UW Medicine Chief Medical Officer and Vice President for Medical Affairs, Carlos Pellegrini discusses the meaning of trust in the patient-physician relationship.

[MUSIC PLAYING]

DOUGLAS WOOD: I'm
Doug Wood, the Chair
of the Department of Surgery.
Welcome to the
Surgical Grand Rounds,
and we've got a special
morning this morning.
And I know that there are many
more people trying to get here
because I just got a text
that the line to get into S1
is 15 minutes long, and
that there are still
people waiting to get into S1.
So it's a very
special morning for us
because we have our own
Dr. Pelligrini that's
giving Grand Rounds.
And I'm going to take advantage
of him being our special guest
to give a little bit
more of an introduction
than we would normally do
particularly because we have
so many guests here, people
beyond the Department
of Surgery from many
other departments.
Dr. Pelligrini grew
up in Argentina
with parents who were
doctors, and if you
look at this first
slide, you can
see that although he had
a very happy childhood,
I guess some days, he
didn't look as happy
as represented by the
rest of his childhood.
But he grew up near
Rosario, Argentina.
And one little known fact
that most people don't know
but was an important
area of connection
between Dr.
Pelligrini and myself
was when he was a
senior in high school he
was a foreign exchange
student and actually
went to high school and
graduated from high school
in Kalamazoo, Michigan.
He graduated from Portage High
School in Kalamazoo, Michigan.
You can see him as a
student in high school,
and he was a good student.
But I also want to emphasize
he was somewhat of a nerd
as you can see from the
well-established pocket
protector so popular
in the 1960s.
So Carlos graduated
from high school
in Portage High School,
Kalamazoo, Michigan, returned
to Argentina, went
to medical school,
and then completed a
general surgery residency
in Rosario, Argentina.
He then had an opportunity
to do a research fellowship
at the University of Chicago,
and he was so well-received
there that they actually offered
him another general surgery
residency.
So Carlos had the benefit
of a second general surgery
residency in the United
States after completing one
in Argentina.
And it was there at the
University of Chicago
where he was mentored both
by Tom DeMeester and David
Skinner, who were important
influences in his life
and important aspects
of him becoming
a prominent esophageal surgeon.
Carlos was then recruited to
UCSF as an assistant professor
and actually has
many connections
here at the University
of Washington
from his time at UCSF.
As an assistant
professor at UCSF,
he rose rapidly
through the ranks,
both in terms of academic
promotion and leadership
to the point that
he was recruited
to be the chair of the
Department of Surgery
here at the University
of Washington in 1993.
So Carlos was the Chair of
the Department of Surgery
for 23 years, by far
the longest Department
of Surgery Chair ever
at the University
of Washington, even exceeding
the first Chair of Surgery,
Henry Harkins himself,
who was chair for 17 years
I put up here– and I think
this speaks volume of the person
that Dr. Pelligrini is.
These are the things
that he is most proud of.
And I want to talk a little
bit about what Carlos
has done within the
Department of Surgery
and within UW Medicine
and why he is giving
this lecture this morning.
In the Department of Surgery
under Carlos's leadership,
the of the faculty and the
number of clinical programs
has more than doubled.
We now have 177 faculty in
the Department of Surgery–
and only a fraction of this
when Dr. Pelligrini came here–
and a breadth of clinical
programs that are outstanding.
We have division chiefs and
faculty that are leaders
locally and nationally.
At the same time, Carlos has
developed 19 Endowed Chairs
and Professorships during his
tenure as Chair, and many of us
are the recipients
and beneficiaries
and support the
research programs
in the Department of Surgery.
Carlos has been focused on
the development of research,
an example being the development
of the Surgical Outcomes
Research Center with Dave Flum,
an example of his leadership
on the side of research.
He has also been
focused on education.
We now have four residency
programs and 11 fellowship
programs in the
Department of Surgery.
And every single one of them
is at the top of their peer
group in the United States.
That has to do with the
leadership of our program
directors and the leadership
of Dr. Pelligrini.
Of course, Carlos has
made numerous scientific
contributions.
His curriculum vitae is a
wealth of accomplishments
and publications.
But I think what people
most respect and know him
for is his leadership.
The fact is he has
been a leader of most
of the important
surgical associations
in the United States–
the American
Surgical Association,
the Society for Surgery
of the Alimentary Tract,
the Society of Surgical
Chairs, and probably
the pinnacle of leadership
in American surgery,
the President of the
American College of Surgeons.
He has honorary fellowships
from all over the world.
In fact, it's kind
of embarrassing
how many honorary fellowships
and professorships he's had.
And he's a recipient
of the French Medal
of Honor from the
French government
for his contributions
to surgery.

