Caring for Fatima
Authors: Terence G. Sparling
Journal: Journal of Clinical Oncology (2006)

When I first began to practice and to teach oncology 30 years ago, I realized that knowing something of the disease itself was not enough. Of equal importance was the ability to develop rapport with my patients. A good rapport leads to trust and a trusting relationship encourages compliance with sometimes difficult treatments. It became clear to me that patients needed to know that their oncologist cares about them and that they are important. This relationship that I achieved with my patients has also provided me the satisfaction necessary to carry on working in this area of medicine. I learned that there were many ways to establish rapport and to gain trust, and I understood that the ability to achieve these goals was integral to a successful career. There are ways to convey these thoughts and feelings and, unconsciously, good physicians begin to develop these tools as time goes by. This is not to say that caring about your patients is not genuine—it must be. The skill used in conveying feelings and developing the right working relationship with the patient is learned and requires time and experience. What are the techniques used to develop such a relationship? In Western culture, where I previously worked, care is expressed by a firm handshake, eye contact, a smile, a reassuring touch, or perhaps a prolonged private visit in the office with a lengthy and personal discussion of the problem. To determine whether I was succeeding, I read body language and facial expressions and listened for nuances in our conversations. Then I moved to the United Arab Emirates and began to look after a population of Muslim patients. This change in my life has given me occasion to think long and hard about all of the techniques I had used in building rapport, and to re-examine them in the light of a different culture. I had worked previously in a multicultural environment but had never been so wholly immersed in a culture as distinct and different from my own. Fatima was one of my first patients. She was 30, a mother of six, and had breast cancer. She arrived in my office with three sisters and her older brother. On my side I had a translator and a nurse. So, the eight of us sat down to talk. “Which of you is Fatima?” I asked. As is the custom for some Muslim women, each was completely covered in a black abaya, a head covering called a shaila, and a black facial covering called a burka. In addition, each sister wore black gloves and long black stockings. The temperature outside on this bright August morning hovered at 48°C (118.4°F) and the humidity was a touch higher than 90%. The brother answered. As the oldest male he is the most important decision maker in the family and is responsible to the family for all that happens. They hold him responsible and he holds me responsible. “This is Fatima,” he said in Arabic to the translator and then to me, in perfect English, “She does not know that she has cancer and you must not tell her. We have told her that she has an ‘inflammation.’ This is what you must tell her.” Now I was expected to participate in this deception. I held out my hand to Fatima and she drew her hands away quickly. In this part of the world women do not shake hands. I would learn this lesson repeatedly, and then be much surprised when a woman would eagerly hold out a hand to be shaken. I was now starting to wonder if I was in over my depth with Fatima. There was not one square inch of this patient that I was able to see. I could not even distinguish her from her sisters. Under her voluminous abaya it was very difficult to read her body language and I was unable to see her face or her eyes to understand the effect of anything that I said. I also knew that direct eye contact here was regarded as being suggestive or forward and I must avoid giving offense. If I touched her hand as a simple reassuring gesture, this also may be misinterpreted. Negotiations began with the eldest brother. He is a powerful family figure. In some situations he may take precedence over the husband in the decision-making process. Fatima’s husband did not come to this visit. He has another wife and he had become more distant. I sense that she was not able to look to him for support. This unfortunate circumstance is not always the case, but I see it from time to time in my practice here. From the Division of Medical Oncology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.