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Communication: A neglected art in clinical medicine
ClinicalRadiology(1985) 36, 21~222 © 1985Royal Collegeof Radiologists
000%9260/85/461217502.00
Communication: A Neglected Art in Clinical Medicine* H. A. F. D U D L E Y
Academic Surgical Unit, St Mary's Hospital, London
1 am sure that many of you are familiar with the degenerative syndrome known as 'named lecture fantasy'. It has two components. The first relates to the invitation and its acceptance. The second to the choice of a title. The letter inviting one comes on grandly headed paper and usually many months, if not years, before the delivery date. One is flattered into accepting, forgetting of course that you are probably about sixth on the list and that the first five truly distinguished invitees have pleaded pressure of work, other engagements usually at conferences being held in warm parts of the world where there is a minimum of duties and a maximum of gastronomy - or have decided, which would be impossible in relation to this College, that there is insufficient mileage in making the effort. You, as the sixth, are the last and forlorn hope but this is mercifully concealed from you at least until a few weeks after the lecture when you are talking proudly to one of your friends, or, more likely, enemies and saying that you delivered this or that lecture recently. You are then suitably put down by being told that he or she was higher in the pecking order than you and had refused. You may say that, as usual and in all respects, I am exaggerating but I can assure you that in another place I have been through just such a sequence. But I am already doing what I am sure you will find characteristic: wandering, as Ernest Bramah's famous character Kai Lung used to do, unchecked in a garden of bright images. Having been so unwise as to accept, two paths are open to you: if you are well organised and not too ashamed of repeating yourself you will possess in your professorial bottom draw a small series of carefully crafted addresses. These will be designed in such a way that they are easily adaptable to any situation by a few manipulations on the word processor and, thus, provide a resource without equal when one is faced with a task such as this. Furthermore, they will show how erudite you are in history, literature or science. One colleague, who had better be nameless, sent me a year or two ago a copy of his departmental report in which I noted with interest, but scarcely with admiration, that he had managed to give the same talk on no less than 38 different occasions in the one year. A feat of determination and single-mindedness, certainly, but not something that I find intellectually attractive. If, on the other hand, you are, like me, disorganised and not, in spite of what my junior staff might say to the contrary, too fond of repeating yourself, you will, when it comes to choosing a title, make the fatal mistake of plucking a sentence out of the air which sounds attractive and to which you are sure you can do justice. You have some ill-formulated ideas about a general subject which you have always been meaning to lick into shape; here now is the chance and out will come a spanking new lecture * The Skinner Lecture of the Royal College of Radiologists, delivered in London, 16 November 1984.
shaped to grace your bibliography if not necessarily to charm your auditors. The months pass; the ideas continue to swirl within your cerebral cortex like the thin smoke of an autumn bonfire but are dissipated through the suburbs of the mind, much as happens to the smell of the fallen leaves. There is not a rack left behind. Gradually panic sets in and this of itself is counter-productive, freezing the thought processes and making the secretary more and more anxious that she will not have time to type the manuscript. This fear on her part has, ! might say, been somewhat mitigated by the changed relationship between secretary and professor brought about by the introduction of the personal computer. No longer does the boss loll at his ease mouthing his thoughts into a dictating machine while the secretary slaves over a manual typewriter. Now he is the slave to his own personal keyboard and, at best, the secretary will make sure that the final draft is proofread on her screen before being automatically printed while she enjoys a long lunch break. Should there be the additional requirement that the lecture is to be published - for the pages of specialist journals must be filled - you receive, when in the depths of despair, a reminder from the Editor that your manuscript was needed yesterday; far from releasing the springs of creativity, the freeze intensifies. What provokes a thaw I have never quite discovered; but here f am to address the subject that I so. casually chose 9 months ago. It will be for you to judge whether there is anything other than the Will-o'-the-wisp of an idea in it. I have chosen this title for two reasons. First, because my experience of 37 years of clinical practice has taught me, often painfully, that it is a central matter to the conduct of clinical practice. Most, if not all, of our failures to order our affairs stem from poor communication and the inability to divorce our personalities from our communication skills; to adopt a professional as distinct from an emotional approach. I am as guilty of this sort of defect as anyone but I hope you would agree that suffering from a disease does not disbar one from discussing it as it occurs in others. I further believe that the interaction between clinicians and radiologists is a particularly good circumstance in which to consider communication. When younger, I was accustomed, in my rudeness, to say that the vocabulary of radiological reports was limited to about 200 words (including the 'ifs' and 'buts') and my early ideas of this lecture were that ! might spend a happy half hour or so taking selected reports, exposing their ambiguities and deriding their imprecision. But not only would this have been unfair, it would also have constituted a quite unjustified slur on the branch of the profession that has done me the courtesy of asking me to speak. Furthermore, though I shall hope to convince you that precision in verbal and written communication is our
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duty, there are wider spheres of communication which are just as, if not more, important. Intercommunication between professionals is central to our role in trying to help the patient. Bits and pieces of information about him or her wash in from a wide variety of sources to be integrated first into diagnosis and secondly into management. Unless the process is well thought out, precise and largely error-free, it is the patient who will suffer. I realise, of course, that we do not practise our profession with the patient always firmly in our sights but he is necessary as substrate to all except those who pursue experimental medicine in the laboratories. The second reason for choosing this subject is that I agree with Laurence Housman who once wrote to his brother A. E. Housman, a distinguished classicist as well as a poet of some renown, that 'Exposure of false pretensions is the duty of a critic and a scholar.' I do not claim to be either but I do aspire to both. indeed, this can be regarded as the main role of a professor: not so much to sit on committees or councils; not in a vague way to be held responsible for teaching and research; not through these roles to give a cachet of respectability to institutions such as London teaching hospitals which are otherwise mainly engaged in the profitable pursuit of professional perquisites and status. But to stand a little apart; to act, if you will excuse the pretensions of the phrase, as the conscience of a group or groups largely linked