On Trust and Shared Decision Making.

To the Editor: In medical school, my classmates and I learned about medicine’s shift from paternalism to shared decision making as a prevailing ideal of care. During residency, I have found that existing structures of care have not uniformly transitioned to support this model. U.S. health systems have moved to a model of decision making that requires more intrinsic trust at the same moment that they have devalued continuity, an essential component of trust. Trust is built over time. I think back to a gentleman I will call Mr. A, whom I cared for as an intern. His family had been his fierce advocates for decades throughout a complex medical course, involving multiple surgeries that had left him with a wisp of a voice and a feeding tube. Upon being transferred from the intensive care unit to our service, Mr. A grabbed my arm, looked intently into my eyes, and whispered hoarsely, “Please let me die.” With my attending and senior resident, I spoke in daily meetings with Mr. A’s family about how to best serve his wishes. Mr. A’s family’s concerns existed on a completely different plane: worries about his vitamin supplements, the best rehabilitation facility, preventing clogging of the feeding tube. I called Mr. A’s long-term primary care physician (PCP), who agreed to travel from another hospital for a family meeting. A sense of comfort pervaded the room when Mr. A’s PCP arrived. This meeting was our first step in engaging Mr. A’s family. Over the next two weeks, having consistency in the team helped Mr. A’s family accept his transition to hospice care, which is where Mr. A was transferred by the end of my rotation on service. Experiencing the trust that opened the door to this difficult transition in Mr. A’s care was one of the most valuable moments in my intern year. However, the current system of shift work, superspecialized teams, and divisions in inpatient vs. outpatient care limits opportunities for building trust. A pilot for a different kind of system could have residents formalize relationships with a handful of “continuity patients” with whom they would navigate significant medical decisions. Similar to a health care proxy, the “continuity provider” would be present during goals-of-care meetings and discussions of difficult medical decisions. Ultimately, scheduled time and reimbursement models would be needed to make participation sustainable. If medical educators are going to teach a model of care that is inclusive of patients’ values through shared decision making, then they must build structures of care that foster continuity, the birthplace of trust. Alyse Wheelock, MDSecond-year resident, Internal Medicine, Boston Medical Center, Boston, Massachusetts; [email protected]