Margaret McCartney: Trust the patient
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3181 (Published 10 June 2015) Cite this as: BMJ 2015;350:h3181All rapid responses
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In answer to the question implied by Shyan Goh's rapid response (this series 13 June) I suspect that the widespread [voice] recording of consultations between doctors and patients would probably have damaging consequences.
My 'background in this' is end-of-life, and my interest was in the 'trust' aspect. Dr Goh's implication that recording a conversation might indicate, or be taken to indicate, a lack of trust, is of course correct - but the entire contemporary 'behaviour set' written by the professionals involved in end-of-life for patients who are in their own homes, 'indicates a lack of trust in family carers'. I find it deeply offensive, that while clinicians understandably take offence when it is implied that they are not to be trusted, for some reason the live-with family carers of dying patients, are supposed to accept that they are not to be trusted by default.
I can't speak for Australia, but in England there is a push to allow more patients to die in their own homes if they wish to do that, while at the same time contemporary guidance seems entirely incapable of properly incorporating the fact that many patients will die without 'having entered an identified 'dying phase'': to put that another way, that many EoL patients will inevitably 'die early' (which equates for contemporary Community EoL Death policies, as 'die before being formally classified as 'expected death' by the GP’). The current protocols for community EoL death, where they do exist, draw a completely inappropriate (because it is too simplistic even in theory) distinction between 'expected death' and 'unexpected death', with the consequence that family carers yo-yo between 'being treated with compassion' and 'being treated like suspects'. It would not be difficult to introduce the necessary sophistication into behaviour for EoL home death (I have explained how this could be done in ref 1) but there is a huge impediment in that the professionals refuse to 'trust the relatives by default'. In particular, the type of behaviour set which makes perfect clinical and logical sense, would I suspect be strongly resisted by police officers.
Dr McCartney mentioned uncertainty as well as trust. When I read, as someone with a doctorate in chemistry, contemporary end-of-life guidance and policies, I see a marked reluctance to properly incorporate both clinical uncertainty and patient self-determination, combined with an 'attitude' that professionals are trustworthy but laymen are not trustworthy: throw in some added complications involving concepts such as 'patient confidentiality', a fairly widespread unease at 'talking about dying', a common interpretation of ‘safeguarding’ which thwarts the patient self-determination so fundamental to the Mental Capacity Act, etc, and at the moment behaviour sets for EoL home death seem to assume an 'idealised model' which is very different from the reality of many EoL home deaths. The guidance and protocols, should be based on the reality of EoL at home, accepting the many complications, and not on 'a guidance-writers' wish-list of how EoL at home should work in a 'perfect and much-simplified world''.
And 'trust and uncertainty' are two of the main issues which need to be properly addressed, if better and more perspective-balanced behaviour sets are to be created.
Ref 1 http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj...
Competing interests: No competing interests
Dear Editors
I agree with Dr Adil's assertion.
If Mr Michael Stone and other readers believe that their private conversations with trusted friends or loved ones is unaffected by them brandishing a voice recorder around, or after discovering that the discussion was recorded covertly without their permission, then I would suggest that they live in a very exclusive world, not shared by the rest of us.
A consultation between a healthcare service provider and healthcare service user is exactly that: a private privileged discussion among trusted individuals.
Put a voice recorder on the table the next time some of you have a boys/girls night out among close friends; see how effective it is as a party pooper.
Competing interests: I am both a healthcare service provider and healthcare service user
I think ,just the fact that a conversation is being recorded will cause inhibition and distraction on both the sides which will reduce the quality of consultation.
Competing interests: No competing interests
It is possible that a patient might wish to record a conversation with a doctor, in order to 'go back and make sure I understood the information', which isn't at all 'threatening' provided the information was clear and correct.
But Dr McCartney also writes 'Uncertainty is the natural state of medicine, and practising cover-my-back medicine is miserable' and it seems to me that professionals, and 'the NHS as a system', struggle to properly handle 'inevitable uncertainty'. I recently wrote about one type of uncertainty in a rapid response (ref 1) where I asked if 999 paramedics should trust the word of family carers by default.