together by guild loyalties and trade traditions. Not, of course, that there is anything wrong with these but they are designed for protection against a wicked outside world rather than for the pursuit of the greatest happiness for the greatest number. In this regard it is a pity that the Royal College of Radiologists can number only a relatively small number of professors amongst its ranks. Your College is strong; your professional status exemplary. But it would be good if there were more of you in the groves of academe. Of course, not all academics take this view of their task. Many prefer to be always at one with their colleagues. Peter Fielding, my former assistant director at St Mary's, puts it nicely when he says of some academics that they prefer to withdraw into 'caves of intellectual refuge' rather than essaying the open ground of the real world. This engenders the view that the activities of academics are divorced from reality and, therefore, irrelevant. I take the opposite view: what academics do - their disinterested intellectual curiosity, as Whitehead expressed it many years ago - is the life blood of any civilisation. George Steiner (1978) has put the same argument to the effect that the drive of Western cultures to know, to analyse, to c]issect problems is what has made both the good and bad in these cultures and that we need to preserve the good while working to eliminate the bad. There may be other definitions of Western civilisation but to me it is its intellectual achievements both in art and science that mark it as unique. But I am taking too long to get to the heart of the matter. I have included in the title of this talk the word 'art' and perhaps I should briefly explain that this, to me, means not something which is at odds with s c i e n c e - the old 'two cultures' argument of C. P. Snow - b u t more the
style or way in which things are done. As such, it is an appendage to the body of professional communication, but if things are to work smoothly it is, nevertheless, a necessary limb. I should like to deal briefly first with straightforward written and verbal communication. It is easy, as many have found, to criticise infelicity and bemoan vulgarity in the writing and speech of all of us. Indeed, with that living, flexible tool, the English language, this is part of everyday life because these very characteristics and the usefulness of our native tongue make it both a victim and a survivor of change. It is a scholar's recreation to write to the Times and point out how a once-useful word has now decayed into inapplicable slang or a meaning that belies its origins. However, in the loom of language such pursuits are little more than the public display of academic spleen. Moreover, elegance of style, though important, must be combined with precision, lack of ambiguity and brevity. Some would say that elegance rests in just these three things and, indeed, this is to a degree so; but we do not need in professional discourse, which is usually fairly brief, the range of embellishment or the verbal grace notes that make sustained conversation or reading a pleasure as distinct from a chore. One of our fundamental shortcomings in medicine is the failure to generate a truly professional vocabulary. Though words, as H u m p t y Dumpty told us - and Carroll was, as usual, exploring a deeper philosophical problem than that ! wish to deal with here - may mean whatever we want them to mean, we should be sure that we all share a common meaning if we wish to use them for the communication of precise information about patients. Time and again in our formal case conferences I find that we have to define what we mean on an ad hoc basis. I will give one, perhaps outdated example from radiology and another from closer to my own practice. For many years when a radiologist reported upon a patient with pyloric stenosis as having 'delayed gastric emptying' I thought that this was what literally was meant: gastric content remaining for an undue length of time in the stomach. It was not until I had been working for some years with Dr H. A. Luke of Melbourne that he was able to explain patiently to me that it really signified 'delayed onset of gastric emptying'. This transformed for me the interpretation of films and reports though, in this instance, it was not so much a life-and-death matter as one of intellectual satisfaction. To pluck another simple and more serious example out of my recent clinical experience, I was rung up recently rather early in the morning - when aging professors are not at their best - by a senior registrar with the information that he had seen a patient who was bleeding from the upper gastrointestinal tract and who had an 'endoscopically proven duodenal ulcer'. I hastened my early morning return to consciousness and told the registrar to get the patient ready for the theatre. When I arrived and read the endoscopic report it was to the effect that clot had been encountered in the antrum and on the way through into the duodenum and it was, therefore, assumed that bleeding was coming from a duodenal ulcer. In fact, he proved to be bleeding from a different lesion and did not require emergency surgery. Imprecision in communication might, in this patient, have led to a real disaster. My cerebral files are full of similar circumstances so the matter is not at all a trivial
C O M M U N I C A T I O N IN C L I N I C A L M E D I C I N E
one. You will, I am sure, be aware how persistent labels attached to people can be: it happens, as I ruefully know, to us all. It is all too easy for a patient to be labelled by slipshod interpretation and communication and then for this label to accompany him throughout his medical career and often to his detriment. A good instance in the past was inflammatory bowel disease where a diagnosis reached on inadequate grounds - in the wrong frame, as I shall try shortly to explain - may lead to labelling and to complex and dangerous treatment over many years, by which time the origins of the label have been forgotten. A sloppy professional vocabulary is very apparent in our ordinary clinical speech and, though not often damaging, it is an affront to the nature of our calling. Students in particular, though others are not exempt, introduce 'seems to be's', 'slightly's' and 'sort of's' into their discourse as a way of hedging their statements around with conditionals. I am also impressed by the way that transient jargon phrases make their way into our professional speech. It is not that some of them lack colour; often the reverse. Rather, it is that they become, as Nigel Rees has recently told us (Rees, 1984), worn out by too frequent and too diffuse usage. At this moment in time I would dearly like to see the bottom line drawn to the ongoing situation of the use of such tired and often clichd-ridden phrases. Imprecision may also be the result of ignorance but it is more usually, in my experience, a cloak to cover uncertainty or a protection against a future debacle. Let me give you some examples - again, you might say, trivial - of both. I culled this piece of prose from a recent issue of a throwaway journal. 'However we would want to ensure that the private sector which is already parasitic on the public sector for both skilled staff and technology receives no undue subsidisation.' It contains an unnecessary conditional statement beloved of those who cannot bring themselves to be totally committed to what they say or write. It changes a noun, parasite, into an adjective, albeit a respectable one. It places an adjective so that, logically, it relates to two subjects when it is meant to relate only to one; not a serious fault in this context but sometimes an error that completely alters meaning. It uses an 'ology, technology, where a simpler word, techniques, is more appropriate. It resorts to the negative statement which, in addition to lacking formal logic - one cannot receive something that does not exist - is clumsy. Finally, and almost inevitably in this sort of jargon, it ends with an 'isation word, that transformation most loved by the bureaucrat. We can rewrite the sentence in plain English, as Gowers would have done. 'The private sector is already a public sector parasite for techniques and skilled staff. We want to ensure that it does not receive undue subsidy.' In this example, and somewhat to my surprise, we have not imparted a great deal of brevity, saving only three words or 9%, though 27 letters or 18%. Nevertheless, steady savings of this kind and the removal of obfuscation can greatly lighten the burden of the reader. You may regard such ruthless textual criticism as the
