In their paper ’Too much medicine: not enough trust?' Zoë Fritz and Richard Holton explore the connection between trust and overtreatment and overinvestigation. Whilst their paper is insightful, here I argue that much more could be made of a doctor’s (mis)trust and how this exacerbates overtreatment and overinvestigation. By taking Fritz and Holton’s view of trust as having ‘our best interests at heart’ as my starting point, I argue that doctor’s do not always trust that patients or the system has their interests at heart and so use overtreatment and overinvestigation to protect themselves. I also point to the tensions created by a lack of trust on the doctor’s part as a focal point for much needed sustained ethical analysis.
- medical error
- clinical ethics
- truth disclosure
- philosophy of medicine
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The increasing use of inappropriate medical investigation and treatment is a concern I share with Zoë Fritz and Richard Holton and welcome their excellent paper drawing a clear line from this to a lack of trust.1 They argue that more trust is needed to counter the problem of ‘too much medicine’, and it is patients whose trust requires a boost. They do point to the importance of doctors trusting their patients for ‘if the doctor trusts the patient she will think both that he is accurately reporting his symptoms, and, perhaps more importantly, that if they were to change in a worrying way, he would come back. But if she lacks that confidence, again she is more likely to order tests’.1 However little more is made of a doctor’s trust and how its absence can throw fuel on the fire of overtreatment and overinvestigation. Here I take Fritz and Holton’s observations on doctors trust further and consider how a doctor’s mistrust in their patients and in the system might also lead to overtreatment and overinvestigation as a method of protecting themselves from complaints and litigation.
Trust, according to Fritz and Holton, entails the belief that somebody has ‘our best interests at heart’.1 This attitude leads to the behaviour of trusting. Where there is trust there is also discretion; discretion to use certain powers. If trust is broken, we rightfully feel betrayed. Fritz and Holton’s paper holds patients’ trust as its central concern: patients believe doctors have their best interests at heart so grant them certain discretions and power. Turning to doctors, they believe that where a doctor trusts her patient she will be confident in the patient’s description of their symptoms. This is important only in so far as this allows the doctor to get the right diagnosis and provide appropriate remedy. Yet this does not further the question of how patients have doctors interests at heart when a doctor trusts her patients. Getting the wrong diagnosis offends the patient’s interests more severely than the doctor’s. Even if doctors do have an interest in getting the diagnosis right it seems odd to think that patients provide an honest account of their symptoms simply because they have the doctor’s interests at heart. Trust, where a doctor believes a patient has their interests at heart, is confused with a belief that the patient’s narrative is true. It is left open what discretionary power over a doctor’s interests is granted to the patient entrusted by the doctor. To make sense of this, it must mean that when a doctor relies on a patient having their interests at heart, some interest not considered by Fritz and Holton is at stake. It is to this differing interpretation of what it means for a doctor to trust her patients that I now turn.
An alternative account of doctors trust that is more fitting to Fritz and Holton’s description of trust is that the interest at stake is the doctor’s interest in avoiding complaints, litigation and investigation by their professional regulator, not to mention the shame and guilt doctors experience as a consequence of medical error.i In other words, one way of thinking about a doctor’s trust in their patients is that a doctor trusts that if she has erred in her professional judgement that she does not face complaints, negligence claims or the General Medical Council. The discretion granted to the patient that a doctor trusts is the freedom to pursue them should that patient feel it appropriate. Clearly the doctor is much more likely to trust a patient who is unlikely to do this, perhaps because the doctor knows the patient trusts them or that they have a good relationship already. When a doctor makes a decision in good faith, trusting that this will not result in litigation, it stands to reason that some of the resulting negative emotions the doctor experiences stem from a sense of betrayal. Thinking about doctors trust in this way opens up another connection between trust and investigations and treatment that interest Fritz and Holton.
