The consulting room
Patients' consultations with surgeons in the main consulting room were highly public, and regularly involved the whole multidisciplinary team. The door was opening and shutting throughout, which allowed other professionals to move between the different areas in the clinic - to 'float about', as the dietician put it. There was always talk and movement in the background. The lack of privacy in this central consultation reflected a real dilemma. Having the team gathered together allowed for
Figure 9.1 The layout of the head and neck cancer clinics Note: Key: Consultation areas and their use by different professionals.
multidisciplinary discussions to take place and decisions to be jointly made; and yet, at the same time, created a situation in which assurance of comfort or confidentiality for the patient became practically impossible. Patients felt deterred from asking questions in the main consulting room, as illustrated here, where this patient describes how different doctors gathered to observe the unusualness of her case (see also Extract 6):
When you find out you've got cancer, and when you go to see [lead surgeon], and he's telling you what's happening, and there's a whole team of people around him ... you're just confronted by a load of men ... and that can be very off-putting. It can be very difficult to ask questions - because they're all looking at you.
(Patient with facial cancer, Interview, A-310)
Recordings of the various interactional encounters showed that patients would reserve their questions for the follow-up consultation with the nurse (see Extract 5), or ask those questions in the corridor, during informal encounters with the nurse, speech and language therapist or dietician (see Extracts 7 and 8).
Because the doctor's input and expertise were confined to the main consulting room, these consultations (with the head and neck cancer surgeon and other clinicians such as the radiologist and the plastic surgeon) contained all the topics within the surgeon's remit (i.e. decisions about surgery, and descriptions of what the surgery would involve). In the case of newly diagnosed patients, this meant that these consultations proceeded immediately from the delivery of the cancer diagnosis to discussion of treatment. This gave priority to the treatment to be provided, and to a certain extent precluded reflection or discussion of patients' concerns regarding the diagnosis and the treatment. The following example illustrates how the surgeon begins by confirming the diagnosis of tonsil cancer, and in the next turn resumes a discussion begun the week before with the patient about possible treatment:
- 1 Dr: ... there's no doubt in my mind that you've got a tumour in your tonsil,
- 2 (0.3)
- 3 Dr: Okay? .hhh and as I said to you last week I think that there are .hh two
- 4 ways of
- 5 Pt: Doin' it
- 6 Dr: Doing that ...
- (Consultation, B-348-102)
This sequence illustrates a pattern identified in surgeons' consultations in this study: proceeding from presenting the diagnosis (line 1) to talking about treatment (lines 3-4) either in the same turn, or in two consecutive turns, with no intervening contribution from the patient (see Collins et al., 2005).
The surgeon continues by describing the operation and the possibility of radiotherapy afterwards, and this presentation of treatment concludes with the surgeon recommending the operation as opposed to doing nothing (lines 7-8):
- 1 Dr: ... having the operation will be (0.3) not the most pleasant experience
- 2 b't I-I you know I wouldn't suggest it if I didn't think it (.) was an
- 3 appropriate course of action,
- 4 (0.4)
- 5 Dr: An I do::,
- 6 (0.4)
- 7 Dr: An I think that (.) yee- as you say, h the other alternative to do nothing, is::
- 8 (.) you know, (.) just (0.5) a hundred percent gonna fai:l,
- 9 (0.4)
- 10 Pt: That's right.
- 11 (0.3)
- 12 Dr: .h So uh
- 13 (0.2)
- 14 Pt: I don't think I have a choice:.
- 15 Dr: No:. not really,
- 16 (0.2)
- 17 Dr: Not really, =
- 18 Pt: =uh: in that f- in that re- respect.
- 19 (0.7)
- 20 Dr: SO, I was planning on doing this a week next Tuesday.
- (Consultation, B-348-102)
The patient expresses agreement ('That's right' line 10; 'don't think I have a choice', line 14), and the surgeon presents the upshot ('SO ... ') of his treatment proposal by stating his plan for when the operation will be done (line 20).
In the main consulting room, in addition to how the structure and pace of the head and neck cancer surgeon's presentation of diagnosis and treatment limited early opportunities for patients to express concerns, there are constraints on how much information can be covered, given the multiple inputs from different doctors, and the necessity of talking about several areas of treatment in quick succession:
I often feel when I'm called in to see the patient, they've already seen enough doctors and are having a job coming to terms with the fact that they're gonna have to come into hospital very soon for a very serious operation ... which will result in that they might never be able to speak or eat normally again. And that they're gonna perhaps look quite deformed. And they've had to take that on board within a space of twenty minutes or even less.
(Interview, Plastic Surgeon, A-104)
Surgeons' talk in the main consulting room carried statements of intent and action couched as forms of reassurance, and (as professionals reported in interviews) came at the cost of progressing patients' understanding of their condition and its treatment:
I tell them they've got cancer and I try to deliver it 'the bad news is you've got cancer; the good news is that we can give you good treatment and you stand a very good chance ...' even if that means that initially, I will gloss or put a very good spin on the outcome.
(Interview, ENT surgeon, A-133)