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‘We need to send you up to the hospital, where we will do tests on you to find out why your liver is abnormal. It could be due to cancer but we think it is probably because you're alcoholic, so we should also send you to alcoholics anonymous for counselling as well,’ a final-year medical student once confidently stated to me in a mock OSCE scenario, ‘Can you tell me more about your drinking habit now?’
A real patient might not know what to do first: object to being labelled an alcoholic on the basis of one set of abnormal liver function tests, protest that he would like some say in whether or not he was ‘sent’ to the hospital for tests, or ask whether there was any benefit in said tests! Watching medical students entering the clinical phase of their training, it often becomes obvious that while they know a lot, and they clearly care about their work, their choice of words can—and often should—be improved.
‘We’ is an often unhelpful and widely abused word that often causes difficulties, especially in potentially volatile consultations. This is because ‘we’ is often used in the context of ‘We, the medical profession, and you, the patient’, rather than ‘we, you and me’.
This is highlighted by another scenario frequently practised for OSCE examinations: telling the distraught father of a suddenly deceased son that a post mortem is necessary. To add pressure, the family often has a pressing (e.g. religious) need for the body to be released for burial, un-tampered with. This is often explained roughly as follows, ‘Because your son died suddenly, we need to arrange some further tests and an autopsy on his body.’ This (in actors, at least) provokes objections, demands to see the consultant, threats of lawyers being involved, and generally increased distress for all concerned. A helpful suggestion that the autopsy might expose hitherto unknown disease in surviving family members often increases the tension. Seeking relatives' consent in the case of a coroner-ordered post mortem can be cruel and counter productive, as this is nearly always legally mandatory. Removing ‘we’ from the discussion can create a more useful dialogue:
‘There is another matter I need to discuss with you. The circumstances in which your son died mean, regrettably, that there is a legal requirement for an autopsy to be performed. Unfortunately none of the team has any say over this.’
The absence of ‘we’ allows the doctor to take the side of the bereaved parent, and offer whatever compromises are possible. These include making every effort to see that the body is released for burial in good time, that no unnecessary tests are performed, and that whatever available support in terms of chaplaincy and/or bereavement counselling is offered (as appropriate to the parents' beliefs). Sincere condolences then sound less hollow. This applies in real life as much as in simulated OSCE scenarios.
An alternative approach I have seen by more personable students to our abnormal liver functions tests scenario is, ‘Some of your blood tests have come back slightly abnormal. These could be possibly due to a strain on your liver, which is often put down to people's lifestyle. Do you mind if I ask you some questions about your lifestyle? For example, how much alcohol would you say you drank over the course of an average week?’
This allows further non-threatening dialogue to establish how alcohol might be threatening someone's life, loves, and livelihood, and thence set up a comment which concludes with an offer of help (in the case of alcohol overuse)—‘Do you think that you might benefit from some help with this? Would you like me to arrange this for you? We could arrange to meet back here in a week to discuss this further.’ Note that ‘we’ means ‘you and I’ here, and represents a desirable sense of doctor and patient working to a common agenda.
Use of alienating language is by no means restricted to undergraduates. In a recent training exercise, I witnessed a fellow senior house officer excellently break the bad news to a (simulated) patient that a barium enema showed an abnormality which raised the suspicion of cancer. The SHO continued, ‘We need to do another test on you. We need to send you back up to the hospital where we will put a camera up your back passage and take some pictures of the abnormal area, as well as removing a small piece to look at under the microscope.’ When asked why this was necessary, the SHO added that it was to be certain of the diagnosis either way, not mentioning why this might be to the patient's benefit. The language used might suggest to the patient that this was all for the benefit of the doctor and his colleagues! Once again, more personable students put a different spin on things, ‘You do need a further test. This is something called a colonoscopy, which involves passing a thin flexible tube via your bottom. The tube contains a device for taking photographs and small microscope samples of the area. This may either provide you with some reassurance that this is not cancer, or it will provide useful information that will help guide the treatment that you are offered.’
‘We’ is useful rhetorically to make a view known on behalf of a group. It should factor in medical dialogue in so far as ‘We must not allow a sense of moral and intellectual superiority to destroy the rapport between patient and doctor,’ and, ‘We should maintain a sense of professional solidarity when training opportunities are under threat.’ It may be used to bring someone into the dialogue—‘How can we taking things forward?’ We should be warned, however, that the first person plural is frequently misapplied, and may be misleading and misunderstood. Whether used by students, juniors, or eminent consultants, the word slips off the tongue all too easily...