When Fritz and Holton claim that treatment and investigation is used to be ‘on the safe side’ we might ask ‘safe for whom?’. Perhaps, to borrow Fritz and Holton’s examples, putting a patient through the CT scanner or prescribing antibiotics is the doctor keeping themselves safe from litigation and complaints. The use of unnecessary tests and treatment is defensive medicine. This is increasing and in one study 78% of doctors say they practice defensively.2 3 If patients are being subjected to defensive medicine through overtreatment and overinvestigation perhaps it is the doctor’s trust in their patients that is lacking and underpins this. When a doctor thinks a patient is not trustworthy, they will attempt to use treatments and investigation to block the discretionary power of recourse against a doctor that would normally be part of a trusting relationship. Fritz and Holton provide evidence that in new interactions between patients and doctors, relationships without a history, patients are more likely to be overinvestigated or overtreated. They rightly point to trust as an important explanatory factor here. None of these cited studies exclude the possibility that these doctors are acting defensively through insufficient trust of patients however. Whether this story is complementary or ultimately usurps Fritz and Holton’s hypotheses on these findings is not relevant to my purposes. I simply want to draw attention to doctors trust as a further part of the picture in explaining why some doctors overinvestigate and overtreat.
Fritz and Holton attend to trust within the doctor-patient relationship. By stepping outside of this and reflecting on doctor’s trust in ‘the system’ there may be one further area where trust could be used to push back against defensive practice. In a recent survey by the British Medical Association, 78% of doctors said they believe that National Health Service resources were inadequate and that this impacts on quality, safety and care.4 Moreover, 55% of doctors felt that they would be unfairly blamed for system failings and pressures. This has only been compounded Dr Hadiza Bawa-Garba’s legal case and the proceedings against her by her professional regulator the GMC.5 Doctors find themselves working in an under-resourced and pressured environment where mistakes seem inevitable, and when they do occur doctors feel particularly vulnerable. It is therefore unsurprising that doctors feel doubly let down. First, by the systems they operate within and again by regulatory frameworks. The result is defensive practice by 49% of doctors according to the aforementioned survey.4 Defensive medicine is used by doctors to shield themselves against systems that appear to operate contrary to their interests. Where the doctor does not trust the system to minimise error or to protect the doctor who does make an error, and where errors can make doctors lives very difficult through litigation for example, then using treatment and investigation can appear to be a rational protection for the doctor. A deficiency of doctors’ trust in the system leaves them in the perverse situation of having to choose between their own interests, anticipating the personal consequences should things go wrong, or the patient’s interest in preventing the harms of unnecessary treatment and investigation. A broken system is acting as a bulwark to doctors placing their patients’ interests first. Clearly there is much philosophical work to be done in here in considering who should shoulder the risks and harms of a system that doctors don’t trust and in balancing the collective versus individual harms and proximate versus distal harms inherent in the tension between the doctor’s interest in avoiding litigation and the patient’s interest in avoiding defensive practice. Perhaps by bolstering doctor’s trust in the system they would be better able to meet their moral and professional obligations to their patients.
My aim here has been to add to Fritz and Holton’s analysis of the relationship between trust and ‘too much medicine’. By focusing on doctor’s (mis)trust in their patients and the system I hope to draw attention to an acute problem for doctors and patients. In light of the spiralling cost of litigation,6 the consequences of doctors’ trust becomes even more urgent. Moreover, the neglected tension between doctors’ and patients’ interests that results from a dearth of trust on the doctor’s part could serve as the focal point for more sustained ethical analysis. Interestingly, many of Fritz and Holton’s solutions can be adapted to soften this tension. In fostering an ‘atmosphere of trust’ Fritz and Holton must include all elements doctors (mis)trust in making progress towards their goal of ensuring decisions are ethical and consistent.
I would like to thank two anonymous referees and Dr Zoë Fritz for valuable comments on earlier drafts of this response.
↵i As a notable anecdote, I am increasingly aware of my medical students’ concern over whether they can trust their patients in my interactions with them in my role as an ethics tutor. I frequently encounter students who are very anxious to discover how far they go in ensuring that a patient is trustworthy. This most often occurs when there might be some risk to them as a doctor. ‘Shouldn’t I call the DVLA to double-check whether the patient really has informed them of their epilepsy?’ one student asks, ‘won’t I get in trouble if the patient doesn’t tell them after I have explained that they must?’ they continue. This observation requires further empirical exploration. Suffice to say that medical students are clearly anxious at putting their trust in patients where their own individual interests are at stake.
Contributors JP is the sole author of this article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None decalred.
Provenance and peer review Not commissioned; externally peer reviewed.
Patient consent for publication Not required.
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