There are few relationships as sacrosanct as the one between a doctor and a patient. Built on trust, communication, mutual respect and empathy it is influenced by the practise of medicine, ethics, and the law—all of which have been disrupted by covid-19.
This crisis has meant patients have been physically and emotionally separated from doctors due to use of personal protective equipment (PPE), telemedicine, and patients’ fear of accessing healthcare.
Empathic and clear communication is seen by patients as a proxy indicator of competence and skill. Furthermore, poor communication is often the differentiating factor between those doctors who are sued and those who are not, even if clinical incident rates are equitable.
Telemedicine relies heavily on communication, which is impaired by loss of verbal and non-verbal cues and impatience. The need for full and open dialogue at this time is highlighted by the claims experienced during SARS and MERS. In some cases, physicians were unduly influenced by the pervading context and incorrectly attributed patient’s symptoms to those diseases. These risks are heightened if examination is limited, but can be mitigated to some degree by altering our consultation style—listening actively, checking back information and warmth of tone. Cost, convenience, and risk means telemedicine will remain a fundamental tool, but potentially to the detriment of the connection we have with patients.
When it comes to the ethical aspect of the relationship, we see the interests of our patient as paramount yet in the time of covid-19 many may have received less care due to constraints, or even no care at all, as many have kept away from GP surgeries and hospitals. We have also struggled to agree on fundamental issues of resource allocation and withdrawal of treatment, though at this stage have been mercifully saved from having to decide whether to withdraw ventilation from one covid-19 patient to benefit another as concerns around ventilator shortages have not materialised. Should we accept the utilitarian ideals advocated by some to act for the greater good? And is this compatible with our sense of empathy or indeed the law?
Consent is fundamental to the trust and respect within the doctor-patient relationship and relies on there being a competent patient in receipt of sufficient information, free of coercion. I question whether informed consent is always possible in the current climate when hearing of patients receiving letters regarding their DNAR status and staff discussing options with vulnerable patients attending alone. I also wonder what unintentional influence society has had on those patients’ decisions in our unremitting focus on saving the NHS.
Similarly, I wonder whether the respect and empathy being shown by the public, and press, towards healthcare workers will translate to greater tolerance of medical error. Can we now accept that stretched staff and resources will not always deliver high quality care and that, on occasion patients may be harmed?
MPS has called for emergency laws to protect UK healthcare workers from criminal and regulatory investigation—a call supported by two thirds of the public, according to a YouGov survey of over 2000 adults in Britain
If immunity from criminal and regulatory investigations is not offered, then we must look to judges to interpret the current law and reflect the attitudes of society. They must question whether it is fair that a psychiatry trainee asked to cover an acute ward in the pandemic be judged at the same level as a medical registrar, as per the Bolam test. Does Bolitho allow them to overlay the covid-19 context to a logical interpretation of negligence? Should the legal test be what a “reasonable society” expects rather than the “reasonable” patient? Will the judiciary who have upheld patient rights for so long intervene to protect our healthcare system and its workers?
There is also fear that a tsunami of claims may be approaching, particularly owing to delayed and missed non covid-19 diagnoses. With outstanding NHS liabilities estimated at £78bn, this raises a challenging question as to whether patients should be prevented from seeking compensation at this time, through legal immunity for doctors?
The crisis may have escalated the break-up with our patients, but perhaps there is a new love affair between the profession and society. Covid-19 has brought disruption to the practice of medicine, our ethics and even the law—it is no surprise then that it has changed the doctor patient relationship forever.
Pallavi Bradshaw, medicolegal lead, risk prevention at the Medical Protection Society.
Pallavi gave a talk on this topic at the 2 June Risky Business conference on Lessons Learned from Covid-19. Read more about the conference here.