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mark of the small-minded pedant but i do not, of course, think this is the case. A scholarly approach is an end in itself but we must, in addition, hone our skills of expression, not just by cultivating simple forms of communicating our ideas but also by trying to be as logical as possible. Such facility does not come naturally to many but it can be developed. Unfortunately, the education of many of us has been more concerned with the grammatical than the logical structure of sentences and though these characteristics overlap they are not identical. I will not try to enter into a detailed dissertation on how logic can be achieved as this would be tedious in the extreme but I have found the following four principles useful. 1. Ideas should not contradict one another or otherwise violate logic. 2. All antitheses should be true ones. 3. The order of ideas in a sentence should not be such that the reader needs to rearrange them in his mind. 4. Sentences should be linked logically. They are derived from a seminal work, now unfortunately out of print, by Martin Hodges and the poet and classicist Robert Graves (Graves and Hodges, 1965). It is not without passing interest that the three individuals that I have quoted as guardians of clarity in expression and guides to achieving it - Housman, Hodges and Graves - are all of the arts, not the sciences. Let me turn next to the cultivation of imprecision and ambiguity as a method of taking out an insurance policy and, in doing so, come a little closer to home. Here we are talking about the coded messages that a sentence or statement contains as either a conscious or an unconscious action of their author. When a radiologist, or anyone else for that matter, says 'malignancy cannot be excluded', he may genuinely mean that there is insufficient evidence to exclude malignancy or that, alternatively, he is passing a coded message that he is hedging his bets in case, retrospectively, his interpretation of the evidence is shown to be wrong and malignancy is found. Nothing much wrong with that, but we should be conscious of the hedge. 'No specific features' has much the same connotation as well as containing the makings of a false antithesis in that the absence of specific features implies the presence of non-specific ones. 'The appearances are compatible with A or B or C' is, in my view, slightly more serious because it evades the issue of what happens if someone then proceeds as if A or B or C were present but this proves not to be the case. It is a method of saying 'but I am not responsible because I did not commit myself'. However, coded messages can also be useful in conveying your superiority, as when the radiologist finds a low-lying rectal tumour on barium enema. The report might justifiably then read 'a sigmoidoscopy might be helpful', which means in effect 'you fool you should have done one before sending the patient to the radiologist'. Some of these phrases also owe their origins to the feeling that we must make a statement in diagnostic or management terms when, in truth, we do not have enough facts_ There is in our current medical culture a lack of clarity about how far to reason from data available at any instant. My speculation is that the cause of this is the dominance of the pathological end-point in diagnosis which we owe to Virchov and which leads us to
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make pathological ascriptions to clinical and radiological circumstances, not because we truly can but because we feel we ought. To try to avoid this I have introduced the concept of a frame of reference which I define as a set of self-consistent data having a common vocabulary. We should, I feel, constantly during communication remind ourselves of the frame in which we are working and use only the vocabulary of that frame. It may, again, appear unnecessarily formal to say 'these are the mammographic features of carcinoma of the breast' but the message so conveyed is precise and does not seek to ascribe to this patient that pathological diagnosis. We can go on to formalise our clinical task as making an appropriate frame transfer so that we have the right information to allow us to act. Thus, a mammographic diagnosis of breast cancer does not permit me to undertake radical treatment of any kind; the frame must be transferred into the pathological. By contrast, an angiographic diagnosis of aorto-iliac obstruction would, if I was a member of the guild of entrepreneurial plumbers - I mean a vascular surgeon - permit me to go ahead without further ado to earn my daily bread. I should like now, and doubtless to your relief, to move away from what may seem to you the pedant's corner and engage with a much more complex and, in my view, serious problem in communication. I speak of the communication of intent or desire about a patient between the clinician in whose hands the individual is and specialists such as yourselves. Now, clinicians regard themselves as the shock troops of patient care, the men in the foxholes actually engaging the fell enemy disease. As with the combatant soldier, they see themselves as far superior to those behind the lines. As well as possessing this superiority, clinicians are also demanding of and complaining about the quality of support needed to pursue their task. Furthermore, they perceive that their decisions are automatically correct because they and only they are sufficiently close to the patient fully to understand what is going on. As every staff officer in battle and every radiologist in practice knows full well, this self view of the clinician is almost wholly false. In fact, he is sometimes too close to the action to see the broader picture; his tactics may be outdated by an adherence to what we could kindly call a conventional wisdom or, less charitably, an inflexible dogma; and he has failed to keep abreast of changes and advance in related fields. The last has been particularly true of imaging, where the technical strides that have been made in the last two decades have left the clinician reeling, not only in his attempts to understand the prestidigitations of the engineer and scientist - what ordinary or even extraordinary clinician practising in my hospital could give, for example, even a semicoherent account of nuclear magnetic resonance? - but also in his ability to take on board the potentials of the new imaging to change the conduct of his practice. The conventional model for the consultation with a specialist department, which flows from this primacy the clinician feels he has, tends to be of the kind shown in Fig. 1. At some encounter with the patient ward round, out-patient session Or case conference - it is thought that a particular image will help elucidate the problem. This thought is communicated either by mouth or by the written word and often by a more
Ward round decision by consultant
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Fig. 1 - 'Conventional model for consultation with a specialist department'.
