis for exploring new options open to them.

The psychotherapeutic notion of transference can help you understand certain kinds of behavior some people might exhibit toward you when you enter into a professional relationship with them. Transference has its root in the theories advanced by Sigmund Freud and further developed by other psychologists who employ this term to convey the process of shifting your feeling about a person in your past to another person.8 A young man, angry that his father “ruled with an iron hand,” might conclude, “Here it comes again!” and respond aggressively to the health professional as soon as he is reminded of his father. One of the authors knows a male nursing student who prepared extensively and carefully to provide care to his first obstetrics-gynecology patient. A part of the clinical evaluation was to conduct a personal exam on her. Upon entering the patient’s room he said, “Good morning. I’m a student who is going to be your nurse today and I will be examining you.” The patient took one look at this bearded, 6-foot-plus student and said, “Oh, no you’re not! You look too much like my son, honey!” His supervisor, who had just stepped into the room, caught this woman’s reaction and judged that to disregard the patient’s discomfort would be a sign of disrespect. Instead she used the occasion as a teaching moment with the student, explaining that this type of transference sometimes happens. Everyone was relieved that this patient was reassigned to another student nurse.

Transference can be negative or positive. A negative transference interferes with trusting the support beams necessary for venturing confidently into a relationship. Examples are the aggressiveness of the young man and discomfort stimulated by the similarity of the student to the woman’s son. For reasons patients sometimes cannot identify or express, their comfort level is low and guard is up. At the other end of the spectrum, positive transference, the good feelings a patient transfers to the health professional, can promote a well-working relationship.

It is not always easy to tell whether the transference will create a problem. A young nurse caught a new male patient staring at her. Finally, he shook his head and said, “Man, I could have sworn my first wife walked in when you came into the room. The resemblance is startling!” Of course, this raised some questions—and the woman responded by saying, “Well, is that a good or bad thing?” He said, “Both!” So she was still in the woods on this one. She felt she had no choice in this case but to continue with the patient, watching for further signs that this man’s association seemed to be affecting his responses and their relationship. (There were none, and the matter never came up again.)

The patient is not the only party in the relationship who experiences transference. Countertransference, the tendency to respond to a patient with associations of others in one’s life, takes place every bit as often. A health professional may transfer feelings to the patient on the basis of name, physical appearance, voice, age, or gestures. Any one of these can increase the chance of countertransference. It is up to you to be self-aware about such associations and adapt your behavior to correct for any negative or other troubling responses you think might be issuing from your mental association of the patient with someone in your past or present relationships.

At the same time, total neutrality is not required. If you have served on a jury, you know that the lawyers try to select jurors whose past experiences and associations do not in any discernible way come into play when the facts of the case and the identification of the defendant and plaintiff are made known. A less rigorous standard is acceptable in the health professional and patient relationship. What is necessary for maintaining a respectful relationship with a patient is to be aware that transference and countertransference take place and try to be aware of how they might affect the interaction. It may not be possible always to identify the person whom the patient is “seeing” in you or you are “seeing” in the patient.⁹

You might think that showing common courtesy to patients is such an obvious component of respectful interaction that it need not be discussed. However, nothing is too basic or obvious to consider if it provides a support beam for you and the patient as you bridge the gap between you and define what your relationship will look like. You can begin to see its importance in the simple dictionary definition of courtesy as “courtly elegance and politeness of manners; graceful politeness or considerateness.”10 It goes beyond “minding your manners” in a superficial sense because it requires doing so with dignity in the way you go about being polite. Patients take their initial cues about whether they matter as people from the courtesy they receive when they first come through the door (or, in the case of home health care, you go through theirs). Although we strive to go beyond courtesy to deeper understandings of care in the health professional and patient relationship, the patient’s first, and often lasting, impression is connected to common courtesies they receive (or do not receive) from you. In this regard the work environment works best when it is a “consumer-friendly” environment.

As with many aspects of respect, you cannot generate a welcoming, courteous environment on your own. In almost every instance you will be a member of teams that schedule patient appointments, keep patients informed, collect fees, work toward making a diagnosis or carrying out a treatment plan, and conduct discharge or follow-up activities. But you can do your part, both personally and as a model for others. For example, common courtesies in an ambulatory care clinic include:

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