Two years ago, Carlos was named
as the first Chief Medical
Officer at UW Medicine.
So we are now privileged to have
his leadership at the highest
level in UW Medicine after
his long and successful tenure
as Chair of the
Department of Surgery.
While all of these
accomplishments are terrific,
I think what most of us respect
and appreciate Carlos for
is his mentorship–
and most of the seven the
recipients of that mentorship
and support–
and his leadership
and integrity.
He has an incredibly deep
well of close friends.
In fact, I don't think there's
anyone that he doesn't know.
Whenever I talk with him about
somebody that I've just met,
Carlos says, oh yes.
I know them.
They're a very close friend.
I mean, it's almost ubiquitous.
Carlos knows everyone
I have ever met,
and he is close to them.
He's shared a meal with them,
they've stayed at his house,
and it's so extreme.
His generosity and the
breadth of his connections
is remarkable.
And as you'd expect, it
even extends to the Pope.
So this is no joke.
Pope Francis and Carlos
are both from Argentina.
And one time I'm
challenging him about
whether he knows the Pope.
And of course, he does.
And I don't remember the
reason, whether they played
on the same soccer
team or whether they
went to school together, but
Carlos knows Pope Francis.
Most of us have been
the beneficiaries
of the great stories
that Carlos tells.
He is an amazing
storyteller, and we've
been the beneficiaries
of stories
of intrigue, excitement,
embarrassment, accomplishment.
And some of them are even true.
Carlos, I think, is one
of the best examples
that we can hold up as a
person of honor, integrity,
and an incredible,
deep, moral compass
and emotional intelligence.
And it's why we
love you and what
we respect as your colleagues
and as your friends.
And those of us here
today are glad that we
are your close friends because
those of us in this room are.
Dr. Pelligrini has had a
long interest in ethics
and in the ethics of surgery.
And last year, he
was honored to be
asked to give the John J.
Conley lecture on ethics
and philosophy at the
American College of Surgeons.
And so we are very lucky to
have Dr. Pelligrini give us
this lecture again this morning
that he gave to the American
College of Surgeons last year–
Trust: The Keystone of the
Physician-Patient Relationship.
Dr. Pelligrini.
[APPLAUSE]

CARLOS PELLEGRINI: Well, Doug
you out did yourself as usual.
I am honored that you'd
introduce me today.
I was thinking Dave was
going to introduce me,
and I would have loved to
have Dave introduce me.
And I had thought about what
to say about Dave, but not
about you.
[LAUGHTER]

