In a December, 2011 Health Affairs Narrative Matters piece, Maran Wolston describes a nightmare. Diagnosed with a serious illness (MS), she seeks care from a clinician-scientist at the forefront of the field (who is not named). He recommends some invasive and high-risk drugs, including a clinical trial. After suffering through one course of his recommended therapy, she begins to feel uneasy about his advice and does some homework. She discovers that manufacturers of drugs he recommends have paid her doctor hundreds-of-thousands in speaking and consultation fees. Ms. Wolston wonders if the doctor recommended invasive treatment because it was best for her or because it was best for the companies who pay him. Eventually, she transfers her care to an unconflicted doctor she can trust.
How do we trust our doctors and healers? As sociologist Talcott Parsons pointed out long ago, we’re vulnerable when we’re ill, we turn to experts for healing and support, and we need to be able to trust those experts. Trusting is fundamental, not a nicety.
Ms. Wolston’s experience taps into our fear that doctors may follow orders from pharma paymasters instead of listening to patients. The data we’ve collected so far in the patient deliberation study suggest it’s far from that simple. The academic experts we study often “like” a particular drug before it has been fully tested. They may even prefer a drug because they like the biological pathway it uses to attack cancer. What if Ms. Wolston’s doctor didn’t listen to her because he believed in the treatment he recommended not because he wanted the money from pharma?
We trust doctors because they’re the experts, but their expertise can undermine our ability to trust them. Talcott Parsons focused on the first part of this equation, arguing that the medical profession needed to have independent expertise precisely so we could know they’re not corrupted. If doctors build and maintain their own storehouse of knowledge, they can do what’s best for patients rather than shill for particular remedies. Paul Starr’s social history of American medicine describes how doctors used their expertise in human biology to establish themselves as a trustworthy caring profession. But expert knowledge can corrupt human relationships just like money or power. The medical profession, having established itself as “the expert” on human biology, must defend its claim. In the patient deliberation study we see doctors (and nurses) struggle as their desire to be a caring profession runs up against their need to be an expert profession.
Let’s stop drug companies from trolling for company shills; such shilling may well have caused Ms. Wolston’s pain and suffering and that’s despicable. But let’s not pretend that ending pharmaceutical shilling will repair breakdowns of trust in contemporary medicine. David Mechanic has a thoughtful essay on the erosion of trust, and he suggests a number of things that can be done. It’s worth reading.
That said, my gut tells me that Mechanic’s suggestions — which focus on changes in the healthcare system — don’t get to the heart of the matter. I’m thinking that larger, structural changes in the kinds of knowledge medicine considers its “expert domain” are needed. My UCSF colleagues Molly Cooke, David Irby, and Bridget O’Brien have suggested some reforms in medical education that seek just that. If doctors make listening a more consequential part of their core knowledge, it might make it easier for the profession to temper its excitement over new treatments and it might make it easier for patients to trust them.