junior member of staff. Most of the time this works but it is prone to error, bias and inflexibility. We are all familiar with the errors produced by the inevitable compression required to get the clinical details thought relevant to the patient's problem onto the request form and the difficulties encountered when neither the request nor the signature beneath it are comprehensible. These problems are the lot of all radiologists and the basis for legitimate criticism of clinicians. More serious problems arise when the radiologist is better informed about the available options than is the clinician: a new definition of disadvantageous negative feedback may then emerge, either because a different investigation is done from that which the clinician requested or, increasingly today, because some action follows, such as the drainage of an abscess or the needling of a mass for diagnostic purposes. Most of us here today will recall examples from our personal experience where this communication mismatch has done nothing to advance the patient's cause or to further interdepartmental relations. Part of the solution to the problem lies in more sophisticated communications within the hospital. We in this country are grossly understaffed, both professionally and in support such as secretaries, and this inhibits communication. Though I am sceptical about the electronic revolution that is always being dangled before our eyes, there is no doubt that if a member of clinical staff could type the details of an investigation request into a computer terminal which would then automatically lodge these in the X-ray department's electronic mailbox it would be possible for a great deal more information to be painlessly transmitted. If I may digress for a m o m e n t to include also the other side of the information transfer - getting the results of any form of imaging to the person who needs them - then the same arguments apply. In my hospital, again mainly from lack of resources and not from unwillingness of my colleagues to help, surgical junior staff may spend up to 15 hours a week hunting for images so that they can make a coherent and comprehensive presentation of clinical problems to the team. How much better would be the use of overall digital imaging with a local area network to transmit the information where it is needed on an instantaneous basis. Far-fetched, you may say, but not in fact so: Fig. 2 shows one facet of a design study which is being undertaken at St Mary's for a completely filmless department. Nothing illustrated here is beyond the state of the art - ouch! I have used a jargon phrase so I might as well compound it by saying at this moment in time. These are technical fixes for closing the loop of information request and production. They are impor-
COMMUNICATION IN CLINICAL MEDICINE EXISTING SOURCES O:: ELECTRONIC IMAGES
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FUTURE SOURCES OF ELECTRONIC IMAGES
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tant but not so much as is the consequent need to review the radiologist's role. A combined approach to the patient's problem is now much more often desirable. It is, indeed, necessary for the clinician to abandon his view that he is, ex officio, primus inter pares. Equally, it is necessary for the radiologist, as he or she becomes a participant in the decision-making that goes into organising a plan of investigation, to engage with more than a merely technical task. This is the more true as interventional radiology becomes more and more accepted as conventional therapy. The role of the diagnostic radiologist is becoming increasingly akin to that which the radiotherapist adopted long ago. I am sufficiently old to recall the bitter demarcation disputes that used to take place over how much the radiotherapist was entitled to take independent action; such would now be inconceivable but we have still a good distance to travel and much communication work to do before we have the same easy and comfortable situation at the new frontier of interventional radiology. Again, the clinician must modify his longstanding dominance; but the radiologist will also have to learn to stand up and be jointly responsible for outcome as well as technique. You will then have to join us in that field of uncertainty that constitutes clinical practice and share our anxieties and occasional anguish. As so often happens when the therapeutic ground shifts, it become difficult to know who owns the patient or perhaps, in deference to any lay people here today, which doctors the patient possesses and can draw on. This is a problem that can only be resolved by good communication between those individuals and groups that have separate skills to bring to bear on a problem. Perhaps the way ahead has already been charted by the increasing confidence in the radiologist that
must be displayed by the clinician over dynamic imaging. We have always, in relation to such things as barium meals and barium enemas, had to take on trust, sometimes supplemented by retrospective discussion, what the radiologist saw. To a much greater degree now we can see it with him through the medium of videotape. This, in turn, has led him or her to be more closely involved with clinical discussion. Specialist groups have emerged, such as cardiological, gastroenterological and vascular, who will work together both in designing investigative and therapeutic sequences for the patient and in reviewing the results. Yet the growing edge remains ragged: for example, I see no unanimity of opinion about the best way to investigate the patient suspected of having gall-stones. I, on the one hand, want an investigation which tells me both that the patient has cholelithiasis and what effect the stones are having on the function of the gall-bladder; most radiologists seem to contend that all that is needed is to demonstrate the presence of the stones by the simplest and most economic method, ultrasound. A middle ground will, doubtless, emerge but it is a slow process. I am concerned also about feedback in new imaging areas, such as ultrasound or the more sophisticated forms of radionuclide investigation. In the forties and fifties surgeons and radiologists rewrote the anatomy of the heart as a consequence of the great surge of activity which followed the introduction of open heart surgery but, as I recall, they did so in close co-operation. I do not always see the same detailed check being made of ultrasound findings against what is ultimately revealed by laparotomy or thoracotomy and I have to confess that good ultrasonographers are also, at times, gifted with imaginative rather than deductive powers. It is, of course, my role to see that they are better informed about the real world, just as it is theirs to accept my
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findings. Communication breaks down when it is impossible to convince someone that what they interpreted is not, in fact, present, just as it will also break down if the clinician refuses to acknowledge that what the image shows is right. Mutual tolerance through close communication is mandatory. Though we have never in this country, i am glad to say, adopted the Scandinavian practice of centring a clinical round on the X-ray department, thus giving the radiologist a territorial advantage, we do need increasingly to bring the radiologist to the bedside and the clinician to the X-ray conference. Such statements may be old hat to many of you but I would hazard a guess that, up and down the country, less than 20% of images which would benefit from consultation are reviewed together. Now, Mr President, I am aware that I have concentrated primarily on the diagnostic side of the work of your College to the neglect of its established major commitment to therapy, of which you are a representative. For this I apologise. Skills in intercommunication are as necessary to your field as to the diagnostician. I have mentioned that radiotherapy has a more secure place and the combined clinic for the management of malignant disease is now a commonplace. It establishes common ground on which exchange of ideas and views can take place and without which the patient is a rubber ball bouncing from place to place, bereft of a doctor personally responsible for his management. In the increasingly complex world of surgery, radiotherapy, chemotherapy, hyperthermia and the laser this is wholly unsatisfactory. But it is no use bringing people together solely on the basis of complementary technologies; they must also have a
common goal through sharing a common vocabulary and styles of thinking. Now I come - thankfully, you may say - to my end. This lecture was endowed in the hope that those who gave it would address the subject of breast cancer or some other related topic which might interest radiologists. No one in his right mind can feel comfortable tackling the enigma of cancer of the breast, it remains, in my view, a biological conundrum which will require much deeper understanding in that frame rather than the clinical one before we, as relatively crude therapists, can make a significant impact on its long-term ravages. ! would only like to say that during my professional lifetime it has been two radiotherapists in particular, Robert McWhirter and Diana Brinkley, who have given us the most understanding of the nature of, if not the solution to, the biological problem and they deserve our belated thanks for so doing. However, Miss Skinner, in her wisdom - or perhaps helped by the wisdom of your Councillors of the day provided the enabling clause that has permitted me to ride one of my many hobby horses. In doing so I would like to thank the College for the privilege and to hope that you have found my meanderings not wholly without interest_
REFERENCES Graves, R. & Hodges, A. (1965). The Reader Over Your Shoulder. Jonathan Cape, London. Rees, N. (1984). Worn-out words. Telegraph Sunday Magazine, 4 November, 53-57. Steiner, G. (1978). Has truth a future? (the Bronowski lecture). The Listener, 99, 42-46.