I can say one thing about you,
and that is, as the new Chair
of Surgery–
obviously, I'm
delighted that you
have taken the Department
of Surgery reigns–
you have an influence
in the school.
I have never seen so many people
come to Surgicial Grand Rounds.
And I realized on
Monday night when
I was at [INAUDIBLE]
department, and he
was making just announcements.
He announced on Wednesday,
October 4, 6:30 in the morning,
everybody has to be in T625.
And I just thought, T625,
that's where I'm speaking.
And I see Richard sitting there
as well as so many of you.
So thank you and good morning.
Thank you all for being here.
I'm certainly very
appreciative that you came,
and I'm confident that
what I have to say
applies to most human beings.
So if you're a surgeon,
this touches you
probably a little bit closer.
But if you are not a surgeon–
you know, we in surgery
talk about surgeons
and the rest of the population,
which we call non-surgeons.
So if you're not a
surgeon, I hope that you
will find this of use as well.
I have no conflict of
interest to disclose,
but I do want to
disclose to you–
and I think Doug alluded to it–
that what I am about
to tell you is not
the usual talk about techniques
or outcomes in surgery.
But it is about ethics,
it is about philosophy,
and it's about relationships
with fellow human beings.
And I say so because if
you think of surgery–
and if you think of
Surgery Grand Rounds–
you sort of think, I
think, this way, right?
You view in your mind a
picture of an individual
with a few others helping,
working, with his hands,
in this case, trying
to solve a problem,
trying to change
the anatomy, trying
to resect, remove, change
what's going on there and take
care of an ailment.
And because of
that, most people,
when you think of
surgery, the reality
is that the focus is on
the technical ability
and the dexterity that
the individual has.
And most of the training
that we tend to receive
has to do with
technique and dexterity.
A lot less has been emphasizing
ethics and philosophy
in general.
And today, my task
is to convince you–
as I talk a little bit about
some thoughts on ethics
and philosophy as I see them–
to convince you that focusing
on the generation of trust
through adequate communications
is an essential elements
of a surgeon's life.
I have come to
believe that it goes
far beyond the relationship that
we establish with the patient.
Because it is the
relationship that we establish
with everybody
around us that makes
surgery and the surgical
results what they are.
To that end, let me
tell you a little bit
about my own journey.
Doug told you my life journey.
I'll tell you my own journey
into this particular field,
I joined surgery because
I had that picture in mind
just as well.
And I was at the time fascinated
and interested in the GI tract.
And I thought that surgery was
a vehicle for me to make changes
to the GI tract with my own
hands that will hopefully
improve the quality of
life of other human beings,
and that occasionally
I would cure somebody
from a dreadful
disease, as it is
a case with esophageal cancer.
Most often I would prolong
life or palliate somebody.
Very often we would be changing
the function of the GI tract
and improving the quality
of life of somebody else.
I did not embrace the study
of philosophy or ethics
or read anything about it in the
early stages of my development.
But as life went by, I came
to realize that the power
to heal that I had,
if any, the ability
to have good outcomes
with patients
was directly related to
the type of relationship
I established with the patient.
That the more I delved
into the patient's life,
the more I established
that relationship
between the surgeon
and the patient
that was based on something
that I couldn't describe then,
but I then realized later
on it would be trust.
As soon as we
established that bond,
the chances of having
a better outcome,
as seen by the eyes
of the patient,
increased significantly.
And [INAUDIBLE] and I
started reading and studying
a little bit about what are
the mechanisms that get two
human beings closer together.
I realized that that allowed
me to understand myself
a lot more, to know what
things ticked me off,
to know how to
control myself when
I was facing one
of those events,
and slowly to understand myself.
And as a consequence of this
not because I programmed it,
but it came to the
realization that we
work in a health system.
We work every day
with other surgeons,
with physicians of other
kinds, and that if I establish
the same relationship– which is
a relationship based on respect
and mutual understanding
of caring for another human
being–
with the members of the team–
and when I'm talking
about members of the team,
I'm talking about members
of the operating team,
but I'm also talking about
the nurses on the ward,
I'm talking about the residents
that are on your team,
I'm talking about the
Department of Surgery
faculty, the administration–
if you had that
essential elements
that I will describe
for you in a moment that
are the basis for the
generational trust,
then life was better.
And to me the greatest
discovery of this–
and maybe one day I can
come and talk about that–
is the tremendous effect that
this has in preventing work–
in preventing burnout.
Because I realized that as you
become happier with what you
do, as you're welcome with
a smile by people that are
working with you that day, as
you find the friends that I was
talking about– people that you
establish a relationship that
maybe is just this story, a
little something that happened
between two human beings that
is a little bit different than
just the professional aspect–
that that to me personally
is the biggest deterrent
to feeling burned out.
I wake up in the morning
sometimes early, sometimes
very early.
And believe it or
not, at my age of 71,
I say, how many hours
before I go to the office?
It is that kind of
thing that makes you not
feel overwhelmed or overburnt.
So the title of this
talk was supposed
to be Trust: The Keystone of the
Patient-Physician Relationship.
And I will keep it
to that, but I just
wanted to give you that
brief introduction in terms
of the importance, I
think, that the generation
of those relationships are.
To the effect of
this talk, I want
you to think for a moment of
trust as a little red stone
there.
And imagine that little red
stone for just a second.
And let me go back to
the human relationships
that I talked to
you about before.
And I think or imagine a
human relationship as an arch
as depicted on this picture.
And I think of the
physician on the one side,
and on the other side of the
arch, I think are the patients,
I think of the physician
herself or himself, I
think of the system that
the individual relates to.
And so that's a
human relationship,
and that little red stone that
I told you there is the trust.
Now that stone, if you
think for a moment,
you remove that stone,
the whole thing crumbles.
The arch disintegrates.
It is that stone, the
so-called keystone,
the concept that was actually
developed by the Etruscans
2,500 years ago, that
keeps that integrity
of that particular arch.
And that concept was not only
developed by them a long time
ago but then taken up by the
Romans who started perfecting
that keystone and started
perfecting it to the extent
that they started
using it on gates,
they started using
an aqueduct, they
started using it on bridges
as something that would have–
as the most important
element of the arch itself–
would have the ability to keep
that in its full integrity.
So I view trust then
to a relationship
like the keystone is to an arch.
I think that it is essential to
keep the integrity of the arch,
and it is with
that concept that I
would like to describe
trust in a little bit
more detail in just a minute.
But before I do that,
if we have agreed
that this is a
pictorial representation
of a human relationship
with somebody else
or with the person himself,
and if we have agreed
on the importance of trust as
represented by the keystone,
I have learned
that communication
is what sits in the middle of
that arch between the person
and himself, or the
person and the patient,
or the person or somebody else.
It is through
communications that we
establish that relationship.
But I'm not talking about a
verbal communication here.
I'm not– I'm talking
communication in the broadest
extent.
Communication is a smile.
Communication is looking
at somebody eye to eye
like I'm looking
at Roger right now.
Communication is
recognizing somebody.
Communication is getting upset.
Communication is making a face.
Communication is
not paying attention
when someone is
telling you something
because you grab your
telephone, and you
start answering a message.
So in every one of those
behaviors that you model,
you're communicating something.
And you're
communicating something
that sometimes you don't
think you're communicating.
But you are
communicating something
no matter what you do.
And that has become
something that I
think if we look at it from
a practical perspective, not
an academic perspective,
is an important aspect
to preserve that.
So let me then start.
I'll give you a few
thoughts about trust itself
as it relates to
medicine and then
three or four slides on what
I think communication is
and how communication
directly relates to trust.
So for trust itself, a
definition that I like
is this one from the dictionary
that says essentially it's
the assured reliance on
the character, the ability,
the strength, or the truth
of someone or something,
where I believe the
key word is reliance.
And reliance from one person
onto another person character
onto another person's strength.
And it's not only
about the persons.
The animal kingdom shows
us trust all the time.
Think of a flock of birds
and think of the leader
of a flock of birds.
It's only trust on the
strength and reliance
on the strength of the
leader of that flock
that makes all the other birds
fly in the same direction.
And that reliance
is very important
because that reliance
brings about vulnerability.
And so Edmund Pellegrini–
Pellegrino actually, a
very famous philosopher
that wrote a lot
about trust, talks
about the fact that to
trust and to entrust
is to become vulnerable–
it's a vulnerability,
because you
are relying on
somebody's character–
and dependent on the goodwill
and the motivation of those
who we trust.
And Bernard Barber,
the sociologist
that writes a lot about
trust, defines trust
with three sort of conditions–
persistent moral order–
remember that reliance
on somebody else is based
on the moral order–
perform technical
role properly when
relating to any profession–
so it's a commitment
that you have–
and altruism, or will do so
with a concern for others.
So there is these
three conditions
that lead us to think that
in medicine you can translate
those conditions from
a practical perspective
in the possession of knowledge
necessary to do something
to another person, the
autonomy given to you
by the person necessary for
you to practice and exercise
your skill and
your set of values
hopefully with the
understanding of the values
of the other person
in the treatment,
and the fiduciary obligation
to individuals or to society.
It is always the
moral character.
It is always the permission.
And it is always the
vulnerability and the altruism
that go together.
It's the beliefs
on the benevolence
and morals of the physician.
In medicine, I view
trust as having
five or six different
twists that are not
seen in most other professions.
The first one is the
affective nature,
the dependence that a person who
is sick has on the physician.
So it is and like most other
professions where perhaps
a relationship with a lawyer–
and I'm not trying to be
disrespectful to a lawyer–
but a relationship to an
accountant or relationship
to a technical person,
that relationship
is subject to less affection
than it is to a physician.
You see embraces,
and you see hugs,
and you see the kinds of things
that most patients associate
with trusting their provider.