I have also written (ref 2) about records of conversations in patient notes, and asked if these should be 'signed off' by both sides of the conversation: the very limited investigation I carried out, matched my expectations that laymen would probably want to read and sign off on any record of a conversation they had been involved in, but professionals and administrators would probably be less keen. However the only obvious way to discover whether a conversation 'was at cross purposes' or was 'misunderstood' is for any description of the conversation made by one party, to be examined by the other party.
Trust is indeed a two-way thing, and it is even harder to build 'trust' into the patient-system interaction, than for trust between a patient and an individual clinician [where the relationship is ongoing] to exist - but in this new 'social media age', it is logical to expect patients and relatives to increasingly share their own experiences of 'where the system did not 'trust me'', with the consequence that increasingly laymen will conclude 'that I cannot trust the system, if it is unwilling to trust me'.
This is a difficult one: I see the main impediments to 'greater trust' as probably being time pressure, the desire of individual professionals to cover their own backs [especially if they are 'out of their own comfort zone'], and the fact that trusting the laymen does equate to lessening the 'control' possessed by the professionals and the system.
Ref 1 http://www.bmj.com/content/350/bmj.h2877/rr
Ref 2 http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj...
Competing interests: No competing interests
Re: Margaret McCartney: Trust the patient
I have discussed this article in detail with others. We have puzzled about what its concluding couple of sentences are really intended to mean, and I wonder if Dr McCartney could be persuaded to provide careful clarification.
None of us is particularly happy with the metaphor, in the context of medical consultations, claiming 'trust is a two way street'. As the author's opening paragraph itself indicates, in such relationships the notion of trust (in fact, on both sides of consulting room) is a more complex and conditional idea than that. Conversely, nobody disagrees with the assertion that 'we need doctors who are worthy of trust'. Our real comprehension difficulty, however, lies in the concluding words: 'we also need to know that the relationships we have with our patients contain the same trust.' This is further figurative language and truly opaque - at least to those with whom I have been discussing the issue, and to me.
If this closing assertion belongs with article's title 'Trust the patient' and the further assertion that 'uncertainty is the natural state of medicine', then one reading of this could be paraphrased as something exhortatory, along the lines of: you need to trust patients about their motivations to record i.e. as being 'benign', at least until the contrary is proven. And that would carry with it the notion that doctors are not entitled to probe patients for their motivations.
On the other hand, it could be taken to mean that 'we' ( = medical practitioners) 'need' ( as in 'are entitled') to know whether the patients actually trust 'us' and\or can be trusted not to 'abuse' their recordings once taken. This latter interpretation would indicate an agenda prompting the practitioner to enquire of patients as to their motivations – which is pretty much the reverse of the previous interpretation, but might be seen as cognate with the article's earlier claim: "There’s a colossal difference between patients recording consultations to help them and their family, and patients doing so to search for imperfection, to complain and sue."
There could, no doubt be other interpretations, but these are the two my discussion group considered the most likely to include the meaning intended.
Candour dictates I should make clear that the same discussion group was unanimous in declaring that the first interpretation represents a position legally and practically correct. And in line with, for example, this conclusion:-
"…physicians should be aware of the possibility that their conversations with patients may be recorded. If physicians embrace this possibility, establish good relationships with their patients, provide compassionate and competent care, and communicate effectively and professionally, the motives of patients and families in recording visits will be irrelevant."[1]
The import of the second interpretation described above we condemned. Doctors are simply not entitled to knowledge of all the inner working of their patients minds at all times, and any attempt to claim such an entitlement could be seriously harmful to all concerned (and some more colourful views were expressed on the issue which don't belong in BMJ print).
I seek enlightenment.
[1] Closing words from: Ethical Implications of Patients and Families Secretly Recording Conversations With Physicians. Michelle Rodriguez, JD; Jason Morrow, MD, PhD; Ali Seifi, MD JAMA. Published online March 12, 2015. doi:10.1001/jama.2015.2424
Competing interests: No competing interests