‘Trust me, I am a doctor’, is a statement that today is used more often than not in a joke or else as a sarcastic reflection on the utter untrustworthiness of doctors. But there was a time when most patients actually trusted their doctors and doctors also respected their position as people deserving that trust.

Even though the relationship based on mutual trust has eroded considerably, most ‘polling data’ in the United States (US) suggests that the general public still ‘trusts’ their doctors at least more than other professionals. From a personal perspective, I can say that over the last forty odd years that I have practiced medicine in the US and in Pakistan, I have indeed seen some deterioration in the ‘doctor-patient’ relationship.

The word ‘doctor’ as well its Urdu counterpart ‘hakeem’ have always represented wisdom. Even today, the highest academic degree awarded is a ‘doctorate’ in any subject. So, from a historical perspective, practitioners of the ‘art and science’ of medicine were always held in great esteem. And to be a doctor was an honour bestowed upon a select few.

Perhaps the eminent position of doctors or, in the context of this discussion, physicians was established by the ‘Hippocratic Oath’ that imposed important constraints on how a physician behaved toward patients as well as others. Here I wish to append the original Hippocratic Oath (Wikipedia) so that my readers and others that are always referring to this oath know what it said.

"I swear by Apollo the healer, Asclepius, Hygeia and Panacea and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; to look upon his children as my own brothers, to teach them this art; and that by my teaching, I will impart a knowledge of this art to my own sons, and to my teacher’s sons, and to disciples bound by an indenture and oath according to the medical laws, and no others.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will give no deadly medicine to any one if asked, nor suggest any such counsel; and similarly I will not give a woman a pessary to cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all humanity and in all times; but if I swerve from it or violate it, may the reverse be my life."

Every time the Young Doctors Association (YDA) went on strike and closed down different hospitals in the Punjab, the Hippocratic Oath was brought up to condemn such activity. Obviously, all those that brought up this oath had never read it and did not realise that it does not say anything about being forced to take care of patients or whether physicians have a right to expect proper treatment as workers in a healthcare bureaucracy.

But then that is typical of our media. Fact checking is just not the ‘done thing’ and is evidently beneath the dignity of most ‘editorialists’. Clearly, the Hippocrates Oath like all other ‘ancient’ writings is not very relevant in modern times. Hippocrates or rather his oath does not address the evolution of medical care from a relatively primitive mixture of observation and mythology to its modern scientific form. And the patient’s trust in a physician was always an important part of any successful medical treatment.

This relationship of trust started eroding many years ago. When I started working in the US, I was referred to as a physician. However, this changed over the next two decades and instead of a physician I became a ‘provider’ of healthcare essentially not much different, except in qualifications, from a nurse or even a hospital orderly.

Obviously, all members of a labour force have important roles to play. Having worked in the Pakistani healthcare system for almost a decade, I can say without any hesitation that if the ‘sweepers’ go on strike, a major hospital like the Mayo Hospital in Lahore will be forced to shut down!

That might be true but then patients come to a hospital so that the physicians can take care of them. And for all practical purposes the physician sits at the top of the healthcare pyramid. As I said above, the physician is now considered as just another healthcare provider. For most patients today, in the US or in Pakistan, physicians are essentially providers of a service for which they get paid.

As a physician, if I am going to be treated by my patients as a businessman than should I not behave like one? Must I then not expect a reasonable ‘financial’ return for my medical expertise? Sadly, once medical care becomes a financial arrangement; ‘trust’ becomes a casualty. And yet without some level of trust, a doctor-patient relationship cannot survive.

When we buy a kilo of tomatoes, we presume that the tomatoes are OK but we can look at the tomatoes and make an independent judgment about their quality. Same might be true of other financial transactions where the end point can be assessed. That is the difference between buying tomatoes and undergoing heart surgery. If you don’t like the tomatoes, you can throw them away, but if you don’t survive the heart surgery, the ‘ball game’ is over.

That is the problem of money and medicine. If you pay enough you can buy the best of most material things but you might think that money will buy you the best in medical care and you just might be wrong. As a physician I can say without any reservations that a patient will get better care if he or she trusts the physician and does not think of it just as a transactional relationship.

But trust is a two-way street. The physician must also inspire trust by providing the best possible treatment and by limiting the cost of treatment to a reasonable level. The best money can do is take you to a physician who has the reputation of being good but that does not assure that you will do as well as you expect. And money cannot buy trust.