The organization #MedsWeCanTrust1 notes that 1 in 10 medicines in low- and middle-income countries cannot be trusted and may actually jeopardize health. I take the liberty here of riffing on this hashtag to explore #MedicineWeCanTrust, investigating aspects of trust in medicine, where trust has been described as “the matrix of the health care enterprise.”2 A matrix is a womb, a feminine place of nourishment and growth. Trust in medicine is a “soft” principle situated in the midst of a “hard” enterprise—modern, managed health care is historically patriarchal, authoritative, and controlling—and is then prone to being squeezed or squashed. Under such conditions, authentic trust is repressed and may reappear in a distorted form as symptom, such as simulated trust on the part of doctors. Knowing this, the public, as patients, may come to mistrust medicine.
Trust in medicine has been poorly conceptualized, where it is polyvalent and complex,3 putting into question simplistic, instrumental definitions of trust, such as “the expectation that institutions and professionals will act in one’s interests.”4 From the patient’s point of view, at a minimum, trust comprises satisfaction, privacy, quality of communication, and perception of capability. This means confidence in both individual doctors and a health care system (in the United Kingdom, the majority of health care is provided by geographically defined “trusts”—referring to an agreement for free provision of services in return for public taxation). Trust affects patients’ willingness to both seek out and comply with treatments, grounded in doctors forming therapeutic relationships with their patients. Developing high levels of trust in doctors also leads to greater willingness to forgive them if things should go awry. Such trusting relationships in their own right offer measurable health interventions.5
Before the language of finance overshadowed that of psychology (“trusts,” “bonds,” “securities,” “futures”), “trust” conveyed a moral meaning. The common denominator between the worlds of economics and human relations is “transaction.” In the world of economics, and to a great extent in law, a transaction is judged by its end results (the profit motive, a good result in court) and can often be opaque. In human relations, however, quality of transaction is judged by the transparency of ongoing process. As a patient, I engage in a professional contract with my doctor in which I expect an informed, supportive, and courteous relationship.
As noted, trust can operate at 2 levels: first, at the institutional level (the culture of medicine, a health care organization, or an individual hospital), and second, involving doctors in general or a specific doctor. Below, I consider a third level of trust beyond medicine that comes to engage with health care provision—that of general interpersonal trust. This can be low in socially deprived or excluded groups and persons, including, importantly, migrants and displaced persons.
An increase in trust leads to greater tolerance of uncertainty. People take more risk in the face of uncertain outcomes if they trust health care organizations or individual doctors and if they perceive such health care as a key element of social justice. Encouraging “questioning” on the part of patients—loosening the historically paternalistic grip of medicine—increases trust.6 This space to voice one’s rights requires responsible and close listening from doctors. Here, medicine engages democracy—a big shift for a historically didactic and hierarchical institution, albeit currently undergoing rapid social transformations. Such democratic habits must be developed early in a career—during medical school—through a medical education that honors social justice and collaboration.7
Will hospital surgery departments carefully scrutinize the origins of their surgical instruments—some of which are made in sweatshops employing child labor?8 Worldwide, social inequalities are a major source of ill health and premature death; meanwhile, higher levels of inequality are also linked to lower levels of interpersonal trust as supportive social networks collapse or are never initiated.9 In the United States in particular, trust in medicine is declining, where “there continues to be unequal access to health care by certain demographic and socioeconomic groups, which likely accounts for even lower levels of trust seen in many minorities and those in lower income brackets.”10
Those Americans who are disenfranchised in terms of health support also show a low level of trust in government interventions tackling health care inequalities.11 Such skepticism, which might seem like a paradox at first, could be a peculiarly American phenomenon, but it has some basis in the reality that government investment has failed to stem increasing deprivation arising from entrenched social hierarchy and unfair distribution of economic and social capital.12 That the United States remains the only advanced economy in the world to not have full health coverage for every citizen is, however, surely an anachronism. Importantly, democracy is a health intervention. A survey of 33 middle- and high-income countries concludes that “the more egalitarian countries had better health.”9 But democracy must be properly exercised to impact and develop.
Trust, however, is readily eroded amongst the privileged too. Lack of trust is both a cause and outcome of “too much medicine”—overdiagnosing, overtesting, and overprescribing.6 And inequality permeates health care culture itself as entrenched autocracies and hierarchies molded and maintained by medicine, breeding mistrust amongst mixed professionals. Structural inequalities at the micro-level of clinical teams lead to symptoms, such as avoidable patient deaths through medical errors grounded in poor communication within and across such teams, particularly in surgical contexts.13
While it may not be medicine’s (or medical education’s) job to fix the wider structural sources of inequality, as a respected profession, medicine must accept responsibility for not modeling democratic structures. Again, medicine remains stubbornly hierarchical and patriarchal. Despite more women than men entering the profession worldwide, medicine is not overtly feminizing, evidenced by its reluctance to embrace #MeToo politics,14 and justifies its lack of democracy in claiming to be a meritocracy. But, while juniors must obviously learn technical skills and knowledge from seniors, nontechnical capabilities (communication, teamwork, emotional intelligence) are often better—or less “hardened” and jaundiced—in juniors than in cynical seniors. Meritocracy only goes so far.
