Honesty. Integrity. Truth.
In a world which has moved from ‘being economical with the truth’ and using spin doctors to full blown ‘fake news’ and ‘alternative facts’ are words like these old fashioned and outdated or, at best, naïve? Or do we, as medical professionals, jealously guard this principle of truthfulness, enforce it effectively and, most importantly, teach and nurture it in our students and junior colleagues. Can we be sure that the old cliche ‘Trust me, I’m a doctor.’ is still applicable in our present reality?
Trust Me, I’m a Doctor.
Trust underpins who we are as doctors. We can talk all we like about autonomy, justice, beneficence, and non-maleficence, create guidelines around confidentiality, consent and shared decision-making but none of it means anything if our patients don’t trust that we believe in and will uphold those ideals. Trust is everything.
So if trust is so important, is it something that we just hope doctors have? Do we select the most trustworthy people to train and hope that they all have, and will maintain, George Washington’s fabled tree chopping sense of honesty? Or, do we accept that we are all flawed, all prone to wander from the path of truth and that we need to teach, train, correct and support each other through our careers?
In a radio programme on the BBC, Matthew Syed spoke candidly about an occasion of his own dishonesty during the final of a national table tennis competition. I’d encourage you to listen to him tell the story yourselves, it only lasts just over two minutes, and you can find it here.
What can we learn from Syed’s story? How can we apply his experience to our situation? Here are five lessons I’ve taken from it:
1 There is a culture of real honesty at the highest level
He sets the scene by explaining that top players admit they have lost a point, even if the umpires have missed it, even if their opponents have missed it. We see that real honesty, costly honesty, isn’t about admitting what everyone already knows, it is about admitting what others have failed to see. Not only that, this form of honesty has become the cultural norm and to break from that norm is considered taboo.
Do we have such a culture in medicine? Do we hold honesty up that highly? Really? My perception is that we certainly discourage dishonesty strongly but when it comes to real honesty, when reality bites, truthfulness can often take a step aside for pragmatism and many of us are far too comfortable with the concept of ‘getting away with it’ rather than owning up, even to ourselves.
2 Mentors matter
For a culture like the one described to survive, it must be continuously upheld by those entering in to it and they learn from those already there. Syed describes his relationship with his mentor Desmond Douglas, an older, more experienced player. Douglas shared his life with Syed, opened his home to him and trained with him and, through this relationship, Syed gets to see how highly his mentor values honesty. How does Syed know how to behave at the table tennis table? Is it because he has occasionally seen Douglas call a point in a big game? No, he understands because he has seen Douglas behave like this in every training game, every match and even in his life beyond sport.
We need to understand the impact our behaviour, not just professionally but personally, has on our colleagues, particularly our juniors. It is important for them to see us value truthfulness in all we do at work, how we code patient attendances, speak to staff or behave in meetings but also that we are truthful in our personal lives too. Don’t kid yourself that you can behave one way at home and another at work, you can’t, or that you aren’t really a role model. Everyone is a role model, either a good one or a bad one… so be a good one!
3 Pressure can alter our behaviour, even when we know it is wrong
I’m sure that Syed considered himself to be an honest player, someone who upheld the culture he had become a part of…and yet, when the pressure was on, he cracked. Despite knowing what he was doing was wrong, knowing it was going against what he should stand for, he chose to lie. What were the factors involved? Was it a desire for achievement, the chance to beat his mentor for the first time? Was it pride, not wishing to lose as the defending champion? Or was it the enormity of the situation, the deciding game in a national championship? Whatever it was, it was enough for him to overcome his desire to maintain that culture of honesty.
What are our pressure points? What is it that we value more than the principle of honesty in medicine? Maybe it is what others think of us, perhaps our pay packet or the desire for career progression, whatever it is, we need to be honest with ourselves about this, feel the strain on our integrity when these areas are threatened, and be prepared. We need to be ready for that occasion, and it will come, when we are tempted to put our own desire above our professional obligation and to act appropriately.
4 Dishonesty must be challenged…particularly by colleagues
Following his dishonesty, Syed is first challenged by Douglas himself and then by another member of his team, a long standing, respected friend. Douglas could have accepted the situation, ‘played to the whistle’ if you like but he didn’t. Perhaps he was motivated by self-interest (personally I think this is unlikely), after all he would be awarded the disputed point, but there is no doubt when it comes to the challenge from another friend who says:
“Look Matthew, I don’t want to allow you to do this. You know that it touched.”
This firm, clear and yet gentle statement shows concern for the perpetrator of this wrong doing and appeals to their sense of truth. It shows an understanding that this behaviour is out of the ordinary, is driven by a fleeting desire that will pass and will ultimately result in long term pain. Whilst it was clearly embarrassing for Syed I’m sure it was very difficult for his friend to do… but he did it because it needed doing for the sake of the honesty culture and for the sake of his friend.
We too must be willing to challenge dishonesty, particularly in our closest colleagues, out of concern for ‘what is right’ but also out of concern for the colleague in question. We need to be understanding of what is driving their behaviour and give them the opportunity to reconsider the situation, their behaviour and their priorities. Sometimes, when it gets hard, we just need to help people do what they know to be right.
5 Forgiveness is necessary
Having finally admitted to the truth Syed is allowed to continue playing, the match concludes and he is crowned British champion. This may seem unfair to some but for a culture of true honesty to exist it must go hand in hand with one of forgiveness. Had Syed been defaulted for finally admitting the truth would he or other players looking on have been more or less likely to admit the truth next time they found themselves in a similar situation arose? Would it have helped the culture of honesty or hindered it?
If people are afraid of being honest because of the risk of sanctions, some may try harder to be honest but it is far more likely to drive people to cover up rather than admit their mistakes, the exact opposite of what we are trying to achieve. We must be quick to forgive, even when people are slow to confess, not because we are pushovers or because we don’t think honesty is important but precisely because we DO understand the value of honesty and want to encourage it. When colleagues admit their mistakes to us we must meet their decision to be honest positively. We must be prepared to support the individual in forgiving themselves, helping them to come to terms with their weakness and understanding why they behaved as they did. Ultimately there may be disappointment, reeducation or disciplinary procedures required… forgiveness does not mean there are not consequences to be borne… but these should come after a clear and continuing response of support for the decision to admit their failings.
Honesty. Integrity. Truth. We must continue to value, uphold and encourage these ideals at every level. The desire of medical students to please a senior member of staff, to ensure a form is filled in or to avoid being caught missing a tutorial may outweigh their embryonic understanding of why honesty in medicine is so important. We must challenge this and educate them on the importance of integrity in medicine. When junior staff offer a clinical presentation that seems hesitant around certain facts or shaky under questioning, we must explain that admitting their ignorance or failure is more important to us than trying to bluff their way out of the situation. And as senior colleagues, we must be prepared to challenge each other through all areas of our practice, clinical, educational or managerial and be prepared to receive such challenges as well because we know that it is not only good for us, it is good for our juniors, our patients and our profession.