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Communication: A Neglected Art in Clinical Medicine* H. A. F. D U D L E Y
Academic Surgical Unit, St Mary's Hospital, London
1 am sure that many of you are familiar with the degenerative syndrome known as 'named lecture fantasy'. It has two components. The first relates to the invitation and its acceptance. The second to the choice of a title. The letter inviting one comes on grandly headed paper and usually many months, if not years, before the delivery date. One is flattered into accepting, forgetting of course that you are probably about sixth on the list and that the first five truly distinguished invitees have pleaded pressure of work, other engagements usually at conferences being held in warm parts of the world where there is a minimum of duties and a maximum of gastronomy - or have decided, which would be impossible in relation to this College, that there is insufficient mileage in making the effort. You, as the sixth, are the last and forlorn hope but this is mercifully concealed from you at least until a few weeks after the lecture when you are talking proudly to one of your friends, or, more likely, enemies and saying that you delivered this or that lecture recently. You are then suitably put down by being told that he or she was higher in the pecking order than you and had refused. You may say that, as usual and in all respects, I am exaggerating but I can assure you that in another place I have been through just such a sequence. But I am already doing what I am sure you will find characteristic: wandering, as Ernest Bramah's famous character Kai Lung used to do, unchecked in a garden of bright images. Having been so unwise as to accept, two paths are open to you: if you are well organised and not too ashamed of repeating yourself you will possess in your professorial bottom draw a small series of carefully crafted addresses. These will be designed in such a way that they are easily adaptable to any situation by a few manipulations on the word processor and, thus, provide a resource without equal when one is faced with a task such as this. Furthermore, they will show how erudite you are in history, literature or science. One colleague, who had better be nameless, sent me a year or two ago a copy of his departmental report in which I noted with interest, but scarcely with admiration, that he had managed to give the same talk on no less than 38 different occasions in the one year. A feat of determination and single-mindedness, certainly, but not something that I find intellectually attractive. If, on the other hand, you are, like me, disorganised and not, in spite of what my junior staff might say to the contrary, too fond of repeating yourself, you will, when it comes to choosing a title, make the fatal mistake of plucking a sentence out of the air which sounds attractive and to which you are sure you can do justice. You have some ill-formulated ideas about a general subject which you have always been meaning to lick into shape; here now is the chance and out will come a spanking new lecture * The Skinner Lecture of the Royal College of Radiologists, delivered in London, 16 November 1984.
shaped to grace your bibliography if not necessarily to charm your auditors. The months pass; the ideas continue to swirl within your cerebral cortex like the thin smoke of an autumn bonfire but are dissipated through the suburbs of the mind, much as happens to the smell of the fallen leaves. There is not a rack left behind. Gradually panic sets in and this of itself is counter-productive, freezing the thought processes and making the secretary more and more anxious that she will not have time to type the manuscript. This fear on her part has, ! might say, been somewhat mitigated by the changed relationship between secretary and professor brought about by the introduction of the personal computer. No longer does the boss loll at his ease mouthing his thoughts into a dictating machine while the secretary slaves over a manual typewriter. Now he is the slave to his own personal keyboard and, at best, the secretary will make sure that the final draft is proofread on her screen before being automatically printed while she enjoys a long lunch break. Should there be the additional requirement that the lecture is to be published - for the pages of specialist journals must be filled - you receive, when in the depths of despair, a reminder from the Editor that your manuscript was needed yesterday; far from releasing the springs of creativity, the freeze intensifies. What provokes a thaw I have never quite discovered; but here f am to address the subject that I so. casually chose 9 months ago. It will be for you to judge whether there is anything other than the Will-o'-the-wisp of an idea in it. I have chosen this title for two reasons. First, because my experience of 37 years of clinical practice has taught me, often painfully, that it is a central matter to the conduct of clinical practice. Most, if not all, of our failures to order our affairs stem from poor communication and the inability to divorce our personalities from our communication skills; to adopt a professional as distinct from an emotional approach. I am as guilty of this sort of defect as anyone but I hope you would agree that suffering from a disease does not disbar one from discussing it as it occurs in others. I further believe that the interaction between clinicians and radiologists is a particularly good circumstance in which to consider communication. When younger, I was accustomed, in my rudeness, to say that the vocabulary of radiological reports was limited to about 200 words (including the 'ifs' and 'buts') and my early ideas of this lecture were that ! might spend a happy half hour or so taking selected reports, exposing their ambiguities and deriding their imprecision. But not only would this have been unfair, it would also have constituted a quite unjustified slur on the branch of the profession that has done me the courtesy of asking me to speak. Furthermore, though I shall hope to convince you that precision in verbal and written communication is our
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duty, there are wider spheres of communication which are just as, if not more, important. Intercommunication between professionals is central to our role in trying to help the patient. Bits and pieces of information about him or her wash in from a wide variety of sources to be integrated first into diagnosis and secondly into management. Unless the process is well thought out, precise and largely error-free, it is the patient who will suffer. I realise, of course, that we do not practise our profession with the patient always firmly in our sights but he is necessary as substrate to all except those who pursue experimental medicine in the laboratories. The second reason for choosing this subject is that I agree with Laurence Housman who once wrote to his brother A. E. Housman, a distinguished classicist as well as a poet of some renown, that 'Exposure of false pretensions is the duty of a critic and a scholar.' I do not claim to be either but I do aspire to both. indeed, this can be regarded as the main role of a professor: not so much to sit on committees or councils; not in a vague way to be held responsible for teaching and research; not through these roles to give a cachet of respectability to institutions such as London teaching hospitals which are otherwise mainly engaged in the profitable pursuit of professional perquisites and status. But to stand a little apart; to act, if you will excuse the pretensions of the phrase, as the conscience of a group or groups largely linked together by guild loyalties and trade traditions. Not, of course, that there is anything wrong with these but they are designed for protection against a wicked outside world rather than for the pursuit of the greatest happiness for the greatest number. In this regard it is a pity that the Royal College of Radiologists can number only a relatively small number of professors amongst its ranks. Your College is strong; your professional status exemplary. But it would be good if there were more of you in the groves of academe. Of course, not all academics take this view of their task. Many prefer to be always at one with their colleagues. Peter Fielding, my former assistant director at St Mary's, puts it nicely when he says of some academics that they prefer to withdraw into 'caves of intellectual refuge' rather than essaying the open ground of the real world. This engenders the view that the activities of academics are divorced from reality and, therefore, irrelevant. I take the opposite view: what academics do - their disinterested intellectual curiosity, as Whitehead expressed it many years ago - is the life blood of any civilisation. George Steiner (1978) has put the same argument to the effect that the drive of Western cultures to know, to analyse, to c]issect problems is what has made both the good and bad in these cultures and that we need to preserve the good while working to eliminate the bad. There may be other definitions of Western civilisation but to me it is its intellectual achievements both in art and science that mark it as unique. But I am taking too long to get to the heart of the matter. I have included in the title of this talk the word 'art' and perhaps I should briefly explain that this, to me, means not something which is at odds with s c i e n c e - the old 'two cultures' argument of C. P. Snow - b u t more the