In medicine, it's important
that we keep skills and values
very clearly up front because
we can make the promise.
We have a contract, if
you wish, with society.
We are relied upon–
as the original sentence
that I showed you said–
to provide skillful work
and that means continuous
learning throughout our lives.
There's a lot of
papers that have
shown that trust is
directly associated
with adherence to treatment.
And this gives a base
to my original premise
when I started telling you
that I thought that my power
to heal somebody was directly
related to the trust generated
on that person.
And we know now from
a lot of studies
that patients who
trust their doctor,
as you would logically think,
tend to adhere to treatment.
And so you can see they discuss
a direct therapeutic effect
on the patient.
Interestingly enough,
patient satisfaction
is directly related to trust.
So if you look at papers that
relate the issue of trust
to patient satisfaction,
you see that, again,
patients that have
trust in physicians,
particularly when they
have [INAUDIBLE] what
I will describe in a
moment, a mutual trust.
That is they, the
patients, perceived
the physician trusting in them.
And satisfaction indices
are much greater.
It is not surprising
to me that [AUDIO OUT]
pay a lot more attention
to the issue of trust
and how to gain the trust
of another human being
and how to deliver on the
promise just for a business
perspective to get
better patient scores.
And of course, in medicine, we
go back to that vulnerability
that Edmund Pellegrino
had described
when you rely on somebody else.
Vulnerability is
something that happens
in every state of dependence,
as the theory goes, right?
Any state of dependence
[? is ?] spiritual,
the state of dependence, a
learning state of dependence.
And you now can tie learning
environment and the power
that the teacher has over
the student, or the resident
or whoever it is, because
that person is relying
on the teacher and that person
is showing their vulnerability.

When the dependence
originates from injury,
originates from disease,
originates from something
that the person who gets it
has very little control on,
and not only has
very little control,
but has very little means
of becoming non-dependent.
Unless and until that person
seeks the care of somebody
else who has the
power of healing, who
has the ability to heal, who has
the skills to heal, et cetera.
So that poses, I think, an
important philosophical duty
on us.
Is that fiduciary
duty that, coming back
to the altruistic portion of
trust, that we have to respect?
We have to be advocates,
and we have to make sure
that we are not in any way
exploiting the vulnerability
of a patient, because
a patient is much more
likely to take my advice.
If I say I think you
need an operation, I
am sure some of you have been
patients, when the doctor says,
you need an
operation, the patient
is much more likely to say yes
because of an inherent trust
on the physician.
It is then our obligation
to make certain
that we have disclosed
the rationale,
that we have
disclosed the risks,
that we have looked
at the values
from the perspective of the
patient to the extent that can.
That we recognize we are
not inside that patient.
We will never know what
the real values are, right,
for that individual.
But it is incumbent
upon us to make sure
that we remember the
tremendous vulnerability
that the state of dependence
caused by an injury cast
on a patient.
That is particularly relevant
at a time of incentives.

