By Joshua Parker.
Working as a junior doctor provides unique insights into other doctors’ reasoning. Being inexperienced and perhaps a little unconfident means junior doctors rely on their seniors for advice. Often I will see a patient and hit a dead end in terms of what to do next. This is where I approach a senior and we will discuss what investigation or management is appropriate. Within this dialogue my senior will show their working which is immensely helpful for my understanding, learning and development. Yet, occasionally, the conversation about what I ought to do next is driven by reference to avoiding complaints or litigation. This type of practice is known as defensive medicine and is disconcertingly common. These kinds of interactions always left me wondering why some doctors make the care of their GMC number their first concern.
Zoë Fritz and Richard Holton provide an answer to the question of why doctors overuse treatments and investigations. Their contention is that it is to enhance trust. So, doctors aren’t practicing defensively when they use treatments or investigations inappropriately; they are signalling that they are trustworthy and using this to build a relationship. Whilst this appears entirely plausible, it didn’t match the reasoning my seniors were using. Reflecting on my own experiences — especially in areas like A&E where interactions are both brief and consequential — in spite of the merits of their account, it didn’t tell the full story.
Fritz and Holton focus largely on patients trusting doctors. Patients believe that doctors have their interests at heart and so grant doctors certain powers. In my response, I considered what it would look like for doctors to trust their patients. What discretionary powers do doctors’ trust grant patients? Could we explain doctors’ defensive practice by reference to (mis)trust in their patients? If defensive practice strips patients of any power of recourse against a doctor then doctors have no need to trust their patients.
Taking this idea of a link between doctors’ trust and defensive practice further I also explored doctors trust in ‘the system’. Recent high-profile cases, not to mention doctors’ current working environment, have eroded doctors’ trust in the system to keep them safe from complaints and litigation.The distrusting doctor’s response to the system might be defensive practice, similarly to within the doctor-patient relationship. Assuming that defensive practice harms patients and that litigation is bad for doctors, doctors who don’t trust the system to protect them are placed in the perverse situation of having to decide between their own professional interests and the patient’s interests in avoiding defensive practice. Clearly this latter concern ought to be subject to further ethical analysis.
Understanding the consequences of a lack of trust in healthcare is important for appreciating how doctors’ practice is altered and the impact on patients. From here, solutions can be generated and hopefully practice improved. My hope is that my paper contributes to this end.
Paper title: Too much medicine: not enough trust? A response.
Author: Joshua Parker
Affiliations: Education and Research Centre, Wythenshawe Hospital, Wythenshawe, Manchester M23 9LT
Competing interests: None
Social media accounts of post author(s): @joshp_j