style or way in which things are done. As such, it is an appendage to the body of professional communication, but if things are to work smoothly it is, nevertheless, a necessary limb. I should like to deal briefly first with straightforward written and verbal communication. It is easy, as many have found, to criticise infelicity and bemoan vulgarity in the writing and speech of all of us. Indeed, with that living, flexible tool, the English language, this is part of everyday life because these very characteristics and the usefulness of our native tongue make it both a victim and a survivor of change. It is a scholar's recreation to write to the Times and point out how a once-useful word has now decayed into inapplicable slang or a meaning that belies its origins. However, in the loom of language such pursuits are little more than the public display of academic spleen. Moreover, elegance of style, though important, must be combined with precision, lack of ambiguity and brevity. Some would say that elegance rests in just these three things and, indeed, this is to a degree so; but we do not need in professional discourse, which is usually fairly brief, the range of embellishment or the verbal grace notes that make sustained conversation or reading a pleasure as distinct from a chore. One of our fundamental shortcomings in medicine is the failure to generate a truly professional vocabulary. Though words, as H u m p t y Dumpty told us - and Carroll was, as usual, exploring a deeper philosophical problem than that ! wish to deal with here - may mean whatever we want them to mean, we should be sure that we all share a common meaning if we wish to use them for the communication of precise information about patients. Time and again in our formal case conferences I find that we have to define what we mean on an ad hoc basis. I will give one, perhaps outdated example from radiology and another from closer to my own practice. For many years when a radiologist reported upon a patient with pyloric stenosis as having 'delayed gastric emptying' I thought that this was what literally was meant: gastric content remaining for an undue length of time in the stomach. It was not until I had been working for some years with Dr H. A. Luke of Melbourne that he was able to explain patiently to me that it really signified 'delayed onset of gastric emptying'. This transformed for me the interpretation of films and reports though, in this instance, it was not so much a life-and-death matter as one of intellectual satisfaction. To pluck another simple and more serious example out of my recent clinical experience, I was rung up recently rather early in the morning - when aging professors are not at their best - by a senior registrar with the information that he had seen a patient who was bleeding from the upper gastrointestinal tract and who had an 'endoscopically proven duodenal ulcer'. I hastened my early morning return to consciousness and told the registrar to get the patient ready for the theatre. When I arrived and read the endoscopic report it was to the effect that clot had been encountered in the antrum and on the way through into the duodenum and it was, therefore, assumed that bleeding was coming from a duodenal ulcer. In fact, he proved to be bleeding from a different lesion and did not require emergency surgery. Imprecision in communication might, in this patient, have led to a real disaster. My cerebral files are full of similar circumstances so the matter is not at all a trivial
C O M M U N I C A T I O N IN C L I N I C A L M E D I C I N E
one. You will, I am sure, be aware how persistent labels attached to people can be: it happens, as I ruefully know, to us all. It is all too easy for a patient to be labelled by slipshod interpretation and communication and then for this label to accompany him throughout his medical career and often to his detriment. A good instance in the past was inflammatory bowel disease where a diagnosis reached on inadequate grounds - in the wrong frame, as I shall try shortly to explain - may lead to labelling and to complex and dangerous treatment over many years, by which time the origins of the label have been forgotten. A sloppy professional vocabulary is very apparent in our ordinary clinical speech and, though not often damaging, it is an affront to the nature of our calling. Students in particular, though others are not exempt, introduce 'seems to be's', 'slightly's' and 'sort of's' into their discourse as a way of hedging their statements around with conditionals. I am also impressed by the way that transient jargon phrases make their way into our professional speech. It is not that some of them lack colour; often the reverse. Rather, it is that they become, as Nigel Rees has recently told us (Rees, 1984), worn out by too frequent and too diffuse usage. At this moment in time I would dearly like to see the bottom line drawn to the ongoing situation of the use of such tired and often clichd-ridden phrases. Imprecision may also be the result of ignorance but it is more usually, in my experience, a cloak to cover uncertainty or a protection against a future debacle. Let me give you some examples - again, you might say, trivial - of both. I culled this piece of prose from a recent issue of a throwaway journal. 'However we would want to ensure that the private sector which is already parasitic on the public sector for both skilled staff and technology receives no undue subsidisation.' It contains an unnecessary conditional statement beloved of those who cannot bring themselves to be totally committed to what they say or write. It changes a noun, parasite, into an adjective, albeit a respectable one. It places an adjective so that, logically, it relates to two subjects when it is meant to relate only to one; not a serious fault in this context but sometimes an error that completely alters meaning. It uses an 'ology, technology, where a simpler word, techniques, is more appropriate. It resorts to the negative statement which, in addition to lacking formal logic - one cannot receive something that does not exist - is clumsy. Finally, and almost inevitably in this sort of jargon, it ends with an 'isation word, that transformation most loved by the bureaucrat. We can rewrite the sentence in plain English, as Gowers would have done. 'The private sector is already a public sector parasite for techniques and skilled staff. We want to ensure that it does not receive undue subsidy.' In this example, and somewhat to my surprise, we have not imparted a great deal of brevity, saving only three words or 9%, though 27 letters or 18%. Nevertheless, steady savings of this kind and the removal of obfuscation can greatly lighten the burden of the reader. You may regard such ruthless textual criticism as the
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mark of the small-minded pedant but i do not, of course, think this is the case. A scholarly approach is an end in itself but we must, in addition, hone our skills of expression, not just by cultivating simple forms of communicating our ideas but also by trying to be as logical as possible. Such facility does not come naturally to many but it can be developed. Unfortunately, the education of many of us has been more concerned with the grammatical than the logical structure of sentences and though these characteristics overlap they are not identical. I will not try to enter into a detailed dissertation on how logic can be achieved as this would be tedious in the extreme but I have found the following four principles useful. 1. Ideas should not contradict one another or otherwise violate logic. 