10 August 2015

Are we still trustworthy?

[published in NZMJDigest, Issue 52]

As doctors—as a profession and as the NZMA—we are often asked our opinion on matters pertaining to the care of patients and the broader healthcare framework.

In the last two months, we have strongly advocated via submissions, media, face-to-face meetings and Select Committee presentations on issues such as climate change targets, the TPPA, gagging of doctors advocating for refugees in Australia, ethics of euthanasia, use of medical cannabis, homeopathy, over-the-counter dispensing and so on.

And, as individual doctors, every day we are asked for our opinions on the care and treatment of the patients in front of us.

I would argue that the reason we are asked is because our answers are trusted and respected. Philosopher Baroness Onora O’Neill, in an outstanding TED talk, discussed the concepts of trust and trustworthiness. She makes some interesting points. As she points out in her TED blog:

If we want others to trust us, the first step is to be trustworthy…The second step is to show that we are trustworthy: we have to provide enough intelligible evidence of competence, honesty and reliability in the relevant matters for others to reach an intelligent judgement. This is not best done by showing that we have ticked all the prescribed boxes…what matters for most people in judging where to place their trust is generally simpler. Most of us look for evidence of trustworthiness—of competence, honesty and reliability—in the relevant matters.

As a profession, are we still trustworthy? The fact that we would rank in the top 10 of “trusted professions” would tend to suggest the answer is ‘Yes’. As would the fact that the NZMA, representing your profession, receives almost daily requests for comment on a wide range of issues about patients and the overall healthcare delivery system in which we work.

Competence, we would argue, is assured by our self-regulating Medical Council of NZ, with worldwide studies of doctors showing competency concerns in less than two percent of practitioners.  

What of our honesty and reliability? Calls have been made recently for the publication of outcome data from individual surgeons. While the intent of this is laudable—wanting to be transparent about care and to augment patient decision making—the concept is riddled with flaws: implementation issues, generalisability, false choice to the patients, and proven risk of reducing patient access.

And this is also a fundamental affront to the trustworthiness of our profession. Call me naïve, but I do not believe that there is a single doctor in New Zealand who has the purposeful intention to do harm to their patients. I do not believe that ‘blaming and shaming’ individual surgeons will improve patient care or increase the trustworthiness of the profession.

On the contrary, the more we try to increase the ‘accountability’ of the profession, then the more we reduce our inherent altruism, which is designed to put patients’ interests above our own interests.

On a wider scale, many ‘accountability’ measures—such as rewarding with financial incentives (eg, paying benefits based on compliance with smoking cessation targets) or developing clinical pathways and then punishing or rewarding to reduce variation—are developed because doctors are not trusted to deliver the best possible care to our patients in the most efficient manner.

If you suspected your partner of having an affair, would you be reassured if he/she showed you his/her texts, lent you his/her phone for the day, spoke to your friends etc? Does accountability rebuild trust? Or does it decrease it?

So what can we do?

For a start, we can start talking about our trustworthiness—not about the measures to prove our worth, but rather about trust itself. If 98% of us are exemplary in our standards and care, should we devise accountability systems to measure everyone and thereby reduce the trust, innovation, altruism and caring of the total?

Then we can ask ourselves, are we worthy of that trust? Are we competent? Are we honest? Are we reliable? And maybe not just ourselves—should we ask our patients about our trustworthiness? Are we ready for the response?

In the coming months, we (the NZMA and your profession) will be continuing discussions around big topics like euthanasia, climate change, TPPA, child poverty and health inequity. We will stand up tall as representatives of the profession that binds us together.

We may also ask some hard questions of ourselves and others—but most importantly we will listen. We welcome your feedback, comments and all efforts surrounding what unites us in the best care of our patients.