When I was a second-year medical student, we spent most of our time in a lecture theatre. Once a week, however, we were permitted to make the excitable ten-minute walk to Leicester Royal Infirmary, where a tired and over-worked consultant valiantly tried to prepare us for life on the wards.
‘Imagine,’ he said one day, ‘that you are seeing a patient about an unrelated condition, and he mentions to you that he has a pre-existing diagnosis of lung cancer. What would you say to him?’
Our nervous little group of ten all side-eyed each other. I was the oldest. I was supposed to make a fool of myself first.
‘I’d tell him I was very sorry to hear that,’ I said.
The consultant frowned into my very soul. ‘No. No, you would not. In fact, that’s the very last thing you would say to him.’
I made a small attempt at arguing. As a second-year medical student, I didn’t have very much, but I did have buckets full of compassion to throw around to make up for an absence of actual knowledge. Doctors were supposed to be kind, weren’t they? Empathetic? What on earth would I say, if I couldn’t say I was sorry?
‘You would say thank you for telling me that information,’ the consultant said. ‘Saying you’re sorry is a value statement. Those are heavy words, and you might be giving him a weight he’s unable to carry.’
He was right. Of course, he was right (I also very soon realised this man was one of the kindest, most compassionate doctors I would ever meet.) Back then, though, I couldn’t understand why saying you’re sorry about something was such a problem. Now I understand. Now I understand that each word we give to someone else carries its own burden, and one person’s light-as-air is another person’s unbearable cargo. We each measure our words with different scales.
I learned a lot about the measuring of words as I travelled through medicine. As a (very) junior doctor, I once had the difficult task of telling a young man (and his family) that he had a diagnosis of schizophrenia. It was a diagnosis made by someone much wiser and more experienced than I was, but thanks to a combination of flooded roads and a pre-arranged, urgent meeting, I was the one bearing the news. I think I did a good job. I hope I did. I remember they were all very upset, and I remember saying to this young man that he was exactly the same person as he was five minutes ago. Nothing had changed, I had just given him a word. He was still the person he was before. But of course, he wasn’t. Because with that one word, I had given him more weight than anyone should ever have to carry in a lifetime. Because words are never, ever, just words.
A few years after my conversation about the dangers of saying you’re sorry, I was sent to Lincolnshire on a med school rotation called Cancer Care. It was a five-hour round trip to Lincoln County Hospital, which always gave me plenty of time each day to reflect on ‘cancer care’ and how the meaning of those words isn’t quite as obvious as you might think. As a student, one of the challenges of being at that hospital – at any hospital – was Finding Patients To Talk To. It’s what medical students do for most of their time. They circle the wards desperately looking for a patient who is willing to tell them a story. It’s a way to practice history taking, to understand investigations and medications, and treatment plans. When you arrive on the wards, role-play becomes reality, and the page in a textbook becomes someone’s life. Talking to patients is the very best way to learn, but it isn’t always easy.
On one particular day, I had just about exhausted the entire oncology department (and the outpatient clinics and the chemotherapy suites) looking for A Patient To Talk To, without any success and in a last-ditch attempt, I approached the friendliest looking nurse on the ward and asked if she knew of anyone who might put up with me for ten minutes.
The nurse glanced around, shook her head and said she didn’t think so.
‘What about the woman in the corner bed?’ I said. ‘The one who’s knitting? She looks like a possibility?’
The nurse stared at me for a moment, and she reached into the trolley and handed me a set of notes.
The woman in the corner bed had end-stage bowel cancer. She had exhausted all the treatment options and was being cared for by the palliative team. With the help of the MacMillan nurses and the skill and expertise of everyone working community healthcare, she was being discharged. The woman in the corner bed was going home to die.
After I’d finished reading, I looked up at the nurse. ‘It would be selfish to ask, wouldn’t it? To waste her time?’
‘It’s not that. She’d be only too happy to speak to you.’
‘You can talk to her,’ the nurse said. ‘But only if you promise not to say the word ‘cancer’.’
‘Or malignancy or palliative or end-stage or even ‘growth’. None of those words. She doesn’t want to hear them. She refuses to hear them.’
‘Then what words do I use?’
‘All the other words,’ said the nurse. ‘All the tens of thousands of other words in the English language – just not those.’
The woman in the corner bed was indeed very happy to talk to me. Her husband, however, stayed silent. He had obviously come straight from work, the remains of his day lying in the folds of his jeans and carved into the leather of his boots. He watched from the chair next to her. The woman chatted non-stop, although the knitting continued as we spoke. There was knitting all over the bed. Wool in every colour you could imagine. Backwards and forwards the needles went, clicking away at all the other thoughts and dismissing them. We talked about many things. We talked about books and television programmes and holidays. She told me she was knitting baby clothes because the woman in the corner bed had just found out her daughter was pregnant. I stayed on the edge of that topic. It would have been so very easy to fall into it. To colour in future scenarios, scenarios we all knew were not destined to happen. I resisted because I knew I would be voicing those scenarios, not for the comfort of the woman in the corner bed, but in order to make my own, carefree life just that little bit easier.
‘She’s been married a year,’ said the woman. ‘A year last August.’
‘Has she?’ I said.
‘Around the same time, they told me I had a problem with my bowel.’
It hid amongst all the other words, but the story was there. You just had to listen for it.
I could see the woman’s husband lean forward just a fraction of an inch.
‘But I’ve had all my treatment now, and I’m going home,’ she said. ‘Although the MacMillan nurses are going to be helping. Just for a while.’
‘Oh, MacMillan nurses are incredible,’ I said. ‘They were so lovely when my Dad was ill.’
I did it.
I was doing so well, and yet I stumbled over a piece of my own misplaced kindness.
The knitting needles stopped, just for a moment.
‘And how is your Dad now?’ said the woman.
I hesitated. I looked at the woman’s husband. The exhaustion in his eyes. The unforgettable, unmistakable look of someone who has a complete absence of hope, and I realised he was the one who gathered up all those unwanted words and carried them around each day all by himself.
My Dad would have understood. He would have forgiven me.
‘He’s fine,’ I said. ‘He’s doing really well.’
When I arrived back at the hospital the following Monday, the woman had been discharged. Someone else was in her place – another story, more words – and I began to circle the wards again, looking for a patient to talk to. I took many histories as a medical student, but the woman in the corner bed taught me more about the power of words than anyone else. How saying you’re sorry isn’t always the kindest thing to say. How some words are so heavy, whether you mean to or not, handing them over will change a person forever. How – medic or non-medic – we should all choose our words with care because we never know the scales with which they are measured.
Medical students are always looking for someone to tell them a story. It’s a way to practice history taking, to understand investigations and medications, and treatment plans. When you arrive on the wards, role-play becomes reality, and the page in a textbook becomes someone’s life.
Talking to patients is the very best way to learn.
It isn’t always easy.
(my thoughts and reactions are real, but all the patients I write about are works of fiction)
Joanna Cannon is a psychiatrist and a writer. She lives in Derbyshire and has a successful blog. This blog originated from a conversation on Twitter initiated by Joanna.