2. All antitheses should be true ones. 3. The order of ideas in a sentence should not be such that the reader needs to rearrange them in his mind. 4. Sentences should be linked logically. They are derived from a seminal work, now unfortunately out of print, by Martin Hodges and the poet and classicist Robert Graves (Graves and Hodges, 1965). It is not without passing interest that the three individuals that I have quoted as guardians of clarity in expression and guides to achieving it - Housman, Hodges and Graves - are all of the arts, not the sciences. Let me turn next to the cultivation of imprecision and ambiguity as a method of taking out an insurance policy and, in doing so, come a little closer to home. Here we are talking about the coded messages that a sentence or statement contains as either a conscious or an unconscious action of their author. When a radiologist, or anyone else for that matter, says 'malignancy cannot be excluded', he may genuinely mean that there is insufficient evidence to exclude malignancy or that, alternatively, he is passing a coded message that he is hedging his bets in case, retrospectively, his interpretation of the evidence is shown to be wrong and malignancy is found. Nothing much wrong with that, but we should be conscious of the hedge. 'No specific features' has much the same connotation as well as containing the makings of a false antithesis in that the absence of specific features implies the presence of non-specific ones. 'The appearances are compatible with A or B or C' is, in my view, slightly more serious because it evades the issue of what happens if someone then proceeds as if A or B or C were present but this proves not to be the case. It is a method of saying 'but I am not responsible because I did not commit myself'. However, coded messages can also be useful in conveying your superiority, as when the radiologist finds a low-lying rectal tumour on barium enema. The report might justifiably then read 'a sigmoidoscopy might be helpful', which means in effect 'you fool you should have done one before sending the patient to the radiologist'. Some of these phrases also owe their origins to the feeling that we must make a statement in diagnostic or management terms when, in truth, we do not have enough facts_ There is in our current medical culture a lack of clarity about how far to reason from data available at any instant. My speculation is that the cause of this is the dominance of the pathological end-point in diagnosis which we owe to Virchov and which leads us to
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make pathological ascriptions to clinical and radiological circumstances, not because we truly can but because we feel we ought. To try to avoid this I have introduced the concept of a frame of reference which I define as a set of self-consistent data having a common vocabulary. We should, I feel, constantly during communication remind ourselves of the frame in which we are working and use only the vocabulary of that frame. It may, again, appear unnecessarily formal to say 'these are the mammographic features of carcinoma of the breast' but the message so conveyed is precise and does not seek to ascribe to this patient that pathological diagnosis. We can go on to formalise our clinical task as making an appropriate frame transfer so that we have the right information to allow us to act. Thus, a mammographic diagnosis of breast cancer does not permit me to undertake radical treatment of any kind; the frame must be transferred into the pathological. By contrast, an angiographic diagnosis of aorto-iliac obstruction would, if I was a member of the guild of entrepreneurial plumbers - I mean a vascular surgeon - permit me to go ahead without further ado to earn my daily bread. I should like now, and doubtless to your relief, to move away from what may seem to you the pedant's corner and engage with a much more complex and, in my view, serious problem in communication. I speak of the communication of intent or desire about a patient between the clinician in whose hands the individual is and specialists such as yourselves. Now, clinicians regard themselves as the shock troops of patient care, the men in the foxholes actually engaging the fell enemy disease. As with the combatant soldier, they see themselves as far superior to those behind the lines. As well as possessing this superiority, clinicians are also demanding of and complaining about the quality of support needed to pursue their task. Furthermore, they perceive that their decisions are automatically correct because they and only they are sufficiently close to the patient fully to understand what is going on. As every staff officer in battle and every radiologist in practice knows full well, this self view of the clinician is almost wholly false. In fact, he is sometimes too close to the action to see the broader picture; his tactics may be outdated by an adherence to what we could kindly call a conventional wisdom or, less charitably, an inflexible dogma; and he has failed to keep abreast of changes and advance in related fields. The last has been particularly true of imaging, where the technical strides that have been made in the last two decades have left the clinician reeling, not only in his attempts to understand the prestidigitations of the engineer and scientist - what ordinary or even extraordinary clinician practising in my hospital could give, for example, even a semicoherent account of nuclear magnetic resonance? - but also in his ability to take on board the potentials of the new imaging to change the conduct of his practice. The conventional model for the consultation with a specialist department, which flows from this primacy the clinician feels he has, tends to be of the kind shown in Fig. 1. At some encounter with the patient ward round, out-patient session Or case conference - it is thought that a particular image will help elucidate the problem. This thought is communicated either by mouth or by the written word and often by a more
Ward round decision by consultant
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~
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Fig. 1 - 'Conventional model for consultation with a specialist department'.
junior member of staff. Most of the time this works but it is prone to error, bias and inflexibility. We are all familiar with the errors produced by the inevitable compression required to get the clinical details thought relevant to the patient's problem onto the request form and the difficulties encountered when neither the request nor the signature beneath it are comprehensible. These problems are the lot of all radiologists and the basis for legitimate criticism of clinicians. More serious problems arise when the radiologist is better informed about the available options than is the clinician: a new definition of disadvantageous negative feedback may then emerge, either because a different investigation is done from that which the clinician requested or, increasingly today, because some action follows, such as the drainage of an abscess or the needling of a mass for diagnostic purposes. Most of us here today will recall examples from our personal experience where this communication mismatch has done nothing to advance the patient's cause or to further interdepartmental relations. Part of the solution to the problem lies in more sophisticated communications within the hospital. We in this country are grossly understaffed, both professionally and in support such as secretaries, and this inhibits communication. Though I am sceptical about the electronic revolution that is always being dangled before our eyes, there is no doubt that if a member of clinical staff could type the details of an investigation request into a computer terminal which would then automatically lodge these in the X-ray department's electronic mailbox it would be possible for a great deal more information to be painlessly transmitted. If I may digress for a m o m e n t to include also the other side of the information transfer - getting the results of any form of imaging to the person who needs them - then the same arguments apply. In my hospital, again mainly from lack of resources and not from unwillingness of my colleagues to help, surgical junior staff may spend up to 15 hours a week hunting for images so that they can make a coherent and comprehensive presentation of clinical problems to the team. How much better would be the use of overall digital imaging with a local area network to transmit the information where it is needed on an instantaneous basis. Far-fetched, you may say, but not in fact so: Fig. 2 shows one facet of a design study which is being undertaken at St Mary's for a completely filmless department. Nothing illustrated here is beyond the state of the art - ouch! I have used a jargon phrase so I might as well compound it by saying at this moment in time. These are technical fixes for closing the loop of information request and production. They are impor-
COMMUNICATION IN CLINICAL MEDICINE EXISTING SOURCES O:: ELECTRONIC IMAGES
OF
USERS IMAGES A N D OTHER DATA
LOCAL AREA NETWORK
FUTURE SOURCES OF ELECTRONIC IMAGES
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Fig. 2 - Electronic picture archiving and communication.
