DOCTORS HAVE RECEIVED PLENTY OF criticism for not knowing how to communicate. The brunt of the problem is borne by patients, who frequently feel that their clinical care has been adversely affected by this deficiency. But there are also dangers associated with doctors not being able to communicate effectively with each other. Information can be misunderstood or lost. More crucially perhaps, the chain of command, which relies on junior doctors being able to seek advice from their seniors, can break down. For these reasons, a lot of time is spent teaching qualified doctors how to communicate better. And no surgical training course seems complete now without time allocated to this task.
In a recent communication skills tutorial, I recall witnessing just how poor the interaction between two doctors can be. Miss Ngozi, one of my attendings, was teaching. We were ten surgical residents, and we were halfway through an afternoon of role play. Each of us was to be given a scenario testing our ability to communicate properly.
The general standard of performance had been bad, and I was keen to have my turn before the intensity of peer ridicule rose any further. But there was still one person in front of me, Asim. This cocky young surgeon now rose to his feet, rolling white linen sleeves up over his handsome brown arms as if he was about to spar. From a piece of paper in his hand, he read out the details of the scene he was to enact.
âYou are the surgical resident on call. You see a patient with acute mastoiditis who needs emergency surgery, and you do not feel equipped to perform it without senior supervision. Please call your attending at home and ask him to come and assist you.â
One of the actors employed to help in the course stood up, but Miss Ngozi gestured for him to sit again, indicating that she would play this part. I wondered whether she too had been irked by the scripted assumption that the attending would naturally be male.
With a perky little shake of her tailored shoulders, a pinky pursing of the lips, she got into the role. And I was struck yet again by her beauty. Age cannot wither her, I thought, warming myself up for thespian action. She was wearing an impeccable trouser suit and a white blouse. By her feet sat a perfectly proportioned briefcase, like the receptacle in which Paddington Bear carries the marmalade sandwiches he cannot fit under his hat. It had sharp corners, but its surface was the alluring hard softness of a babyâs forehead.
Returning to the scene in front of me, I saw that Asim had taken up his position at the center of the circle of his viewing peers. But despite his confidence, he seemed uncertain of how to step into the world of make-believe. Miss Ngozi kept her seat, a boss at the end of a witching-hour phone line. And she started the skit off by trilling out the ring of an old-fashioned phone three times. She then lifted an imaginary receiver before saying hello in a sleepy voice. This set a few of us twitching nervouslyâit seemed such a private, bedroom tone.
In a lower, posher voice than his real one, Asim began, âI am very sorry to disturb you, madam. This is Mr. Choudry. I am the resident on call tonight.â Without waiting for a response, he began to describe the clinical situation written on the chit in front of him, adding extra details to give a fuller surgical picture. But what he did not do was ask for help.
I sensed Miss Ngoziâs impatience. She started to tap her pointed shoe on the ground and gave an ostentatiously huge, fanning yawn. I am sure she did this semihumorously, but Asimâs tone was irritated as he responded with, âThe fact of the matter is that I need to take this patient to the OR,â to which she immediately quipped, âSo why donât you, then? Are you saying that you canât do this yourself?â
âNo,â he replied, drawing this word out. His head was tilted down, but his eyes sought Miss Ngoziâs from under impressive brows. The arrangement of his lips and teeth looked more like a bite than a smile as he said, âI am in fact quite capable of doing this myself. I just wanted to inform you that this was my intention.â
Miss Ngozi had had enough. She tossed her clipboard down onto one of the plastic chairs with what I expected would make a slapping sound but in fact made a clatter. She started, and several of us jumped with her. Then she sniffed peremptorily and took the center of the circle. With one of her slim arms, she gestured that she wanted Asim to resume his seat among the rest of us.