Some of you have heard me
talk about incentives before.
We work in a system where
every service that we provide
is remunerated in
some form or fashion
and you receive, I receive,
and every one of us
does, a certain amount of
payment for the services
that we provide.
We are in a system that, by
the nature of fee for service,
the system is
potentially facilitating
the exploitation of the
vulnerability of a patient.
Now, I do not want
to get too deep.
This is not a political talk
about how the system should be,
but perhaps I give you my
own thought on my stance.
The system of fee
for service is one
that has to be used
very carefully by us,
the entrusted
parties, if we want
to deliver the fiduciary
duty that I was talking about
before, because the system
is asking us to do more.
And for those of
you who think that I
am talking against a
value based system,
value based does not
solve this problem at all,
because on the
value based system
we have the opposite, right?
On the value based system,
we are asked to do less.
The system is asking
us to do less.
On the fee for services system
it is asking us to do more.
And in either case, we can err
in delivering the entrustment
that the patient had to us.
I believe that it is
very important for us
to learn a little bit about
how to generate that trust.
To learn a little bit about
the philosophical aspects
of how do you deliver the
moral contract that we
have as physicians.
Whether we are in the
fee for service system
or on the value
based system, how
do we guard the rights
of those patients,
and how do we protect
the vulnerability
that I was talking about?
Because of these underlying
currents that systems have
developed, there is a whole
chapter in ethics that is
the ethics of distrust and the
ethics of distrust in one word
is to say we cannot trust that.
How do we get around that?
We get around that
with a contract.
What we do is we convert,
we transfer the trust
from the person to
person relationship
to a formal obligation in
the form of a contract.
And that could be a living will,
a power of attorney, an advance
directive.
That would be the consent that
we sign every day for surgery.
As you think about it, when
the signatures come into place
and when you do
a lot of promises
that this is going
to happen, or I
will give you permission to
draw my blood, to hit my head,
to putting my picture
up on the web.
Whatever it is that
patients give permission to,
those are contractual
relationships
that, to a certain extent,
are the result of someone
having lost their trust on
the person to person issue.
If you go to practice
in underdeveloped areas
of the world, you will
see that, for some reason,
trust has been
preserved in those areas
to a much greater extent, and
contractual obligations are not
as commonly set.
Those contractual
obligations sometimes
have problems
because people tend
to write down what they
think they would like
to do in a certain
position at a certain time,
when that has never been
faced by the individual.
Sometimes that
eventually conflicts
with the values of the persons.
I told you a little bit
about the mistrust that
has occurred in our culture
as we become more pervasive.
The rise in suspicion
that patients
harbor towards physicians.
Occasionally, the
degradation of social trust
in our political systems,
and the general erosion
of trust between
employees and employers.
That leads to something that
society has created to replace,
I think in a very
imperfect fashion, trust.
And you have to be careful
what you write in an advance
directive, you know?
Interpretation of wishes,
as this cartoon says.
As one is telling the wife,
just so that you know,
I never want to live
in a vegetative state
dependent on some machine.
If that ever happens,
just unplug, OK?
How that is interpreted
by the other person
is sometimes
important to remember.

