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TRUST – IN GENERAL PRACTICE

The James MacKenzie lecture, 2 000

(British Journal of General Practice 2001; 51: 575-9.)

Per Fugelli

"And though I have the gift of prophecy, and understand all mysteries, and all knowledge, and though I have all faith, so that I could remove mountains, and have no trust, I am nothing."
Paul the apostle in his first letter to the Corinthians (amended version).

In Switzerland, in Cern, in the giant European atom smasher centre, in the large Hadron Collider, the Nobel physics laureate, Leon Lenderman, on 19th September 2 000, got a glimpse of The God Particle. It lies at the heart of one of the most important mysteries of modern science: What mechanism holds all the stuff in the Universe together?
I have, to honour James MacKenzie and you, been pursuing a similar particle. It lies at the heart of one of the most important mysteries of modern medicine: What mechanism holds patients and doctors together?
The God Particle I have glimpsed is called Trust. I feel privileged to present my findings to The Royal College of General Practitioners, because I regard you as the Masters of trust in the medical universe.

SAFARI
Come with me first, on a safari to the jungle, to the mountain, in search of trust.
In April 1996, Botswana armed troops marched into the villages of Ngamiland, gathered all the cattle, shot them dead and burned them. The motive of the central government was to prevent Contagious Bovine Pleuropneumonia spreading to all the cattle herds in Botswana, and thereby destabilising the national economy. The perception among the Okawango tribes was that once again in a never ending story of neglect and provocations, the central government was trying to undermine the basis of their existence. One year later the District Health Team, ordered by central government, launched a polio vaccination campaign aimed at Okawango children. Only a minority attended. The fear hypothesised: First our cattle, now our children. Perhaps, the government's syringes contained poison? The bullets from the army killed the trust, and without trust the vaccine became 100% ineffective. The consequence of dead trust was paralysed children. This case demonstrates the power of trust and the impotency of biomedicine, isolated from social life and moral universe.
Last year, in Western Nepal I followed the work in Tansen Hospital. Every Friday doctor Maradishu, general practitioner of good heart and bright brain, ran an out patient clinic for a very special clientele. The patients belonged to the upwardly mobile Nepalese middle class, with some money, some education and immense expectations of Western biomedicine. These people became easy preys to a shoal of medical piranhas stealing their money and health by endless, costly laboratory tests, investigations, drugs, referrals. At the sad end people came to doctor Maradishu's Clinic of broken dreams. He brought them back to reality. He confiscated their plastic bags with 42 different drugs, and 4 kilos of nonsense medical documentation. Doctor Maradishu draw a clear demarcation line between heaven, medicine and earth. Often his message would be: Doctors, drugs, X-rays, can never reveal your pain. Go to the Brahman. Many patients felt that doctor Maradishu brought them through a medical catharsis. They trusted him because he was honest. He did not exploit them. He acted in their best interest.

WHAT IS TRUST?
Trust is an individual's belief that the sincerity, benevolence and truthfulness of others can be relied on (1,2). Trust often implies a transference of power, to a person or to a system, to act on my behalf, in my best interest. Trust is divided into two categories:
Personal trust is trust in your wife, your friend, your doctor. Personal trust evolves between people with names, identities, feelings and faces. Personal trust must be gained, actively.
Social trust is trust in societal institutions, for example the Parliament, the military, the health care system. Social trust develops between a person and faceless, feelingless abstractions. Social trust is often passive, inherited.

WHAT DO WE NEED TRUST FOR?
Trust is essential (1,2):
• to cope with existential angst
• to simplify complexity
• to reduce risk
• to function as a chaos pilot in life and society

