Why Doesn’t Anyone Trust Doctors Anymore?

“Scrommiting” is often a clue to the diagnosis of cannabinoid hyperemesis syndrome (CHS), because patients both scream and vomit loudly. We started seeing CHS — a syndrome that causes relentless, intense abdominal cramping and dry heaving — in the emergency department about 15 to 20 years ago. It’s caused by cannabis usage as the name implies, and is almost exclusively seen in younger patients who use marijuana at least daily.

These patients are suffering, and they feel miserable when they show up at our doors. Standard pain and nausea treatments often provide no relief to them. While we’ve discovered medicines that can and do help these patients, the ultimate cure — once other diagnoses are ruled out — is complete abstinence from cannabis, including from second-hand smoke.

This can be a difficult subject to bring up, even once these patients are feeling better. Some patients use cannabis for anxiety symptoms, while others, ironically, started smoking to help with chronic nausea. Still others live with people who smoke cannabis, making my recommendation for complete cessation a challenge. When I talk with them, most patients look at me skeptically, doubting my diagnosis and trusting my medical advice even less. Having never heard of CHS, they wonder, how could cannabis do this?

But I’ve found several approaches that help me convince them, and they all focus on one thing: gaining their trust.

Trust is the foundation of the patient-doctor relationship. When I started writing this piece, I wanted to focus on the health policy changes coming from the new administration and how doctors are coping with them. But over the past few weeks, I’ve come to see this as a larger story about the erosion of trust. This isn’t about RFK Jr., or vaccines, or MAHA. But why is it that Mr. Kennedy’s lack of credentials and expertise — and of basic knowledge about the agencies under his purview — are exactly what people find so appealing about him and his views?

It’s become clear to me that we as physicians and a healthcare system have lost the trust of the public, and I think it’s time we talk openly about what we as a medical community can do to gain it back.

How Social Media and COVID Helped Erode Medical Trust

The erosion of trust in medical experts is a problem that’s been simmering for years — the New England Journal of Medicine examined the trend already over a decade ago. But distrust became impossible to ignore during COVID, and has only gained steam since then, as trust in numerous professions recently fell to new lows, and only 40% of Americans now trust physicians and hospitals. These trends are even affecting nursing, always the most trusted group of professionals year after year.

In many ways, COVID exposed how modern technology sows distrust: Social media algorithms filter information in ways that reinforce our views. It’s also getting harder to trust the information we’re seeing, which might be biased, inaccurate, artificially generated, or intentionally deceptive. Moreover, with such democratized access to information and trends encouraging everyone to do your own research, anyone can now weigh in and go viral, including those without any scientific background or training.

While there were plenty of unforced communication errors by our experts, our leaders, and our institutions, providing public health messaging that applied broadly while also tailoring advice unique to individuals was an almost impossible task. Two steps forward, one misstep back. We had a crisis with people dying, an unknown contagion, and conflicting information on how to respond appropriately. As we gathered better information and gained more clarity about the virus, guidelines changed, but for people outside of science, this was often interpreted as confusion or incompetence. Do masks work or don’t they? Can they be cloth, or only N95s?

I would be remiss if I didn’t mention another factor that contributed to mistrust during COVID: People outside of healthcare aren't exposed to daily suffering and did not fully appreciate what doctors confronted inside hospitals. Being shielded from the full extent of what was happening made it easier to dismiss and doubt reports about COVID fatality rates, and to believe they were exaggerations or even lies. As a result, people were more likely to question the expertise of medical professionals.

How This Erosion of Trust Has Impacted Physicians

For physicians, the erosion of trust in healthcare professionals by patients is not just a statistic, it’s palpable in our everyday work. Patients are increasingly arriving for an appointment seeking care, but then distrusting the recommendations we offer. What’s more, doctors are getting blamed for systemic failures beyond our control. Doctors cannot force an insurance company to approve a test or medication — even if the doctor spends 45 minutes on the phone arguing about it. But when a patient gets denied, they may feel as though it’s the physician who cannot be trusted (leaving physicians feeling exasperated, too). For example, if I order a CT scan to follow a patient’s cancer or prescribe nausea medication for their chemo and the insurance company denies them, I am the closest human target for blame.

But can you blame patients? They have every right to be suspicious of a system so dysfunctional as to deny them care in the name of profit. Look at the behavior of drug manufacturers, pharmacy benefit managers, insurance companies, and hospitals — they all prioritize profits over patient care. Each sector plays a game of cat and mouse with the next, adding fees here, offering discounts there, and competing rather than working together to deliver healthcare as a service instead of a cash cow.

On the flip side, here’s what we as physicians wish patients knew about us: We, too, feel betrayed by the very same system that creates moral injury, prevents us from delivering great care, and turns us into the enemy. We, too, are frustrated after dedicating our lives to this profession — sacrificing our youth and going into deep debt, and missing birthdays, holidays, and time with loved ones — only to be viewed as shills for Big Pharma or corrupt agents keeping patients sick.

