<img height="1" width="1" style="display:none" src="https://www.facebook.com/tr?id=799546403794687&amp;ev=PageView&amp;noscript=1">

Trusting the Patient: A CU Department of Medicine Leader’s Transformational Encounter

Mark Earnest, MD, PhD, shares the story behind his deeply personal New England Journal of Medicine article.

minute read

Written by Mark Harden on December 14, 2023
What You Need To Know

Click here to access Mark Earnest's online article in the New England Journal of Medicine. Non-subscribers can create a free account to read the article.

It was a quarter-century ago, but Mark Earnest, MD, PhD, still vividly recalls an “odd request” from a patient.

“My sleep is terrible. I’ve tried everything I can think of, and nothing works,” the patient told him. “Would you write me a prescription for Seconal so I can get some rest?”

Odd because his longtime patient, a woman in her 50s, had never before discussed insomnia or needing a sleeping aide with him, and was now asking for Seconal, “a barbiturate with a high potential for a fatal overdose,” Earnest recalls.

But Earnest – who today is a professor and division head of the Division of General Internal Medicine at the University of Colorado Department of Medicine – knew that the patient had recently been diagnosed with a leiomyosarcoma, a rare, aggressive type of cancer.

It took him “just a moment,” he says, to realize that she was requesting a prescription to help her end her life. At the time, Colorado voters had not yet passed a law allowing medical aid in dying.

Earnest writes of that encounter and the ethical and trust questions that followed in an article entitled “Something for Sleep,” published December 9 by the New England Journal of Medicine.

In an esteemed medical journal that dates back to 1812, where most articles have titles like “Teplizumab in Youth with New-Onset Type 1 Diabetes” and “Inhaled Amikacin to Prevent Ventilator-Associated Pneumonia,” Earnest’s piece stands out as heartfelt and deeply personal.

We talked with Earnest about his extraordinary article and what led him to write it.

Q&A Header

I didn’t realize medical journals published pieces like this.

Until recently, I didn’t, either. Over the last year or so I’ve written a series of pieces, mostly about things that have been rattling around in my head, largely about patient cases where there was something that I struggled with.

I had not written much of this sort of piece, partly because I didn't have much hope that they would get published. And then when I had a piece published a couple of years ago, I thought, maybe it’s time to put pen to paper and take some of these things out of my head and try to make some sense of them.

I've always liked writing. When I was in college, trying to decide what to do with myself, my fantasy was to be a writer. I think my attraction to medicine was very similar to my attraction to writing. Medicine is where lots of stories happen. So I’m coming full circle now, towards the end of my career, in trying to bring the two interests together a bit, and it’s been fun to have some success with it

It's been decades since this happened. What prompted you to write this now?

This was pretty early in my career, and this was the first time that medical aid in dying had come up for me with a patient. It was the place where I first started struggling with that ethically. So this situation has been – I don’t know if “haunt” is the right word, but it comes back up from time to time for me in terms of thinking through the choices I made and how I made them, and what I can learn from that.

I’ve seen thousands and thousands of patients over the years. But I think if we were having a conversation and you asked me what five patients I’ve thought of the most over the years, this would be on that list.

At the end of the piece you pose a question about your patient: “Why was it her responsibility to trust me and not equally mine to trust her?” Is that really a question for your peers in dealing with their own patients?

I'm always hesitant to dictate what others should do. But I will say that we use the term “patient-centered care” a lot, and I don’t know that we always think about what that means. I’ve moved a long way in the course of my career on that question. The struggle I had with what I should do in this case from a legal perspective was pretty clear, but I ended up moving that line a bit and I don’t regret doing that.

Even at the time I didn’t feel nervous about doing what I did once I went through the process and came to the conclusion I did. I felt like I’d done the right thing, and that came from seeking to find a deeper level of understanding of what the patient’s needs were, what her fears were, what she needed from me and trying to meet those needs. That seems to me to be what patient-centered care is supposed to be.

Just this morning I got an email from a woman dealing with lung cancer who had read the article and said she was moved by my collaboration with the patient. She says she often feels the doctor-patient relationship is “magisterial,” as she put it.

On the question of trust, I think there are people with addictions, for example, or things like that where what they want is not what they need. A doctor has to be guarded about that. But in general, I’ve found that patients make choices that are true to them, and often my job is to try to expand what they think is being true to themselves.

Is there a key lesson here for yourself and your readers?

I didn’t write this with the intent of delivering a lesson, but the lesson I took away from this is to try at a very deep level to understand what the patient’s needs are, what their wishes are, what their values are. And also, for me to challenge myself in asking, why am I saying no to this? And to be open to the fact that the patient may have a great deal to teach me about what they need.

Featured Experts
Staff Mention

Mark Earnest, MD, PhD