Trust is the social vitamin that enables us to live. Graham Greene says in The Ministry of Fear: "It is impossible to go through life without trust, that is to be imprisoned in the worst cell of all, oneself."
Sick people have always had a particular need for trust, because to fall ill implies a loss of trust in yourself, in your body, in your social role, in your future. This loss of trust fortifies the need to trust others, among them the doctor.
That people trust our moral integrity and medical competence is the very basis of professional autonomy (1,2). The trust of the people signs to some extent a declaration of independence for medicine. Without trust medicine will be nothing but a battlefield invaded by lawyers, politicians, bureaucrats, journalists, controllers, sophisticated consumers and money-makers (3).
Now, I will invite you to a clinical meeting in the Room of Trust and in the Room of Angst (3,4,5,6):
• In the Room of Trust the patient's genuine ideas will be presented, even when sensitive. In the Room of Angst there may be hidden agendas. The patient is reluctant to reveal the real thing.
• In the Room of Trust the patient will feel secure with low technology and high fidelity. In the Room of Angst there will be cravings for multiple tests and sophisticated referrals.
• In the Room of Trust there will be patience, allowing the doctor to use time as a diagnostic instrument and healing remedy. In the Angst Room there is a silent cry for action and solution now.
• In the Room of Trust, what Balint calls the drug doctor, is potently present, making the therapeutic alliance and compliance strong. In the Room of Angst the molecules are alone, deprived of the power of trust, faith, hope.
• In the Room of Trust the clinician can feel free to use his personal judgement and tailor medicine to fit this unique patient, in this life situation, on this strange Wednesday. In the Room of Angst clinical practice will be restrained by guidelines, quality control standards, fear of being sued, fear of being made the subject of media scandal.
• In the Room of Trust the doctor will be forgiven. In the Room of Angst he will be accused for the same mistake.
• In the Trust Room doctors thrive. In the Angst Room doctors burn out.

Trust is for general practice like blood is for the body. As the flow of blood enables the organs to function, so the flow of trust enables the GP to function as a personal doctor, as a clinician of temperance and patience, as a gate-keeper to the medical tower of Babel. Trust is the oxygen of general practice. Without trust our vital functions will suffocate.

APOCALYPSE NOW?
How is the state of trust in medicine to day?
We have few researchers and many prophets in this field, mainly prophets of doom, forecasting apocalypse now! But the sober research evidence indicates that the majority of patients still trust their personal doctor, while confidence in the health care system is under strain (3,7,8). Symptoms of ailing trust in the medical professions may be:
• the increasing proclivity of patients to complain and sue
• the rise of patients' rights
• the invasion of controllers and reviewers in clinical practice
• the proliferation of alternative medicine
• the enthusiasm with which the media scrutinise us
• the burn out epidemic among doctors

WHAT IS TRUST MADE OF ?
These are the genuine sources of trust in general practice (3,5,6,9,10,11,12,13):
• the good society
• moral integrity
• personal doctoring
• sharing of power
• compassion
• realistic medicine
• competence

The good society
Strange, the good society, what has that to do in the GP’s consultation room?
You remember the Okawango-case. If people lose basic trust in society, they will carry a rucksack of fear and cravings into the consultation room. Trust and mistrust are contagious phenomena fluctuating between the macrocosm of society and the microcosm of medicine. Therefore, doctors can enhance trust in medicine by contributing to the good society. How can we do that ?
By playing a part in healing the ills of society (14,15). The GP, working in the front line, in the midst of the social jungle, has an unique observation post, enabling him for early warning. The political pathology is inscribed in our patients' bodies and souls. It is our duty to read the signs and symptoms of unemployment, poverty, racism and not to medicalise them, but to act as social messengers, report back to the people and their politicians. Like James MacKenzie did when the social injustices he witnessed in Burnley lent wings to his pen and fire to his words, resulting in the novel Only A Working Lass (16).

Moral integrity
There are four elements in the amalgamation of trust called moral integrity (1,2):
• honesty
• transparency
• confidentiality
• autonomy

I will focus on the last element, autonomy, since that is the most endangered value.

Autonomy
An essential element in the very definition of trust is the firm belief that the other, the trusted one, will act in your best interest. You remember dr. Maradishu in Nepal. Modern times are characterised by the intrusion of external parties into the doctor-patient-relationship (3,6,13,17,18). The autonomy of the GP, and thereby the capacity to create trust, is now compromised by:
• Big business
• Big government
• Big science
• Big Brother

Big business confounds the doctor-patient-relationship with greed, profit, financial incentives. The New-speak of medicine is: market share, productivity index, covered lives, medical loss ratio.
Big government compromises loyalty to the patient by recruiting the doctor as double-agent. Fund-holding, gate-keeping, outcome measures divide loyalties with a bias towards the System.
Big science reduces the GP’s freedom by changing the clinical jungle into a clinical park. Big science steals loyalty from the individual patient to evidence-based programmes and standardised guidelines.
Big Brother takes a toll on autonomy by means of the new information technology and invasive monitoring systems.