Two more aspects
of trust before I
turn it to
communications briefly,
and that is the physician's
trust in the patient.
It is also
extraordinarily important.
We know that when
the patients believe
that there is mutual trust,
the potential consequences
for both parties,
studies have shown that,
and these are
mostly soft studies
based on philosophical
analysis, that physicians derive
a substantial amount
of pleasure when
they feel trusted by patients.
And not difficult to
understand, patients
derive a substantial
amount of pleasure
in their relationship when they
feel the physician trusts them.
To the extent that you can with
your patients, entrust them.
Just like in other states of
dependence, like learning,
we tend to empower
our residents.
Show them that we are
confident that what
they can do by allowing
them to do something that
goes a little bit further and
perhaps beyond what they think
they are capable of.
And as that little stretching,
carefully done over time,
whether it is in a procedure
or in a conversation
with a patient or a decision
making or something,
that empowers another
human being, that
shows the other person you
have trust on the person.
That is an important
element that patients
come in with trust
in the institution,
they establish
trust to patients,
they trust a physician,
trust a patient.
That eventually leads to
more enhanced treatment,
more satisfaction, and
better outcomes all together.
The last element of trust
in this medicine part
is the social aspect of trust.
Social trust is a little
bit of a different animal,
but it is essentially based on
people's experiences in life.
So every one of us, just
think of you at any time,
you walk into an environment.
In this case, let's make
it that the environment
is the hospital, or the
clinic, or the place where you
are going to see a physician.
You walk into that area with
a certain amount of trust
in the system, in the
institution, right?
That is what I was talking
about vulnerability.
How important it is that
when somebody is sick,
somebody does not have any other
place to go than the hospital.
Every one of us has
a different degree
of trust on the system itself.
Think communities of color.
How they would
feel when you think
of the Tuskegee experiment, or
many other genetic experiments
that have been done on
Native Americans and others.
How those communities
feel with regards
to the trust of the
system and the people that
populate the system that is us.
Physicians, health care
providers of all sorts.
The interesting
aspect of social trust
is that it is much
easier to manipulate,
much easier to change, much
more dynamic than the person
to person trust.
To me, that was a very
important discovery
as I was reading because we
physicians and health care
providers in general can
really improve the social trust
by things that we
do in a visit, or we
can decrease the social trust.
As shown, for example,
that the patient that
comes in sort of like,
what is this going
to be like, I am going to
see a doctor, the doctor
makes a lot of money, doctor
has abused my community.
You know, those kinds of things.
And finds a person that
greets them with a smile.
Finds a person that maybe
is a little bit late
and apologizes for being late.
Takes responsibility
for being late.
How that starts working on the
social trust of that patient
that is looking at
that individual.
Think for a minute
of the opposite.
Think that you walk
in and you say,
I did not know you were
here, I work in this place
and they gave you an
appointment at the wrong time.
They had me overbooked.
it is always the same.
In this hospital, they
overbook me all the time.
So what is your problem?
And think of the two differences
on how the person there
would perceive the trust in the
institution or the improvement
or the disapproval of trust.
Trust in general, as I told you
before, is to the relationships
like the keystone
is to the arch.
It is essential
for the integrity.
Without it, you cannot have
a good relationship with
a patient.
And you can translate this
to the other health care
workers that work around you.
With it, I think you not
only improve the patients,
but you also improve yourself.
So, communication.
How does communication come into
play in my mind with regards
to the trust?
Communication is
the act or process
of using words, sounds,
signs, or behaviors, OK?
To express or
exchange information,
or to express ideas,
thoughts, feelings.
Communication is a very broad
perspective, first of all.
Remember when I talked
to you about the smile,
when I talked to
you about the things
that we do to pay attention to
somebody else who was talking
to us et cetera, is
the behavior that
becomes part of communication.
Wikipedia defines
communication as the act
of conveying intended
meanings from one entity
to another through the use
of mutually understood signs.
I do not think it is
always intended meaning.
Sometimes you communicate
a lot that is unintended.
You did not mean
to offend somebody
when you said
something, when you
make a smirk on the face, when
you did something different.
You did not mean it.
So, it is not always intentions.
I am not giving you all
of that just because I
want to make it
more complicated,
but because I wanted to
bring you to this graph
that, to me, it was very
revealing the first time I
saw it.
Communication
starts with intent,
and I would say to you many
times, starts without intent,
so I differ a little bit
of this sort of mechanism
that I am putting
in here for you.
Let's assume that there
is an intent in your brain
to communicate
somebody do something.
Your brain very rapidly
composes a message.
Is the message
going to be a smile?
Is the message going
to be being upset?
Is it a word?
Is it a scream?
Very rapidly then the
brain encodes that message
and then the brain transmits
that message usually
through movements, through
expressions, through behaviors.
This is all, more or less,
part of your control.
Then the other party
receives the message, right?
Remember what we talked about
social trust and so forth.
They decode that
message but then
they have to
interpret the message.
You can see that, in any aspect
of communication from here,
the way you compose and encode
it, the way you transmit it,
the way the other person
receives the [? codes ?]
[? and ?] interpreted, it
is possible that at the end
of the day, you actually relay
the intended message or that
you did not.
And that the message perceived
by others was not what
you actually intended to do.

First of all, it is
obvious that communication
is much more than words, right?
Let me show you this
slide, and then I
will tell you what I was about
to tell you a minute ago.
This is somebody that studied
what people hear or interpret
from actions from
other individuals.
Look at how little
verbal, how much
more tone, and how much
nonverbal communication exists.
This is not scientific.
This is philosophy and
ethics and interpretations
of observations of human life.
They are not
statistically significant.
But it just gives you
an idea that what we say
is tiny, little.
it is what we do.
It is the way we walk the walk
of life that that really means.
My personal tips.
Knowing that from the intent
to the interpretation,
there will be a lot
of potential changes.
Whether I am talking to
a patient to a colleague
or to somebody else,
it is first of all,
I love this sentence,
do not attribute
ill intent to anything
that you hear.
My first posture when I do
not understand the message,
when a message as I have
decoded it in my mind
and as I have
interpreted the message,
is not in parallel
with my values
or with the values
of the other person,
is to not attribute ill intent.
It is very easy to
get upset otherwise.
It is very easy to just
attribute ill intent.
I believe most human
beings are this
and most human beings have
values similar to mine
and therefore I give them
the benefit of the doubt.
If I cannot reconcile
it after some thought,
and sometimes I cannot, and
you will find that in your life
many times as well, then if I
cannot reconcile what I heard
with my values, [? our ?]
feelings, viewpoints,
et cetera, then I seek a
chance to re-discuss it.
I give it another
thought, another chance,
and I tell the other person.
When you are
talking with me, try
not to get the god damn phone
and start answering messages.
It displeases me.
You are not paying
attention to me.
You are doing something else.
You are diverting
your attention.
I know that you do
not mean it, right?
I try to go on that route.
Give the person a second chance.

