BMJ 2003; 327 doi: (Published 17 July 2003) Cite this as: BMJ 2003;327:171
  1. Kevin Barraclough, general practitioner
  1. Painswick, Gloucestershire

    I remember that we were sitting in a room analysing videoed consultations. The registrar on the video sat the patient down. “You have sacroiliitis,” she said.

    We all finished watching the video, consultation technique was discussed, and then someone pointed out that the registrar couldn't possibly say that the diagnosis was sacroiliitis. All that one could say on the information presented was that the patient had mechanical low back pain.

    “Oh, well,” someone else said, “We all do that.” I assumed by this that they meant that we all made up diagnoses of spurious diagnostic accuracy to keep the patient happy.

    There was a pause, and then a colleague said in a slightly embarrassed tone: “Well, I don't do that.” There was an awkward silence and then we moved on to discuss the knotty question of whether the registrar had empathised with the patient.

    This episode occurred several years ago but it has stayed with me. I suspect that I was probably guilty of the same sin—of dressing up diagnostic uncertainty with an impressive, but spurious, diagnostic accuracy. I have avoided doing it ever since.

    There is quite a lot published about why patients trust some doctors and not others. The reasons for trust, or the lack of it, are undoubtedly multiple. As junior doctors we assume that the patient will distrust us if we seem uncertain, and that may be true.

    The risk is that the bullshitting learnt as a junior may persist. And the odd thing is that it is tolerated. “We all do it.” But I suspect that most human beings are rather finely attuned to picking up the minor levels of deceit in such a practice, which may explain part of the spectrum between trust and distrust that patients feel.

    I recently had to fill out a form for appraisal, which asked me about my “probity.” I remembered the story of Evelyn Waugh visiting the United States. The entry form asked him if any part of the purpose of his visit was to “subjugate the government of the United States.” He wrote, “sole purpose of visit,” and was detained for a week. Maybe my appraisal form should, more profitably, have asked me if I bullshitted to patients. It would at least have caused me to examine my conscience.

    Now, instead of saying to patients that they have sacroiliitis, I tell them that they are allergic to candida.

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