I’m a doctor. Must you trust me?

By: Dr. Faisal Saeed

When Luke Fildes painted The Doctor in 1891 as a tribute to the status of the English doctor, it was heralded by the doctors at the time as a symbol of their profession. The painting depicts a well-dressed doctor sitting by the bed of a young patient contemplating on the next course of action, with his gaze fixed on the patient. The patient lies in bed with a hand held out in supplication. The father of the patient stands in the shadows, with a comforting hand on the distraught mother, looking at the doctor, waiting for his assessment. If need be, the doctor will dispense some medication. If need be, he will roll up his sleeves and operate. The painting was drawn at a time when there was little doctors could do in terms of treatment. Yet the family places their trust in him fully, and the doctor is allowed to get near the child that they value and love, with the belief that the doctor will act for the benefit of the child, instead of harming him. There is uncertain knowledge about what action the doctor will take and the family depends on the doctor’s ‘expertise’ to cure their child. This vulnerability, uncertainty and dependence forms the basis of trust, and in many ways, the sense of trust that emanates from this iconic picture is characteristic of the trust public places in the medical profession.

The doctor-patient relationship is one that is grounded on trust. There is a tacit belief in the doctor’s goodwill and competence, resulting from an imbalance of power between the patient and doctor in terms of knowledge. And where there is ignorance, and uncertainty, trust is a must. The lack of knowledge seems crucial to the notion of trust. Even where knowledge is possible, as when the patient is a doctor himself, he must feign ignorance, because trust is described as one of the virtues of being a good patient, together with truthfulness, justice, and probity. Trust is required because medical care depends upon judgement calls that are not predictable, and the good patient is one who recognizes this. A doctor is not allowed to treat himself as his judgement is deemed clouded when sick, and he must submit to the treatment of other doctors and pretend not to be certain of outcomes. The struggle here is obvious, and it is not surprising that doctors qua doctors turn out to be the worst of patients.

A trustworthy person is someone who has a quality that we desire, and we trust our doctors to have goodwill towards us and to work in our best interests. The burden of trust mostly rests on the doctor because he has to work for our best interest, while being impartially concerned for our wellbeing. When we put trust in our doctor, we do so on the assumption that the probability of him doing what is beneficial to us is higher than what is detrimental, high enough for us to consider cooperating with him. Trust therefore enables patients to co-operate in making clinical decisions together. But while the doctor’s goodwill towards the patient would be desirable, it is not a necessary condition for trust. The patient may well know that the doctor bears him little good will and regards him as a gomer, yet trust him to treat him competently. The patient only has to trust the doctor to provide a good outcome for the patient. For his part, the patient could regard the doctor as a ‘dirtball’, be seductive or deceptive, or even pretend to be ill and the doctor would still have to treat him.

Trust also works to reduce the many complexities that arise in the modern health care setting.^ Medicine has become complex and highly technical, and it does little good for the patient to know every detail to guide the surgeon’s hands, or to know all the side effects of each medicament or all the complications of every procedure. The patient can rely and depend on the doctors to process this complex information. In the therapeutic setting, trust is instrumental because it encourages positive health behaviours such as seeking medical help, revealing sensitive information, consenting for, submitting to and complying with treatment and returning for follow-ups when advised. It is also therapeutic in the sense that it promotes healing (the placebo effect is a striking example). Trust fosters an effective healthcare relationship and also acts to promotes the doctor’s job satisfaction. Conversely, if this trust were lacking, patients are more likely to seek second opinions, to switch doctors, resort to self-treatment or alternative forms of treatment, conceal information that may be key to diagnosis or even decline to take up preventive measures such as vaccines or comply with treatment in general. The predilection of our patients to fly abroad, even for available treatment, could also be a symptom of the general lack of trust, be it in our doctors or in the system.

Trust therefore functions to provide the context which enables the uptake of the benefits of medicine by the public. In doing so the public places its trust in both the doctor and the medical system or the medical profession. Trust for the physician derives from his professionalism and mannerisms, and the doctor-patient relationship reflects aspects of enduring emotional bonds that form early on in life, amplified cognitively over time. This trust is interpersonal and patients act under conditions of uncertainty, and choose to trust the doctor, with the assurance that the doctor will accept responsibility when this trust results in disappointment, or harmful outcomes.

A lot of trust is hence evidently placed in medicine. What matters is not the amount of trust,  but whether this trust is well placed or not. The paternalistic conception of the doctor-patient relationship does not provide a context to put reasonable trust in because of the power and knowledge asymmetries between the doctor and the patient. Trust is only well-placed when the patient and the doctor are on an equal footing through more information and less dependence. There is a loss of context for the traditional forms of trust to arise because of considerable changes in the practice of medicine. Firstly, it has become more technical and less personal. Unlike in Luke Filde’s painting, the doctor’s gaze has come not to be fixed on the patient, “that concrete body, that visible whole, that positive plenitude that faces him” but towards…“the signs that differentiate one disease from another,” on lab reports, x-rays and the numerous equipment to which the patient is connected. This biomedical model of medicine deprives the patient of every moral and social dimension, and decisions taken at the bedside become technical and efficient, but unemotional. Secondly, patients are beginning to be more empowered and are more (if not always accurately) informed about the medical care, and are encouraged to be seen as partners in health care decision-making. The right of the patient to be informed on treatment and the right to refuse or accept treatment is well established, and professional paternalism is discouraged in modern medical practice. Instead of waiting in the shadows as a background figure as in Filde’s painting, the father would be very much in the spotlight, participating in making decisions with the doctor. In this context the patient takes on a position of trust-as-confidence rather than trust-as-faith because what necessitated trust as faith, goodwill towards the patient and lack of information, are no longer present.

While it may be said that there is a loss of the context for trust to thrive in, with the change in medical practice, the general decline of trust in social and political institutions, weak medical regulation, more empowered patients, and a  public suspicious of failings on the part of doctors, it remains yet to ascertain if there is a crisis of decline of trust in the medical profession. However, as Justice Irwin states: “Public trust in doctors is essential to the whole enterprise of medicine. A destruction of that trust would be corrosive to the general attitude to the profession and therefore to the effectiveness overall of treatment”.