More Than Skin Deep: Building a Workforce Patients Can Trust

I was a fresh intern when my otolaryngology team was called to assess a patient with stridor and respiratory distress. We quickly identified her problem and determined she needed an urgent tracheostomy. But there was an issue: Despite being in an emergency department room full of physicians explaining why she needed this life-saving surgery, she did not want it.

As I examined her, I noticed her frailty. Her thin neck made anatomic landmarks clearly visible beneath her skin. Her chart told a story of surgeries and complications stretching back years. Her daughter was at her bedside, her face tight with worry, pleading with her mother to listen to the doctors. But my patient held herself with a fierce, quiet pride, firmly against surgery. In some ways, she seemed unreasonable, stating she would only do it if her primary care provider agreed. When logic stopped adding up, I knew the issue was not misunderstanding—it was trust, and the real reason went deeper.

My patient was Black. She was in a room with only white physicians and providers, aside from me. Though she could barely complete a sentence due to her respiratory decompensation, the discussions around her continued. I knew the rational explanations were futile, but still I stayed quiet. I assumed that, as an intern, I had nothing more to contribute beyond what my colleagues had already said. She then said in a remarkably clear voice, “What – does – he – think?”—her words broken by ragged inhalations. She pointed straight at me, and the room fell silent. In shock, I told her that if she were my grandmother, I would ask her to do it.

She immediately agreed to undergo surgery.

After her airway was secured, our team debriefed with her daughter. She told us that following her many past surgeries with complications, my patient had grown deeply distrustful of the medical system. Those complications were directly connected to the very condition that brought her to the hospital that day, furthering her disillusionment. Her hesitation was not misguided: Tracheostomy-related outcomes are universally poorer for Black patients, with Black patients facing higher complication and mortality rates (Laryngoscope. doi: 10.1002/lary.27500).

The very procedure we were asking her to undergo was therefore not benign, and if anything, the data showed that the odds continued to be stacked against her. In a medical system she believed had wronged her time and time again, she just wanted to hear from someone she trusted. For her, that meant someone like her primary care provider—or in this instance, someone she believed would not put her through another procedure that would cause unnecessary pain. In that critical moment, when no one else in the room had earned her trust, that person was me.