Scene from the play Two Rooms
Doctors speak several dialects, and the contrast between that used with patients and that used with colleagues can be stark. I sometimes wonder how patients would react if they heard every conversation that concerned them?
Such a notion seems absurd, practically, though they surely have a right to such access. We have already been through a process of openness with letters, which used to be sent to GPs but not patients. There was a vogue to ask patients if they wanted to receive them, and now patients get them automatically (in my experience anyway). This has caused a change in the way letters are written, such that doctors tend to avoid opaque medical terms and provide more accessible explanations. Personally, I still write in a ‘doctor- to doctor’ way, as the GP is the primary recipient, but I know that if I use lots of acronyms or eponyms the patient will a) be excluded from the thought processes behind their management and b) likely to hold up a highlighted copy when I next see them in clinic.
But back to the conversations. If there is a suspicion of cancer, for instance, it is common to discuss a patient’s condition and scan results in a multidisciplinary team (MDT) meeting. MDTs are designed to bring the opinions of several specialists to the table, for example: surgeons, oncologists, specialist physicians, nurses and dieticians. Some of these meetings go on for hours. Cases may require prolonged discussion, and can become heated if opinions are not in alignment. But other cases are easy, because it is clear that nothing to be done. The liver may be overwhelmed with infiltrates of cancer. Conclusion: no treatment options – palliative care only. Somebody might say, ‘Hopeless’. They are not being heartless; they have never met the patient. But it’s just true. Next patient. It may have taken no more than a minute to reach that conclusion. It is medicine at its coldest and at its most efficient. Time will be spent on the ones for whom there is a therapeutic option, a chance of cure or prolongation.
As soon as practically possible the patient is seen and the results are communicated to them. We move to the second room. As much time as necessary is taken to break the news, and, if done well, the scene will demonstrate medicine at its most compassionate. What a contrast.
If the patient had witnessed the MDT discussion they may well have been sickened by the speed with which their case was dismissed. What about all the other details? Their wishes, their social situation, their feelings… but no, those aspects were not relevant. It was, to be brutal, a technical decision. Too advanced for surgery; too frail for chemotherapy.
Each discussion has a distinct purpose, and each requires a different set of medical skills. To perform well in each environment a doctor has to adapt. Engage emotionally when required, but remain objective, scientifically accurate and evidenced based at other times. To bewail the lack of a more holistic discussion in the MDT would not be appropriate – it would not meaningfully contribute to the decision, and it would hold up the flow. The doctor or nurse in that meeting who actually knows the patient might find it too cold, and might experience a degree of dissonance as everything they have learnt about this unfortunate person is shorn from the presentation. But, come the face to face meeting, all those details come back into play, and are, of course, essential.
What does this contrast tell us? It suggests to me that there will always be a place for compartmentalisation. The modern, post-paternalistic culture, perhaps best summarised in the phrase ‘no decision about me without me’, seems to reach a limit in circumstances where highly focussed and specialised discussion must take place in a clear, unemotional atmosphere. MDT meetings are a necessary but, at times, somewhat surprising throwback to the sacerdotal, impenetrable practice of medicine in centuries past.
Click icon to explore paperback, or here for ebook