In order to get
here, I would not
say that every single
time, that I do not like
something I go for a second go.
Sometimes I say I
do not think I am
going to go anywhere
with a second discussion,
so I just quit.
But in general, I
think it is a good idea
to say there are
these three steps that
are possible if you want
to preserve a working
relationship.
The third one is the most
difficult one by far and away.
For me anyway.
If it still does not work,
maybe it is time to let go.
It is the most difficult
one because if you
decide that you are going to
let go, then you have to let go.
You have to do that.
You have to let go,
meaning you are never
going to think about it again
or talk to that person about it
again.
Just let it go, OK?
It is not worth it.
If this one did not
provide the explanation,
then you can let go.
Sometimes you are not
going to be able to let go
and you are going
to hold a grudge,
and that relationship
will, by necessity,
crumble because that
communication led
to a falling of that keystone.
The trust that you have
in that person is gone,
and that is OK too.
Not everybody is perfect, and
sometimes human relationships
go that way.

A very important aspect
of communications
is the patient
centered communication.
Epstein, who has written
the most about that,
defines it as, one that elicits
understands and validates
the perspective of the patient.
This is very difficult
to do as you know.
Understands the patient's
psychological and social
context.
The more you read
about this, the more
you realize how difficult
it is for any one of us
walking into a clinic today and
meeting another human being who
is facing a tremendous problem.
Really, really put ourselves
in the shoes of that patient.
We should try it.
But it is extremely difficult.
If you do those two, you
reach a certain understanding,
and then eventually
you empower the patient
with that relationship.
The environment has a lot to
do with the communication.
I like this picture, which is
actually a picture of ours here
and it is on our own
website, because I
see the right [INAUDIBLE]
of this person really tight.
She does not have a
neurological disease
she is just trying to
use it to raise her head.
As an elderly person,
it is very hard
to extend the neck muscles
to look at the physician who
are standing up and talking.
To the extent that you
can, try to make it look
like you are not in a hurry.
Try to sit down.
Try to put yourself at the
same level of a patient.
Try to remember that, in
all this communications,
there is a lot that can happen.
Studies have shown
that we communicate
in a very different way.
We all, men and women,
communicate in a different way
to women than to men.
I will let you read all
those things for yourself.
We communicate differently
to elderly patients.
Significantly different.
When we perceive somebody to
be a lot less knowledgeable,
we treat those patients
in a different way.
I am sure that if you
look in your mind,
you will remember
events in which you
gave no credit to somebody
and you started describing
something in childish ways.
Wanting to realize that this
person is an engineer that
worked all his life in Boeing
and is now in 78 years of age.
But he invented the triple seven
or something of that nature,
and you feel like an
idiot and you should.

A particular aspect
of the communication,
of course, that hurts
us every single day,
is when we have to
communicate with people that
speak a different language.
Many think that having
interpretive services
is the key to that.
Well, remember,
interpreters can only
tell you words that they know
how to translate into English.
Remember that those words
originate from somebody whose
social trust is different.
Whose experiences in
life have been different,
whose culture, whose
ethnic background,
whose beliefs on others
are completely different.
There is a lot
more than the words
that the interpreters
can do that
have to do with the
culture of the person
or where the person comes from.

I have tried to describe
primarily for you today
aspects that I believe
are important in the
patient-physician relationship.
I believe that, when
that is enhanced
through the practical
understanding of what
trust and communications
are, that you
improve physician well-being.
I am absolutely convinced
that for many of us,
it is a great
deterrent to burn out.
I have told you almost nothing
about the surgeon and the team
because a lot of this
is related to this.
If this worked well,
if you know yourself
and you can talk to your soul,
and the only way that you
can talk your soul is when
you walk the walk that we are
talking about, then this
one almost automatically
works just as well.
All of that is to try to show
you that trust is important.
That trust takes a tremendous
amount of time to construct.
As this picture tries to
show you, it is complicated,
it is fragile and it can
be destroyed in one minute.
It takes forever
to get it really
cemented as a bond
between two human beings
and it can be completely
destroyed in just one second.
Be aware of both circumstances.
You cannot accelerate the
process by which somebody will
trust you.
You can certainly
accelerate the process
by which somebody
will not destroy it.
With that in mind,
I submit to you,
take every opportunity that you
have in your professional life,
in your personal life, to show
other people that you really
care.
That way, as you [? transcend ?]
the life of yours,
and through the
winding parts of life,
keep remembering that as people
[? he ?] said in other words,
no one will care how much you
know until you show them how
much you care.
Thank you very much.
[APPLAUSE]