Patients' trust depends on their perception, their conviction that the GPs are free to act in their best interest. Milan Kundera states in The Unbearable Lightness of Being: "The doctor is judged only by his patients, that is behind closed doors, man to man". This is the moment of trust: The consultation, not the big systems, is the true battlefield where trust is won or lost. And precisely here, in the consultation, the GP has an exceptional potential for trust, in the capacity of:

Personal doctoring

Doctors in other parts of medicine are devoted to an organ or a technology. They practice according to what the Germans call: Das Schema. The GP is devoted to the person, the strange, subtle, and unpredictable being we call man (19,20,21,22). Das Schema is not workable in general practice. Our patients are tales of the unexpected. While many doctors are double-blinded by objectivity and science, the GP’s eyes try to find the patient's eyes, creating a meeting between what Martin Buber calls: An I and a You. When a diagnosis enters into a person, a new disease arises every time. Every time a new disease arises, sculptured by this person’s history, character and life situation. Therefore, each man becomes ill in his own way. The only significance test relevant for general practice signifies that:

p = 1
The Patient is One.

How do we maintain personal doctoring and thereby trust in general practice?
Personal doctoring depends on small scaledness. Trust thrives better in a local home-like setting, than in the alien supermarket. Trust grows in the context of on-going relationships (8). Albert Einstein has formulated this truism in a classical equation (amended version):

t = m x c2
Trust equals medicine practised in continuity squared.

Sharing of power
To the GP, personal doctoring is more than an instrumental strategy. Personal doctoring arises from a deep-rooted conviction that the patient is not a subordinate biomachine, but a fellow human being who we approach with humility, respect and non-dominance. General practice at its best is democracy between two. The GP realises that there is only one expert on the patient's feelings, fears, hopes, bodily sensations, social sentiments - the patient. Therefore, the two experts, the expert on medicine, and the expert on me and my life, must cooperate, merge expert domains, share power.
How to do it? You know, you have done it for thousands of years.

Compassion
Trust is facilitated by personal doctoring and by sharing of power with the patient. But if personal doctoring and sharing of power are done in cold blood, as a cerebral calculation, trust may fade away (14). There must be moderated love in the air. Compassion, to suffer with, to convey empathy for the patient's distress, to show concern for his or her good, promotes trust (9).
How to do it? You know. You have done it for thousands of years.

Realistic medicine
To be compassionate, personal doctors does not mean to be doctors without limits. Trust is not linked to an eager-to-please attitude. Realistic and trustworthy medicine implies saying no. Trust is associated with clear, predictable limits, limits to the patients expectations, limits to the doctors promises. Modern medicine promises people too much, too much healing, too much certainty (23,24). There is a great divide between what we, inspired by Erving Goffman, may call medicine's front stage and medicine's back stage.
On medicine's front stage, physicians play the masters of the Universe, the conquerors of nature, the terminators of ills, suffering and death.
On medicine's back stage, we play hidden tragedies, tremble and burn out.
We labour in a sea of uncertainty and confront continuously the failings of our profession – on the back stage.
When patients experience too large a difference between front stage medicine and back stage medicine, trust is lost. Then medicine calls upon the GP to lighten the burden of perfection (25). In the capacity of near-life doctors with continuity of care, the GPs are bound to sober, realistic practice. We are judged by the people all the time. Reality commands us to move medicine's front stage and back stage closer together This contributes to honesty, promise keeping and trust.

Competence
The moral integrity and the personal quality of the doctor are important for trust, but must not indemnify competence, professional knowledge and skills. To preserve trust, we have to be good on the specific tasks of general practice (21,22,26):
• first line medicine, discerning the vague shadows of pre-diseases
• generalist medicine, confronting the total portfolio of human misery and pathology
• jungle medicine, coping with the manifold mysteries of man and society.
• coaching medicine, coaching the patient wisely, safely, through the dangerous labyrinth of medicine