âThank you, Asim.â She smiled at him directly and approached him on soft, quiet feet, no angle on her glance or her beauty. She went nearer still, and just as she came within a foot of a young man who no longer looked proud of himself, she returned to the middle of the circle. And then, taking us all in, she pronounced, âAsim may be the first junior resident I have ever known who is capable of performing a cortical mastoidectomy unassisted, but he is not the first to overestimate his own communication skills. What he missed was that this scenario was asking him to ask for help. It is critical that you all become proficient at knowing your limits. These arenât the dark ages in which I did my training. Ask your attending for help and you will get it with no fight. Okay. Whoâs next?â
Watching this scene unfold, I had been struck not just by the importance of learning how to ask for help directly and Asimâs failure to do this, but also by my observation that the words exchanged between these two had made up only a small part of their overall interaction. And this had reminded me of a time, not two months before, when I had asked a different attending for help, and had found a subtext to our conversation too.
On the night in question, I was on call from home and had been asked to come into the hospital by one of the junior doctors to see a man who had swallowed a piece of glass. It is part of normal development for children to experiment with putting beads or bits of Lego into the nose, ears, or anywhere else they will fit. As I listened to the story from my bed I wondered if certain adults never evolve through this stage. Every medic I know has a list of bizarre foreign bodies they have removed from adult orifices. In my case, this includes a carrot and battery inserted into the rectum, a Bic pen pushed under the skin of the forearm, and a candy, still in its wrapper, that one patient had lost inside her own vagina.
Arriving at the hospital, I found my patient was unpleasant. Mr. Smith, a big fat sunburned man, was in majors because of the sharp nature of what he had swallowed. He was sitting sideways on the bed, despite the attempts of a nurse to get him to lie back. His arms were held in what looked like a body-building curve, slightly away from his torso, and his jaw had a pugnacious, almost prognathic set. A tattoo on one forearm, written in a bizarrely calligraphic font, read, âHating.â And although the print was blurred, suggesting the body art had been there for some time, the expression on Mr. Smithâs face showed that the sentiment still had strong currency.
I introduced myself overbrightly, a gesture of optimism before receiving what I instinctively knew would be a rough response. My patient offered no name or handshake, merely stating, âTook your bloody time, didnât you?â He then made a show of looking me up and down before letting his eyes rest intently on my ID badge. âYou are a doctor, arenât you?â
It is important not to become preoccupied by dislike for a patient, because doing so can mean you miss things. And I have found that the best way to handle people like Mr. Smith is to be extra polite to them and absolutely correct. Nonetheless, I didnât want to acquiesce with so much as the word yes, so I simply reintroduced myself again by name and position. I then added that I needed to make sure I had the important facts right. That he had swallowed a piece of glass and could feel it sticking in his throat.
Aggressively, and in short sentences, he told me his story. He had been in the pub. He had had a few, by which he meant ten pints. He had noticed an old rival on the other side of the room. When he went to take a leak, he spat in the manâs beer. When he came back from the bathroom, this other man came around the bar with a beer bottle and smashed it against one of the walls in front of Mr. Smith. The glass base of this smashed bottle landed in Mr. Smithâs nearly empty pint glass of beer, with what my patient took to be an insulting splash. So Mr. Smith looked his foe in the eye, picked the glass up, and downed its contents, ostentatiously swallowing the piece of glass with his last beery gulp. The other guy then retired to his seat, and Mr. Smith got a bus to the hospital.
Examining my patient revealed little of note other than some mild tenderness when I pressed his thyroid cartilage. I stood behind him to palpate the rest of his neck and looked down on the childlike rolls of skin on the back of his shaven head. This part of him made him seem almost vulnerable, but I was reminded of his general animosity by the fact that I could see him holding his hands just above his lap, as if poised to grab an assailant. As if I myself might be seized at any moment if I examined him too thoroughly or crossed some undefined line. By talking Mr. Smith through each part of the brief examination as I reached it, I hoped to soften this threatening atmosphere.