DOUGLAS WOOD: Stay up here.
[APPLAUSE]

Well, I think you can all
see why there was value
in coming here this
morning, including
canceling neurosurgery,
Grand Rounds, and being here.
Thank you, Rich.
We have time for a
couple of questions.
What questions do
you have for Carlos?
Rich.
We will use the microphone.
RICH: Carlos, that was a
wonderful talk as usual.
Have you ever gotten a patient
that you say I will not operate
on because I cannot
establish trust with?
In other words, someone
who comes to you,
says I want a 100%
confidence that you
will take the
esophageal tumor out
or I will go somewhere else.
CARLOS PELLEGRINI: Yes, Rich.
The answer is yes.
Very rarely,
because I have tried
to get around and show around,
but I have had both situations.

Unfortunately, I remember
one in particular,
walked away, feeling that
I had disillusioned him.
He was a 60 some year old
patient whose values, he said,
had nothing to do with mine and
I was unwilling to help him.
So the patient
walked away from me.
I have rarely, but I
have occasionally found,
that I could not deal with a
patient because I cannot trust
them.
I just tell them, look, I
have been trying desperately
to help you.
That is why I chose
to go into medicine.
I am unable to do that.
I am not putting a
judgement on this–
I am just not the right
person will help you.
So I can connect you with
somebody else but I cannot
help.
And I think we have to
be truthful with that.

DOUGLAS WOOD: You talked
early on about trust
and about being
educated about how
to gain trust, that
there is obviously
courses and processes.
I was thinking about it
and how much value we could
have in that, but also
thinking about, in a sense,
a way that there are
conflicts and incentives.
Trust can also be
used adversely.
It can be manipulative.
Salesmen gain trust and use
it to manipulate emotions
and to make us want something
that maybe we do not need.
How do we navigate
that and get educated
about how to gain trust
better and use it sincerely?

CARLOS PELLEGRINI: I understand
exactly what you are saying,
but I think that that
relates back to the concept
that we were talking about.
I look at the
physician in a way,
and it may sound
paternalistic, but I look
at the physician as a guardian.
As a guardian of that
trust that you want
to generate from the patient.
In order not to manipulate it,
I think that the best we can do
is to remember what
are the incentives that
drive us to do X or to not do
X. And to then back off and say,
I have a commitment to altruism.
That was one of the
three conditions of trust
that Barbara described, the
sociologist that I showed you
earlier.
How do I best
protect the interest
of this vulnerable person today?
What is my role in doing that?
I think if you know
as much as you can,
what drives you to do that–
I want to sell this
car to you, but I
have a moral obligation that
that salesman does not have.
The person who is trying to
sell you a car, for example,
does not have a social contract
that obligates that person.
The trust that society
has put on us physicians
is totally different.
Patients are not going
to be checking you out,
usually, as much as they
would check the salesman.
Knowing what drives us, knowing
that the patient is vulnerable,
knowing our obligation
to altruism.
I say, all I can do is try
to navigate the best I can
with balance between
what incentives I have,
what obligations to
society I would have,
and what obligations
I have to the patient.
There isn't a perfect solution.
DOUGLAS WOOD: Right.

Well Carlos, you
kept a straight face
while this came down during
the questions and that was a–
CARLOS PELLEGRINI:
I kind of imagined.
DOUGLAS WOOD: That
was impressive.
I am glad that you did that.
[? Barclay, ?]
[? Acelle, ?] and Katie,
can you come back up here?
You guys disappeared.
You were up here.

In honor of Dr.
Pellegrini's 23 years
as chair of the
Department of Surgery,
we commissioned a painting,
a portrait of Dr. Pellegrini
to be hung up in the hallway
of the Department of Surgery.
We thought this was a
great place to unveil it.
You have just given us
the perfect Grand Rounds
on trust and on all
the reasons that you
have had the leadership
positions that you have had
and the reasons that we
respect you and admire you.
So, three of our
chief residents who
managed to navigate
that down here,
because I could not
find a place to hide it
upfront, and managed to navigate
it successfully, good job.
I thought you guys would be
the great people to unveil it.

CARLOS PELLEGRINI: I
cannot see it from here.
[APPLAUSE]

Great job.
Great job.
[APPLAUSE]
Great job.
[APPLAUSE]

Thank you.
Thank you.
DOUGLAS WOOD: Thank you.
CARLOS PELLEGRINI: Thank you.
DOUGLAS WOOD: Thank you, Carlos.
Thank you all for
coming to Grand Rounds.
Perfect.
Really appreciate it.
CARLOS PELLEGRINI: Very nice.
I love it.
[MUSIC PLAYING]

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