You have discovered now, with pride and joy I hope, that you are the Masters of trust in the house of medicine.
This is the drama of general practice year 2 000: Trust is the fuel, the essence, the foundation of general practice. Trust in general practice is at this very moment, in danger. What to do?
Hitherto, we have done close to nothing. We have been too permissive and flexible (27). We have made general practice compatible with modern trends as if they were Newtonian laws. We have accepted hostile take-overs from the politicians, from the bureaucrats, from the market, from science, at the cost of autonomy and trust in general practice. The last 20-30 years have been a sad story of permanent retreat. And retreat, according to the military theorists, is the most hazardous and difficult of all manoeuvres. General practitioners belong traditionally to the benevolence value type, profiled by helpfulness, loyalty, forgiveness, responsibility (28). So let it be, but it may be timely to read Machiavelli on the exercise of power.
The global market and neo-capitalism will brutalise medicine. We must realise that there is a war coming up out there. Perhaps, we ought to change from scouts to warriors. Perhaps we should bring some iron to our soft souls and fight harder, tougher, for the core values of general practice and their outcome: Trust.
Then we need:

A STRATEGY FOR TRUST IN GENERAL PRACTICE
Professional capital
First, we have to unmask the swindlers claiming that we live:
• in times of unprecedented change
• in times of radically new challenges
• in times where old values have passed their expiry date

This is not true. This is a bluff, sold on the vanity fair of modernity, bought by people without memory and professions without history. In a strategy for trust in general practice, we have to go retro, and define our eternal gold amongst the modern dust. Only in the archaeology of general practice, can we find our basic values with the capacity to carry us into the future (21,22,25,29):
• personal doctoring
• sharing of power
• compassion
• realistic medicine
• competence

These are the diamonds of general practice, and they are for ever. They constitute what Bourdieu calls: The professional capital of general practice. Our teaching, research, clinical practice and policy-making, should aim at fortifying this professional capital.
This is our professional capital deposited in the Bank of Heaven. But general practice is an earthly enterprise. So, how can we make the God particle, trust, work on Earth, in England, on a Wednesday, year 2 000? We must:

Build trust in The new order
General practice ought to redress trust, according to modern styles, - to some extent (3,4,13). We have to submit to political priorities, - to some extent. General practice must accept regulations and control from outside – to some extent. We have to comply with post-modern mentalities, - to some extent. General practice ought to worship the holy market, - to some extent. But only to some extent. General practice must find a wise compromise between modernisation and fundamentalism. We must adjust trust to reality, but we must adjust reality to trust – too. We must not modernise, adapt, obey, beyond trust (17,27).

Oh, what a lovely war!
If the lawmakers, the politicians, the bureaucrats, the health authorities, the holy market, the sophisticated consumers force us, tempt us to devaluate our professional capital, to betray the very basis of trust in general practice, then we must stand firm and declare: "Oh, what a lovely war!".
In the war for trust we have two allies, the market and the people.

Join the market
• La grande epoque, when general practice survived by social heritage is passe. In the future the to be or not to be for general practice will be determined in the market place. The market is conquering the world, superseding politics, colonising mentalities. We cannot fight it, so let us join it. We do have a product that sick people demand desperately: Medical trust embedded in personal doctoring. Trust is the very trade mark of general practice. So let us polish our gold particle, make it shine on the holy market place, give people an offer they cannot refuse: Trust. Let us brand trust, sell trust, aggressively.

Therapeutic alliance with the people
The ultimate ally for general practice in the battle for trust, is the people. Our best clinical instrument is the patient-centred method, based on trust in the patient (30). Our best political instrument remains to be forged: The people-centred method based on trust in the people. In times of trouble, personal doctoring is not enough, we must engage in political doctoring too. Our experience from the consultation room: Ally with the patient, should be extrapolated to the societal level: Ally with the people. In times of trouble, we should ally:
• not with the biomedical meritocracy
• not with the economic plutocracy
• not with the political hypocrisy,
but with the people.

This is what James MacKenzie experienced as a general practitioner in Burnley for fifteen years, always praising the sterling quality of its people (16): "Boom and slump, poverty and unemployment during the 19th century may have dimmed, but had certainly not extinguished their vitality, and the ardour of their spirits. Kind, simple, blunt, but transparently honest, they imparted to the stranger an immediate warmth and friendliness. Fate or fortune had brought a Scots doctor to their midst. MacKenzie was at home".
Colleagues, for the sake of trust, for the future of general practice, let us follow James MacKenzie, and go home, - to the patient, to the people.

REFERENCES
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Adress for correspondence
Per Fugelli, Institute of general practice and community medicine, University of Oslo, PO Box 1130, 0317 Oslo, Norway. E-mail: per.fugelli@samfunnsmed.uio.no

 

 

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