tant but not so much as is the consequent need to review the radiologist's role. A combined approach to the patient's problem is now much more often desirable. It is, indeed, necessary for the clinician to abandon his view that he is, ex officio, primus inter pares. Equally, it is necessary for the radiologist, as he or she becomes a participant in the decision-making that goes into organising a plan of investigation, to engage with more than a merely technical task. This is the more true as interventional radiology becomes more and more accepted as conventional therapy. The role of the diagnostic radiologist is becoming increasingly akin to that which the radiotherapist adopted long ago. I am sufficiently old to recall the bitter demarcation disputes that used to take place over how much the radiotherapist was entitled to take independent action; such would now be inconceivable but we have still a good distance to travel and much communication work to do before we have the same easy and comfortable situation at the new frontier of interventional radiology. Again, the clinician must modify his longstanding dominance; but the radiologist will also have to learn to stand up and be jointly responsible for outcome as well as technique. You will then have to join us in that field of uncertainty that constitutes clinical practice and share our anxieties and occasional anguish. As so often happens when the therapeutic ground shifts, it become difficult to know who owns the patient or perhaps, in deference to any lay people here today, which doctors the patient possesses and can draw on. This is a problem that can only be resolved by good communication between those individuals and groups that have separate skills to bring to bear on a problem. Perhaps the way ahead has already been charted by the increasing confidence in the radiologist that
must be displayed by the clinician over dynamic imaging. We have always, in relation to such things as barium meals and barium enemas, had to take on trust, sometimes supplemented by retrospective discussion, what the radiologist saw. To a much greater degree now we can see it with him through the medium of videotape. This, in turn, has led him or her to be more closely involved with clinical discussion. Specialist groups have emerged, such as cardiological, gastroenterological and vascular, who will work together both in designing investigative and therapeutic sequences for the patient and in reviewing the results. Yet the growing edge remains ragged: for example, I see no unanimity of opinion about the best way to investigate the patient suspected of having gall-stones. I, on the one hand, want an investigation which tells me both that the patient has cholelithiasis and what effect the stones are having on the function of the gall-bladder; most radiologists seem to contend that all that is needed is to demonstrate the presence of the stones by the simplest and most economic method, ultrasound. A middle ground will, doubtless, emerge but it is a slow process. I am concerned also about feedback in new imaging areas, such as ultrasound or the more sophisticated forms of radionuclide investigation. In the forties and fifties surgeons and radiologists rewrote the anatomy of the heart as a consequence of the great surge of activity which followed the introduction of open heart surgery but, as I recall, they did so in close co-operation. I do not always see the same detailed check being made of ultrasound findings against what is ultimately revealed by laparotomy or thoracotomy and I have to confess that good ultrasonographers are also, at times, gifted with imaginative rather than deductive powers. It is, of course, my role to see that they are better informed about the real world, just as it is theirs to accept my
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findings. Communication breaks down when it is impossible to convince someone that what they interpreted is not, in fact, present, just as it will also break down if the clinician refuses to acknowledge that what the image shows is right. Mutual tolerance through close communication is mandatory. Though we have never in this country, i am glad to say, adopted the Scandinavian practice of centring a clinical round on the X-ray department, thus giving the radiologist a territorial advantage, we do need increasingly to bring the radiologist to the bedside and the clinician to the X-ray conference. Such statements may be old hat to many of you but I would hazard a guess that, up and down the country, less than 20% of images which would benefit from consultation are reviewed together. Now, Mr President, I am aware that I have concentrated primarily on the diagnostic side of the work of your College to the neglect of its established major commitment to therapy, of which you are a representative. For this I apologise. Skills in intercommunication are as necessary to your field as to the diagnostician. I have mentioned that radiotherapy has a more secure place and the combined clinic for the management of malignant disease is now a commonplace. It establishes common ground on which exchange of ideas and views can take place and without which the patient is a rubber ball bouncing from place to place, bereft of a doctor personally responsible for his management. In the increasingly complex world of surgery, radiotherapy, chemotherapy, hyperthermia and the laser this is wholly unsatisfactory. But it is no use bringing people together solely on the basis of complementary technologies; they must also have a
common goal through sharing a common vocabulary and styles of thinking. Now I come - thankfully, you may say - to my end. This lecture was endowed in the hope that those who gave it would address the subject of breast cancer or some other related topic which might interest radiologists. No one in his right mind can feel comfortable tackling the enigma of cancer of the breast, it remains, in my view, a biological conundrum which will require much deeper understanding in that frame rather than the clinical one before we, as relatively crude therapists, can make a significant impact on its long-term ravages. ! would only like to say that during my professional lifetime it has been two radiotherapists in particular, Robert McWhirter and Diana Brinkley, who have given us the most understanding of the nature of, if not the solution to, the biological problem and they deserve our belated thanks for so doing. However, Miss Skinner, in her wisdom - or perhaps helped by the wisdom of your Councillors of the day provided the enabling clause that has permitted me to ride one of my many hobby horses. In doing so I would like to thank the College for the privilege and to hope that you have found my meanderings not wholly without interest_
REFERENCES Graves, R. & Hodges, A. (1965). The Reader Over Your Shoulder. Jonathan Cape, London. Rees, N. (1984). Worn-out words. Telegraph Sunday Magazine, 4 November, 53-57. Steiner, G. (1978). Has truth a future? (the Bronowski lecture). The Listener, 99, 42-46.