What didnât show on examination was plain to see on the neck X-ray that my junior had organized: a circular piece of glass at the level of the thoracic esophagus. Removing this obstruction would require a general anesthetic and the passage of a rigid esophagoscope into Mr. Smithâs gullet. I knew that this was a dangerous procedure and that I was not prepared to do it myself. The scope is rigid, the food pipe soft and easily torn. And a tear can be fatal.
As I was thinking these thoughts, I recognized the cardiothoracic resident sitting a little way along the same bench, writing in a patientâs notes. I knew he was much more experienced than me, so I thought Iâd show him the X-ray and tell him about my patient. As it turned out, I was very glad I did, because he pointed out that we would need a cardiothoracic team on hand in the OR while performing this esophagoscopy. If the glass lacerated any major vessels as we were pulling it free, they would need to be there to do an open thoracotomy and repair any life-threatening damage.
I was thinking what an idiot the patient was to have caused all this trouble, and also wondering how I was going to lure my attending in from home to help. On call that night was Mr. Graham, a fit and creepily handsome man in his fifties with gray hair and a silver tongueâa foxy favorite with the secretaries. He had a reputation among the residents for being incredibly hard to summon. An old-school surgeon, he had trained at a time when senior residents were able to handle most surgical emergencies and was squarely unimpressed by how often he was asked to come in. Rumor had it that he sometimes simply turned off his mobile phone.
As far as the task at hand was concerned, there was no doubt I needed help. I had removed one ten-pence piece from a childâs throat under attending supervision since becoming a resident, but otherwise had no experience of handling the potentially hazardous esophagoscope in an emergency setting. I definitely needed Mr. Graham alongside me if I was to free the glass from Mr. Smithâs insides. With this in mind, I asked the switchboard to call him and was relieved when, after waiting out a few rings, he answered. I began by introducing myself and stated clearly that I needed him to come in to help me in the OR. And then I went back to the beginning of the history, to tell him about Mr. Smith.
But before I could get my story under way, Mr. Graham said, âOh, so Iâve got you tonight have I, Flossie?â I had no idea why he had given me this vile diminutive, but pressed on regardless, trying to ignore the luxurious stretching-in-bed noises he was making all the while.
When I had finished, he said, âWell, Flossie, I donât know whoâs more annoying, your Mr. Smith, for being such a tit, or you for waking me up.â I had been prepared for a strict, impatient sort of response, but not for this horrible languor, this unseemly nicknaming. âWhat am I going to do with you?â
Keeping calm, I replied, âWell, I would be very grateful if you could come in and assist me. The cardiothoracics attending is already on his way.â
âOh, dear, dear. You know, I do like to give you boys a bit of rope. Let you find your own way. Itâs the only way youâll ever get anywhere you know. But if youâre telling me youâre a damsel in distressâŠwell, then youâve seduced me. Is that what youâre telling me, mmm?â
âYes. I need your help, Mr. Graham, I do,â I said, wanting at all cost to bring this conversation to an end.
âIn that case, Iâll come in and hold your hand,â he replied, just slightly less indolently. And the phone call was over, with no goodbyes. Leaving me feeling strangely compromised and sleazy.
He came and helped, and there was no question that he needed to be there. I wasnât able to pull the glass out and had to hand over to Mr. Graham, who succeeded without needing the cardiothoracics guys standing close by to wade in and save the day. And once he was in the hospital, surrounded by colleagues and drama, he even managed to communicate with me more normally.
But the universal surprise that was expressed by my resident colleagues when I told them he had come to help reminded me of the nauseated feeling I had had when talking to Mr. Graham on the phone. I sensed that our communication had not been straightforward or direct. I had asked for help as simply as I knew how, but still felt that I had been complicit in something else. That I had earned the rare gift of Mr. Grahamâs assistance by an interaction that had had more than words in it.
