Trust me, I'm a communicator

A medical degree, according to George Bernard Shaw, is no substitute for clairvoyance. We can never eliminate the insecurity of medical uncertainty, which is precisely why we need trust.1 In the paternalistic model of consulting, doctors are accorded blind trust and in response take the emotional ‘hit’ for their patients' uncertainty. In the new model of shared decision making, professional trust has to be earned through honesty about the limits of medicine and the unpredictability of illness. But sharing uncertainty requires skilful communication to avoid the ultimate irony of truth undermining trust.

Absolute truth may be an egalitarian ideal but it may not be practical, or indeed desirable. As Mendel argues:

‘Whilst hypocrisy is odious, it is absurd to go to the other extreme. Role-playing, with its inevitable less-than-complete truthfulness, is an integral part of the art of medicine’.2

Nearly half a century ago, Balint observed that the doctor's attention is a potent prescription,3 a view later echoed by Blau:

‘The doctor who fails to have a placebo effect on his patients should become a pathologist or an anaesthetist … In simple English, if the patient does not feel better for your consultation you are in the wrong game’.4

Although this is undoubtedly unfair to today's anaesthetists and pathologists, the concept of ‘doctor as drug’ is as relevant as ever. The challenge is whether, and how, we can retain our placebo …