In hospital medicine, long term relationships with patients are rarer than one might expect. During training (which lasts until your mid-30’s, and even longer for those who prevaricate!) it is unusual to stay in one Trust for more than a year. Becoming a consultant allows such relationships to develop, and this adds a depth of understanding and reward that cannot be experienced as a trainee. These are with patients who have chronic conditions, who attend clinic regularly, and who are occasionally admitted to the ward with complications; they comprise a small number compared to the thousands of ‘one time only’ interactions that take place each year. The irony is that while familiarity leads to trust and sincerity borne of shared experience, it is the fresh, short term clinical contacts that present the gravest clinical and emotional challenges. In these circumstances doctors must learn how to fast-track the communication strategies that will have already developed when meeting a long term patient. The classic example is talking to the patient with a new diagnosis of cancer.
In my mind breaking bad news follows a U shaped dynamic; constructive, forward planning allows the patient to be lifted from the despondency into which the word ‘cancer’ will have dragged them. By talking about what can be done, who they are likely to meet, resources and timescales…glimmers of hope may begin to permeate the gloom, and the certainty of death is diluted. The presence, ideally, of a cancer nurse specialist, reassures them that there will be continuity and reciprocal contact. Together we talk about the support that will be available, and the priority that will be given to their case.
But it is here that the limited nature of my role as ‘first contact’ begins to become clear. For however empathic my style, and however embracing my words, I know that I will have very little do with what happens from now on. As the patient (and family members, if present) look at me and the intensity of the situation burns its way into their memory, I know that it is not my face that they will be seeing in clinic. It will be that of the oncologist, or the surgeon (should the tumour prove operable). Already I am beginning to deflect responsibility to others – ‘the oncologist will talk to you about that…’, ‘they will decide if you should have surgery in a special meeting, the MDT…’ ‘You’ll get an appointment very soon to see one of the lung doctors…’
Sometimes you do meet the patient again – if they become acutely unwell. This might be due to chemotherapy induced bone marrow suppression and sepsis, an inter-current pneumonia; anything that requires admission via the ED. They might just happen to be admitted when I am on call, just as they happened to come in under my care the first time. There may have been an interval of two months. She looks worse. You read the notes, and catch up on all that has been going on. Appointments here, procedures there, PET scans, problems… You wonder if any of the things you said came true. Did the oncologist discuss prognosis with you – did you ask him the ‘big’ question (‘How long?’) that you asked me? Did the appointment come through? Did you wait too long? Did the nurse specialist call you to keep you informed? So much has happened since that first shocked conversation by the bedside, curtains drawn, your husband leaning forward, staring at the tops of his shoes mutely…the day I broke the news and tapped into your deepest fears.
It is not possible to remain involved in every patient’s journey, especially when their illness falls outside our own area of expertise. The best we can do, it seems, is deliver the first message skilfully and with conviction, while hoping that the promises we offer are realistic, and the undertakings we take on behalf of our colleagues are achievable. Beyond that, we cannot realistically hope to observe their progress or influence their experience. Trainees on the ward soon experience emotionally intense interactions that seem to be over just hours or days after they have begun. A working week might involve many such micro-relationships, and learning how to move nimbly – but not too smoothly – through this gauntlet of emotions is hugely important.
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