My first rotation, in August, was supposed to be about pharmacy compounding. As it turns out, though, compounding pharmacies tend to do a LOT of alternative medicine, herbal medicine, supplements, weird off-label uses of drugs with no evidence to support them...whatever you want to call it. This one, in particular, also had a clinic where "alternative medicine" doctors came to see patients.

I won't get into how unhappy I was about my situation, or how ethically compromised I felt. What I do want to talk about is one of the first questions that came to mind. Most of our patients were from Ann Arbor, and they were fairly homogenous. They were well-educated, upper middle class, and typically (though not always) women in their 40s and 50s. And so I wondered. What was it that made these people come to us? What made them turn from their doctors and from normal medical practice? Why were they more willing to trust someone who charged $200 for a consultation than someone they could see for a $15 copay?

The inevitable conclusion was that these were people who, for one reason or another, had lost faith in the medical system. They all had PCPs, who they were disillusioned with. They all had medical problems that could not be or had not been solved. They were intelligent, well-educated, independent people and you knew that they had thought, well, if my doctor can't

fix me, maybe someone else can. One of the most common questions we got was, why couldn't my doctor diagnose this? Why didn't they know about this (weird, alternative) diagnosis?

As a healthcare provider, this disturbed me very much. All the good we do is based on the assumption that our patients trust us. If they don't trust us, they won't come back for followup appointments, they won't take their meds, and they won't do the things necessary for staying healthy.

So what is the problem here? Why didn't these patients trust their doctors? Three points come to mind.

1. We don't spend enough time with our patients. This goes for both doctors and pharmacists, and probably other providers as well. Our days are busy- we see lots of patients and we deal with a seemingly endless stream of paperwork and insurance issues. It's sometimes easier to just tell the patient, this is what you have and this is what you need to do, and not spend any time explaining why, or going through the risks and benefits of treatment (or no treatment).

We had a patient, in the compounding pharmacy, who came to us because she had been having some generalized symptoms- headache, fatigue, lack of energy, etc, and also had some weird rash/dermal thing on her foot. When the pharmacist asked her if she'd seen a dermatologist, the patient said, "well, no, that's just it. My doctor didn't even look at it! She just told me to go see a dermatologist." That was probably a reasonable reaction on the part of the doctor- if the patient described this rash thing, it probably would have sounded like something outside the realm of a PCP. And if any specialty work were to be done on it, she would have to go see a dermatologist anyway. But all the patient heard was that the doctor was brushing her off, or didn't have time for her, or didn't care about her. If the doctor had taken the time to stop and look at this rash, or to explain to the patient that she wasn't really trained to deal with this sort of thing, and that a dermatologist might be better able to help her, then maybe our patient wouldn't have abandoned the entire medical system.

Those consultations were a full hour for new patients, or half an hour for repeat patients. How many normal doctors have time to spend more than 15 minutes talking with a patient? How many pharmacists have time to spend more than 15 seconds talking with a patient?

2. Educated patients like to have some say in their care. In the pharmacy world (and probably in the medical world as well) we call this "patient autonomy." If you give patients options, discuss treatments, discuss disease states and let the patient decide that treatment is necessary, they are more likely to follow through with it. Not to mention that in most cases the patient does have a right to have some input into what their treatment will be.

And if your patient has done some Internet research and has come up with some alternative treatment, it then becomes necessary to acknowledge that treatment and explain why it is unlikely that it will work, rather than just brushing it off.

We had a case where a women came to us for hormone replacement therapy (HRT) after her doctor put her on estrogen alone, and the patient thought that this was the wrong decision. As it turns out, she was right to an extent- using estrogen alone, without progesterone, can increase your risk of breast cancer. Now, progesterone itself has side effects, and without knowing the details of the patient's history and family history I can't say whether it was the right decision or not. But our patient came to us because she felt that she didn't have any say in her treatment.

3. We don't communicate clear expectations for patients of what medical treatment has to offer. The classic case is the patient taking an anti-depressant, which can take up to 6-8 weeks to reach its full effect, who stops taking the medication after a week because it's not helping. Many of our patients at the compounding pharmacy had been put on antidepressants for those general physical symptoms, depressed mood, and lack of energy. Only very rarely did these patients stay with the antidepressants for more than a few weeks. Maybe it would have helped, maybe not- but no one ever told these patients that we wouldn't know for a while.

In the end, like some many things, it comes down to communication. We in the healthcare world have a responsibility to communicate with our patients, to tell them what we are doing and why, and what they should do and why. Equally, our patients have a responsibility to come to us when they have questions, or problems, or side effects, or treatment failures. This is one of the best ways in which we can build trust in ourselves, our patients, and the medical system in general.