Oh, for a little humanity
BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7072.1601 (Published 21 December 1996) Cite this as: BMJ 1996;313:1601
Not many laughs this last fortnight. I went to visit a close friend in a hospital near London who had recently had a breast lump and her lymph glands removed. I found her curled like a fetus on her bed in one of those grim wards that seem positively designed to make you feel ill.
I was shocked by how utterly drained and beaten she looked. She had been home since the operation and had sounded quite perky on the telephone. Yet after being in this hospital for only a couple of days she looked finished.
Physically, it transpired, she was feeling not too bad; emotionally she was wrecked. Two days before, still weak from the operation, she had been invited to turn up at 10 00 am to learn the results of a scan. She waited all day. At 6 00 pm she was told that she had cancer of the liver and four small brain tumours. She seemed to have no idea what the treatment would be, whether it was worth having, what her options were, where she would have it, what the effects might be. To just about all of the hundred and one questions I asked her, she said: “I don't know.”
“Haven't you asked the doctor?” I kept saying. Oh, she had tried. But he was so dry, so distant, always in such a hurry. It wasn't that he was rude, exactly, just that he never looked her in the eye, never seemed to speak directly to her, just barked questions at the nurse over her head, and grunted in reply.
“I kept trying to focus on the right question, but the next minute he was gone. In and out like a whirlwind. It happens every time I see him. I get so confused. He flusters me. Nothing comes out right. I think he's taken one look at that scan and consigned me to the scrap heap. Three people have died in this ward since I got here. All I can think about is whether I'm going to wake up tomorrow.
“Am I going to wake up tomorrow?”
“Am I going to wake up tomorrow, Sally? Will I be here in a few weeks time? Can you look me in the eye and tell me that?”
I looked her in the eye and said, very slowly and wishing I knew more about the liver: “I am absolutely certain that you're going to be here in a few weeks time.”
She relaxed, even smiled a bit, and began to talk about other things. I sat there wrestling with my rage.
Who was this man who called himself a healer yet could so effortlessly turn an illness into a trauma and so casually crush a fragile spirit long before the body had done its worst? Do doctors like him have no imagination? Has familiarity with illness and fearfulness bred something worse than contempt? Has it atrophied their very humanity?
What had this man done? He'd done nothing. Precisely nothing. I honestly don't believe it would have ruined his schedule to treat her as an individual rather than the next in a line of diseased flesh, and encourage her to ask some of the questions he must have known were crowding into her mind. A couple of minutes spent looking directly at her, touching her hand maybe, goodness, even perching on the end of her bed, would have prompted her to burst out with the big question haunting her most: “Will I die tomorrow?”
He could have made the elementary steps towards forming a relationship, so that she felt the person in authority over her, the person in whose hands she had been obliged to place her life, was someone she could trust. He probably thinks that he's done his job by diagnosing correctly and ordering the right treatment; the counsellors can do the rest. But he has left behind a shattered woman.
The weakest fare worst
It infuriates me that it is always the weakest people, the least equipped to fight for themselves, who fare worst in hospitals. The articulate, the well informed, the brass necked, the ones with the money to have private treatment or the backing of tenacious families can play the system. They ask questions, they complain, they shop around, they demand second opinions.
It is the quiet ones who suffer, easily intimidated by authority and paralysed by their own humiliation, confused by illness or age, too nervous to ask the things they have a right to know, often simply too fearful to formulate questions whose answers they dread.
These are the ones, like my friend with no one but a 20 year old daughter to support her, who find themselves at the mercy of grumpy doctors, the brusque, uncommunicative type, too busy to talk, too superior to explain, too dense to realise that bedside manners are the heart of healing, not an optional extra.
I know that it must be hard for those harassed hospital doctors, who see dozens of ill people every day—none of them at their best, some of them querulous and slow to understand—to remember that each one is a human being with only one life that is infinitely precious to them and a spirit that can be bruised as easily as a butterfly by a steely reply or a curt brush off. But if they can't remember it they shouldn't be in the job.
Many, many of them do remember it. By the next day I had found another doctor, a respected cancer specialist in London, who was prepared to see my friend. Even down the telephone he sounded so nice I nearly wept in relief.
He fitted her into an already busy clinic and assured her she wasn't going to die tomorrow. He answered all her questions and maintained, I suspect, a discreet silence about the ones she didn't ask. He reassured her that he had studied the proposed treatment and agreed with it.
As far as I can tell, he neither pretended everything was going to be okay, nor offered the sort of blunt prognosis she didn't want to hear, but she went away knowing that she hadn't been discarded on some scrap heap of wasting flesh and that her life was valued.
This wasn't a private consultation or a not so busy hospital. It was simply a kinder man, whose eminence, intellect, and overloaded schedule have cost him neither his humanity nor his capacity to empathise with confused and frightened patients.
All down to personality
However much they try and teach bedside manners in the medical schools these days, I reckon it comes down to personality in the end. Unless we can somehow screen out the supercilious, the unimaginative, and the cold eyed before they hit the wards, the chances of being dealt with kindly when our lives are on the line will remain cruelly arbitrary.
The make up lady at the BBC encapsulated the problem rather neatly when I asked her if she had had a nice weekend. “No,” she replied. “We had my nephew to stay. He's a medical student and he's so boring. Nothing to say, no interest in what anyone else is saying, no interest in anyone full stop. God help his patients when that one qualifies.”
Postscript (some time later)
My friend died a week ago. She died in her own home, not many miles but a whole universe away from the hospital which forgot she was a human being. In the two weeks she was home, tended by a wonderfully attentive general practitioner, a big, cuddly district nurse, a Macmillan nurse, a Marie Curie nurse, her own daughter, and many friends. She was emotionally at ease and looked at times as near as you can get to happy when you know your life is ebbing fast.
When I saw her for the last time, supported by pillows in her living room, resplendent in a pink turban to cover her ravaged hair, I could hardly believe that this was the woman I had visited that first time in the hospital. She looked terribly ill, that's true; but the twinkle was back in her eyes, she was laughing, she had lost the defeated look that had so appalled me before. The hospital was far behind her.
In today's post I found a letter from a doctor in Stirling who said she had been privileged to care for many patients with a terminal illness in the course of her work as a general practitioner. “Some time ago,” she wrote, “while having a cup of tea with the family of a dying patient, his wife turned to me and said, ‘I suppose you get used to this, Doctor.’ The day I ‘get used’ to human tragedy is the day I will hang up my stethoscope and go home.”
It was that kind of humanity from the medical profession that my friend found in her last days. It made the end of her life worth living and her death an easier thing for the rest of us to endure.