Over the past decade, physicians have become mostly employees of someone else, and just like the frog in boiling water, we are slowly getting stretched past our limits. We are exploited by every other part of the system — whether by hospital employers demanding we see more patients in less time, or insurance companies forcing us to spend hours on prior authorizations. We all took an oath to do no harm and we spend hours filing insurance paperwork and fighting denials for free because it’s the right thing to do.

We’re increasingly exhausted and frustrated — as snake-oil “wellness” influencers push misinformation and supplements and earn piles of cash, or the latest TikTok health trend spreads virally just like the contagions we are trying to prevent. As a result, many doctors openly discuss throwing in the towel. Others are considering moving to direct primary care, where they can serve only a few hundred patients at a time, or are seeking careers outside of medicine, leaving the physician workforce to dwindle further.

How Physicians Can Lead the Way Forward

All of this brings us to the confirmation of RFK Jr. to lead the Department of Health and Human Services. In some ways, RFK Jr.’s rise should be no surprise: He or someone like him wasn’t just a possibility; he was an inevitable outcome of the growing distrust in science research and healthcare. But while that may be true, like so many of my colleagues and peers, I believe that Kennedy’s leadership may have dire consequences and could serve to cause further distrust of our already crumbling system.

Where can we go from here? Going back to my story about cannabinoid hyperemesis syndrome, I’ve learned several lessons about how to regain trust with patients who are skeptical of my diagnosis and recommendations, and I believe they could be helpful on a more systemic level.

Lesson #1: Show you're on the same team. I always try to emphasize that I want the same thing as my patients: For them to get better. Much of this comes through in non-verbal communication: sitting down, making eye contact, and using a compassion tone of voice. This is something we could be doing better on a societal level: Embracing the spirit of teamwork and emphasizing that it is not “us versus them” with patients.

Lesson #2 Demonstrate transparency and humility. With my patients, I always try to make clear that I may not have all the answers, and where there may be conflicting information, that this is my best understanding based on my training and experience. Leaning into humility is something we could all do better, too.

Lesson #3: When relevant, predictive insights can be extremely powerful. Whenever I’m able to accurately predict that a CHS patient’s symptoms improve from hot showers (a common feature of CHS that exists in almost no other syndrome), patients feel like I’m either reading their minds or that I’m actually correct about their diagnosis. This builds trust, and comes from the education, training, and experience we possess as physicians.

Lesson #4: Use third-party validation when possible. For example, I print out this article about cannabinoid hyperemesis syndrome from the cannabis magazine High Times, and provide my patients with information to demonstrate that this condition is common and is even described in cannabis culture, not just medical journals and hospital websites.

Beyond these lessons, I’d also like to see more doctors speaking out publicly in support of patients and finding areas of commonality on which to rebuild that foundational layer of trust. There are many ways we could go about this:

Posting on social media about the injustices in our healthcare system, and the challenges we personally face when fighting a denial, taking call and operating at 2am and then working all day on 3 hours of sleep, or demonstrating our commitment to our patients.

Forcing medical professional societies to speak out and use our voice and lobbying power in the name of helping our patients. Notably, many individual doctors feel betrayed by our own leaders. Look no further than this article in Politico: The American Medical Association has said nothing about RFK Jr.’s nomination, nor has the American Association of Pediatrics, whose members stand to be the most impacted by Kennedy’s anti-vaccination rhetoric.

Calling out bad actors in medicine who intentionally create or distribute misinformation, who profit off of snake oil and false hope, or who shirk their ethical responsibilities as medical professionals. (State bars aggressively censure and sanction their own; why can’t we in medicine?)

Acknowledging that we don’t have all the answers. (Hint: one of the easiest ways to find quacks is to look for so-called “experts” who report the ability to provide answers and cures with 100% confidence; medicine, nor human biology, nor life itself ever work that way.) I think there’s strength in vulnerability and honesty, and I think most doctors want our patients to understand that we are human beings, not flawless robots.

As measles spreads in Texas; Ebola spreads in Uganda; Tuberculosis in Kansas; Avian flu in Nevada; and Mpox in New York, it is more urgent than ever that we as physicians take action. Yet many feel so angry and exhausted that they would rather choose apathy or even abandon our profession altogether. After the trauma of COVID, few doctors could endure another pandemic in which we are first hailed as heroes and then viewed as villains. Many of us fear that we are barreling toward another public health crisis with the new administration’s policies on vaccines, medical research, public health, and the very funding of healthcare for our poorest and most vulnerable Americans.

If you’re feeling this way, I want you to know that we can rebuild trust in our healthcare system and in each other. But just like I have seen with my own patients, it will take active and conscious work on all of our parts to do so. I just hope we’re not too late.