A 29-year-old woman comes to the emergency department due to abdominal pain and fever. This morning, while crossing a street, she was struck in the stomach by a motorcyclist. On arrival, the patient tells the triage nurse that she does not have medical insurance. She has no chronic medical conditions. Temperature is 38 C (100.4 F), blood pressure is 109/82 mm Hg, and pulse is 88/min. The abdomen is distended with bruising, rebound tenderness, and guarding. The patient is told she needs exploratory surgery to treat her condition. She refuses and states angrily, "I'm suffering and I'm not going to be a guinea pig for this system. If I had insurance, you'd give me something that would actually cure me." In addition to clarifying the details of the surgical procedure with the patient, which of the following is the most appropriate response by the physician?
Trust (ie, belief in the physician's recommendations and intentions) is central to the physician-patient therapeutic alliance and necessary for optimal outcomes. Distrust may arise from prior negative health care experiences, such as adverse events (eg, diagnostic error, treatment failure) or overt or perceived physician bias (eg, against uninsured patients).
This patient with signs of posttraumatic peritonitis (eg, rebound tenderness, guarding) expresses reluctance to undergo surgery in a way that signals distrust (ie, concern that she is being treated as a guinea pig). To ensure that the patient receives appropriate treatment and an optimal outcome, the physician should apply the following principles to build trust and promote treatment acceptability:
Acknowledge trust as a central therapeutic goal.
Find common ground (eg, identify a shared goal of feeling better).
Seek patient perspectives and prioritize patient-centered care (ie, treatment aligned with patient values).
(Choice A) This statement unnecessarily focuses the discussion on the physician's perspective (eg, compensation) without addressing the patient's concern about being a guinea pig or exploring her underlying reasons for refusing surgery.
(Choice B) This statement reflects empathy for the patient's suffering but is fear based (ie, focuses on negative consequences). It is unlikely to promote acceptance in a patient whose reason for refusing surgery is low trust; in fact, the patient could perceive this statement as coercive or threatening.
(Choice C) This question assumes that the patient's refusal is based on financial concerns; her statement is more indicative of distrust.
(Choice E) Attributing this patient's response to pain ignores her central concern of trust and may be viewed as condescending.
Educational objective:
Trust is central to the physician-patient relationship, and distrust may arise from prior negative experiences (eg, adverse events, bias). Physicians can build trust by identifying shared goals, seeking patient perspectives, and prioritizing patient-centered care.