There is, then, work of reparation that medicine must carry out across its own ranks (democratizing and feminizing), with other health care professionals (establishing authentic interprofessional teamwork), and with patients (encouraging patient-centeredness and positive engagement with social inequalities), to increase trust capital and to distribute this fairly. This work can begin in medical education with the doctors of the future—medical students—through pedagogies that educate first for democratic habits and then for the development of interpersonal and institutional trust. This might be characterized, to draw on William James, as developing a “tender-minded,” optimistic medicine to counter the “tough-minded” medicine of cynics.
The latter has been described frankly by Tom Inui,15 where medical “students learn that medicine is a profession in which you say one thing and do another, a profession of cynics.” The English surgeon and memoirist Henry Marsh worryingly suggests that doctors “have a very complicated relationship with patients . . . as soon as we have any interaction with patients, we start lying. We have to. There is nothing more frightening for a patient than an anxious or doubtful doctor.”16 For his part, the writer Denis Johnson notes, “it’s always been my tendency to lie to doctors, as if good health consisted only of the ability to fool them.”17 We should hope that medical students of the future, even where they are “trained” within an instrumental paradigm illustrated by competency-based medical education and entrustable professional activities,18 will not engage with these kinds of duplicities that appear to mock trust.
The Medical Humanities as a Democratizing Process
I have argued elsewhere at length that we can best educate for democratic habits (and then for nourishment of trust) in undergraduate medical education through core, integrated, and longitudinal curricula in the medical humanities, where there is good evidence for efficacy if input is carefully designed.19 The medical humanities can educate for tolerance of ambiguity, mirroring the work of trust. Martha Nussbaum, Mark Slouka, and Parker J. Palmer, among others, claim that the humanities in general provide the best available media through which we can educate for democratic habits,19 bearing in mind that “democracy” is a complex project-in-process, which Jacques Derrida termed “the democracy to come” and a “horizon” project.20
Drawing on the work of the psychoanalyst Donald Winnicott, Martha Nussbaum21 makes an argument for paralleling authentic democratic participation with “adult play.” Play, for children, is a way they can come to understand the outlook of the other and then learn to accommodate it, rather than compulsively seeking to control as the key element of self-centeredness. Such a need to control (and to be controlled as you fit into a traditional hierarchy as a preferred social structure), a result of deprivation of social play as a child, lingers into adulthood as a personality trait, often as “ego inflation.” According to Nussbaum, Winnicott suggested this can be transformed into a more democratic, sharing outlook through therapeutic engagement with “adult play”—the arts and humanities. Nussbaum progresses this to a model of democratic participation, where the humanities provide the civilizing provocation. The parallels with medicine are clear—medical culture needs to grow up, moving through issues of control to embrace democracy (flattening hierarchies, feminizing, engaging positively with issues of social justice, practicing authentic interprofessionalism, embracing patient-centeredness, and developing medicine as practice artistry or a thing of elegance and beauty).
Medicine promises to “First, Do No Harm,” but the institution of medicine is culpable for progressively generating mistrust, even distrust, among patients and then doing psychological harm. While technically smart, when it comes to building relationships, modern medicine is like a spoiled child who becomes unable to develop adult caring and warm relationships or emotionally satisfying collaboration. This phenomenon is characterized by the poet Wallace Stevens as preferring the habit of “force” over “presence.”22,23
Research evidence has consistently shown that medical students in the later years of training show empathy decline and emotional detachment and insulation, compounded by growth of cynicism. Medicine has been the saturnine father who eats his young. The onus is on the institution of medicine to generate the conditions under which trust between doctors and other health care practitioners, and between patients and doctors, can be enhanced to improve clinical care and patient safety. Medicine must embrace trust as the matrix of health care, and the medical humanities can educate for values such as tolerance of uncertainty and ambiguity as a basis for engendering trust. We must remind ourselves that intolerance of ambiguity characterizes the authoritarian personality,24 a species that must in time become extinct as a trustworthy medicine evolves to an authentic #MedicineWeCanTrust, where patients and providers are yoked together in a common humanity.
The author is grateful to Dr. Arno Kumagai for stimulating conversations on medical humanities and social justice issues.
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