And this was what I was reminded of that day in the communication skills tutorial when I watched the way that Asim and Miss Ngozi had behaved with one another. The words they had spoken had been only a part of the text, because power and sex were somehow expressing themselves too, and getting in the way of clear and useful clinical discourse. I wondered whether there could ever be a situation in which help could be asked for simply and without complication. Wouldnât these obstacles fall away if two women were talking to each other? Surely I would encounter no such problems when asking for help from a female boss?
A couple of weeks after that course, I had the opportunity to find out. I was doing a pleasant general ENT list in the OR by myself. The anesthetist was quick, the list had started on time, and there had been no hitches. The grommets had gone in the first time and all the patients had been children, so their tonsils had popped out like little cherries, with no resistance. The last patient on the list was a large twenty-five-year-old woman with a lifetime history of tonsillitis and quinsy. This is a complication of tonsillitis that causes pus to collect in the capsule that surrounds the tonsil. A simple tonsillectomy relies on the surgeon finding the plane between the tonsil and the muscle bed in which it lies. Quinsy often destroys this dissecting layer and can make for a very tricky operation.
But what had given me cause for slight alarm about this lady when I had got her consent was not her history of quinsy. No, it was the fact of her hair, which was that kind of auburn that leans right into being red. I found her sitting on her bed by the window looking out onto the garden, and the sunshine had found her head with its beam. I thought, Beware of this coppery hair, this flame-colored head. It is a common view among surgeons that redheads bleed profusely.
Superstitiously I thought, If I donât mention my thought to anyone else, she wonât bleed. If I do, she will. And then the anesthetist was there and had pulled back the curtain to reveal me getting her consent. I met his eye and looked back at my patient just as a little cloud in the busy sky made room for the sun, and there again was that thin ray of light coming right down on her head. I could see the glints of redness along each pretty keratinous shaft. I turned with a fatalistic smile to him and said, âHasnât she got lovely red hair?â And his look to me was the admonishing look one actor must give another before Macbeth when someone has said that word: half humorous, but also as if to say, Now youâve really done it.
The operation started well. I love tonsillectomies. And the advantage of adults are their size, their very roominess. I had on my headlight, which looks like a spelunking light, and I arranged the spot of it to the perfect size and brightness, using my hands as a template. I was in the usual position, sitting at the patientâs head, upside down to her. I had draped all of her head above her mouth. Another drape covered her body. I had chosen the biggest metal gag and had slotted it into the little winch whose job it is to keep the mouth open. Sometimes putting this in can be tricky. The anesthetic tube has to be negotiated and the blade of the gag should fit right in the middle of the tongue, lifting that whole slippery muscle out of the way. But oftentimes, just as you are opening the gag, the tongue will slip to one side or another, forcing you to loosen the metal winch and start again.
This gag went in easily and I used the Draffin rods to steady it. These are two metal poles with holes in them. You cross them over in your hands like a wigwam so that two of the holes interlace. Then you hook the gag into these holes. It makes a kind of metal tent, holding the patientâs mouth open. And here was my patientâs oropharynx, perfectly exposed, tongue in the center. Plenty of room for maneuver and two decent-sized tonsils: big enough to grip, small enough to leave me room to work. Two tonsil swabs lay through the holes of the rods, like soft white fingers.
Using forceps in my left hand to hold the tonsil away from the muscle bed, I eyed the place where I would make my first cut and took the scissors the scrub nurse was offering me. This first cut tells all. If you can find the right plane with the first incision, the rest of the operation is usually straightforward. The end of the scissorsâ blades sliced through the capsule, revealing a clear space between tonsil and constrictor muscle beneath it. I handed the instrument back and took the bipolar forceps, with which to proceed.
There is a view that if adult tonsils are easy to remove, the patient evidently hasnât had much tonsillitis and probably shouldnât be having the operation. Extracting this womanâs right tonsil was just hard enough for me to feel that she had been appropriately listed. The tissue I was dissecting was fibrosed and had the texture of hardened chewing gum. There was enough blood coming from the operative field that I had to ask the scrub nurse to hold the sucker in ...
