Personal View: The relief of communication
Authors: William G Pickering
Journal: BMJ (2006)

Even in the best of medical hands communication can be incomplete. Some time ago an acquaintance, knowing I was medical, told me that she had discovered a problem in her breast and had made an appointment to see the general practitioner. She added that she had been aware of it for some months, and asked if I thought she had been silly to wait, to which I replied evasively that I was pleased she was now seeing someone about it. This was the first of many questions she had for me.

Her “very nice” GP, of whom she had apparently asked several questions, which had been sympathetically answered, saw and referred her promptly. Within three weeks she had seen a surgeon and reported that he too was “very nice, and I liked him.” She unhesitatingly used the word cancer, although she did not say whether or not the doctors had used it; nor did I ask. “I think they have been very good to me,” she kept saying, and she meant it. The biopsy was followed by plenty of questions during the eight day wait for the result.


The internet, handouts, and even careful formal medical explanation do not replace a tailored human response


As it turned out, a mastectomy rapidly followed, for which she knew the reasons well enough. The hospital was “very good,” the surgeon comfortingly saw her just before her operation, she recovered without problem, the breast nurse was exceedingly helpful and available, and upon discharge from hospital she had not a grumble in the world. She was given a phone number if she had questions or problems (“I don't like bothering them, though”). She and her family felt that she had received first class treatment and support.

What was striking, however, were the many questions she asked me during these events. She had already asked the people mentioned above several of them (and she told me their answers). There were other questions that had not occurred to her at the time, and still others that she felt, for one reason or another, she could not ask—for example, “Do you think they got it all away at the operation?” Her reports strongly suggested that all the medical people had done their best with their answers—but notwithstanding, she demonstrated how in medicine, as in life, one answer or one afterthought can lead to more questions, especially with catalytic anxiety fizzing around. Such questions at such times are seldom trivial. And asking the same question of another person is not unique to patients—it is a feature of worry and fear.

Some issues mystified her, including the function of the biopsy and its relevance to subsequent treatment; and the questions “how big was the cancer and did they get it all?” and “will it have spread?” The significance of the removed tissue at operation, discussed carefully by the surgeon postoperatively and at follow-up, remained a puzzle to her. “What can they tell from that?” “Why did they have to use a microscope?”

It was interesting to be a medical spectator and translator. Her additional and sometimes repeated informal questions only underlined what many doctors know already. With the best will and personnel available, patients still often need different information than they get, and even that which they receive is frequently not fully assimilated in the concentrated and fretful clinical circumstances.

Nurses pick up the medical pieces often enough and some learn to re-serve them in digestible, nourishing form. The internet, handouts (“About your operation”), and even careful formal medical explanation do not replace a tailored human response, but the latter is, of course, not invariably available, either at the time it is sought or on the neutral nonmedical turf where it is perhaps better absorbed.

When all the boxes are ticked (these days), when clinical practice has been impeccable, there is a fair chance that the patient may still be overflowing with ill understood answers and unasked questions. It is often impossible to ensure that patients comprehend medical issues. One wonders, however, whether it is the anxiety-dissipating opportunity to ask the question, often more than once, that is therapeutically as important as the answer.

I roughly calculated the time taken for her to put her queries, and for me to reply— around 10 minutes, certainly no more than 15. Although there were many, they came episodically, not torrentially, spread—one or two a day over weeks, on easy home ground, and they often took a mere sentence to answer.

The woman has not asked any more questions and sometimes seems to have nearly forgotten about her treatment. Constitutionally tough and forward looking, her apparent peace of mind may have resulted from her excellent clinical management alone. Additional informal explanation and communication may have been superfluous to her recovery. Who knows?