Issue 43 / 11 November 2013

The best way to find out if you can trust somebody is to trust them. Ernest Hemingway

TRUST is a leap of faith. As has been widely reported, including in MJA InSight, this leap landed badly for some doctors recently covertly filmed by A Current Affair (ACA) in what has become a scandal concerning the ethical behaviour of the journalists involved.

The doctors involved are correct to feel hard done by. To have your work practices reviewed can be intimidating at the best of times, but to have it done in public, without permission, without notice and covertly is outrageous. Editing the footage to make the doctors appear to be handing out medical certificates without due care,  and removing footage of them making appropriate inquiries about the presenting problem, is tantamount to an assault.

A medical consultation has traditionally been considered as an imbalance of power, with the patient considered to be the more vulnerable party. Communication research and education has tried to redress this asymmetry by moving away from a paternalistic approach towards a more patient-centred approach based on shared decision making.

Indeed, shared decision making has been shown to improve a range of health outcomes, including patient acceptance of recommendations, compliance, and symptom control.

Shared decision making is based on a “trust relationship” which acts as a bridge between the patient and doctor.

Yet, trust must be a two-way street. How much can we trust our patients?

The ACA episode demonstrates an extreme example of betrayal of trust, but the changing nature of doctor–patient relationships is leading to an increasing variety of ways in which we as doctors need to take care that our trust is well placed.

The roles of doctors as gatekeepers to funding streams, regulators of publicly funded treatments, and judge and jury of a patient’s right to a driver’s licence, a pension, or indeed a certificate of fitness or otherwise for work are becoming an increasing part of what we do. These roles require a level of trust on our part — that we (or those we are representing) are not being taken for a ride.

A recent systematic review in the International Journal for Quality in Health Care highlights the imbalance in research into trust in the health care provider–patient relationship. The review revealed that most studies done in this area concentrate on patients’ trust in providers, and not the other way around.

Of the nearly 600 studies identified, less than 5% examined providers’ trust in patients and only one explicitly set out to examine this relationship.

The lack of research in this area is concerning. It is an area we need to understand, as trust in a relationship can, like a mirror, break quickly and irreversibly. Trust is fragile.

If we, as a profession, are increasingly exposed to examples of patient deception, we could start to raise the drawbridge and put up barriers to connecting meaningfully with our patients.

If we start to practise in a way that has large caveats to our trust, those patients that are deserving of our trust will also lose. Defensive medicine can be engendered in ways other than a medicolegal threat.

Hemingway was right in that to find out whether to trust is best done by trusting. To be effective as doctors, we need to continue to trust — to leap.

However, at times we may want to take a bit of a peek as to where we might land.

 

Dr James Best is a GP practising in Sydney and a winner of the Royal Australian College of General Practitioner General Practice Supervisor of the Year Award.

3 thoughts on “James Best: Trust me

  1. rod ryan says:

    For the last few years I have seriously thought I might as well just give some patients a copy of MIMS and one of my prescription pads. These patients (sorry, “clients”, or does that still represent too much power imbalance?) seem to have decided before seeing me what they want so I may as well let them make all the decisions and have some time off.

  2. Stuart Kirkham says:

    My default position is that I tend to trust every patient – until they break that trust by their words and/or actions. 

    Even an angry patient seeking a second opinion often can be “turned around” into a happy camper if they can see that you (their doctor) is acting in their best interests and has taken the time to listen to their views of the problem. Most (if not all) have already googled the condition and probably have googled you as well to minimise surprises, but as we all know this yields highly varied qualities of information. 

    I look for patients responses as a guide to when they dont trust me ; If Ive acted in their best interests and then their guard is still up (for whatever reason) then I would consider that response by them as unnatural & abnormal (for whatever reason) & often I would choose to remain quite distant with that patient , as a self-defence mechanism I guess. They’ve not trusted me and I sense an unrealistic patient. We are not heading for a mutually satisfactory outcome here. You cannot make everyone happy. Impossible. 

    Doctors need to be aware of why the patient is coming to see them. Is it for a diagnosis? Is it just for a script ? every patient has a reason ; maybe its the second opinion cause the first doc was “no good” . Whatever it is there will be no trust if both parties dont finish on a satisfied note. 

    I believe that despite Dr Google , the huge majority of patients do still trust us as their guiding advisor, and for that reason medicine remains a great profession to be part of. 

    Trust them ; until they show they cant be trusted. You will win their trust a majority of times.

    Dr Stuart Kirkham 

  3. rod ryan says:

    Stuart – I was feeling a bit frustrated and being a bit facetious. What you describe is akin to “tit-for-tat”, a famous simple program by Robert Axelrod which won a computer gaming competition (twice), and has been proposed as the most useful model for international relations. 

    http://en.wikipedia.org/wiki/The_Evolution_of_Cooperation

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