The right thing to say

The right thing to say

Vijay Gopichandran


It is very challenging to exactly know the right thing to say and end up saying it. Often in the flow of conversations, we say things that can be interpreted in other ways than what we intended. Today I saw a patient who had a cough, cold, breathing difficulty, chest pain for three weeks now. He has been coming to me for the past three weeks, every Sunday. When I saw this 18-year young college boy today for the third consecutive week, I started getting worried. What is wrong with this guy? Why is his symptom not going away? I examined him thoroughly. I found that the air entry in his right lung was diminished. He was also pointing to the lower part of the right side of his chest and complaining of pain. So I clinically diagnosed him to have a pleural effusion, the medical term for a collection of fluids around the right lung. The most common cause for this condition is tuberculosis of the lung. I know this boy’s father, as he is also my patient for diabetes. He had tuberculosis of the lung about 2 years ago and I had treated him at that time. He is completely cured now. So my index of suspicion was high, as this young boy had close household contact with tuberculosis. As tuberculosis spreads through air droplets, it is likely that this boy contracted the condition from his father.


With this suspicion in my mind, I sent the boy to the nearest X-ray center, about 10 KM away from the clinic, to get an X-ray of the chest. Towards the close of the clinic's timing, the boy returned with his father with the X-ray image. The X-ray clearly showed a condition called ‘fibrosis of the right lung with a right-sided upper zone fibro cavity’. This condition happens in tuberculosis of the lung. The right lung was damaged quite severely that there was practically no air entering the right lung and so there were diminished breath sounds. My suspicion was confirmed. In my clinical mind, I had an answer for the long duration of cough and breathing problems. I had an answer that could potentially be fixed. I knew exactly what treatment to give. He had to be started on tablets to treat the tuberculosis of the lungs.


In medicine, often the diagnostic process is a complex maze. Many times, we never arrive at a proper diagnosis and we are left standing with folded hands in submission to the uncertainty accompanying the lack of a clear diagnosis. This was not the case in this boy’s condition. I knew exactly what the disease was, and the answer was also quite clear. This gave me instant relief. If the X-ray chest had been normal, I would have been in deep trouble. I would have had to initiate other lines of inquiry to understand the cause of the condition. I may have to do a CT scan of the lung to study the finer details. I may have to do a lung function test using spirometry to understand whether the air passages are blocked, or any other chronic lung disease was simmering. Anyways, a normal chest x-ray would have meant a more complicated follow-up process. All this was not needed now, and I was immensely relieved that I had a diagnosis that could potentially be treated.


Combined with this relief of having a proper diagnosis, was the clinical excitement of picking up a diagnostic hunch just with the help of a clinical finding of a diminished breath sound on the right side. I was feeling self-congratulatory for a moment, that I had diagnosed tuberculosis of the right lung clinically with the help of a thorough clinical examination. In the era of the dying art of clinical examination, I felt rather proud to have arrived at this diagnosis and felt that my teachers would feel proud too if they were here to see this. This heady combination of clinical excitement and relief of having a clear diagnosis had me off guard with respect to what was the right thing to say to the patient.


I said to the young boy and his father, “The X-ray shows a condition called as fibrocavity of the right lung. This indicates tuberculosis.” I then pointed to the father and said, “your son has the same condition that you had 2 years ago. You became alright after treatment and similarly, he will also become better if he takes 6 months of treatment”. After I said this the father and the son, both had a very desolate look on their faces. The father became highly distressed and his eyes started welling up. I was not sure what I had said wrong. They both sat down with their eyes bent down facing their feet. I couldn’t understand what I had said wrong. I did not expect this kind of reaction. Here I had a clear diagnosis and a very clear plan of treatment and follow up. What is their problem now? I referred them to the nearest government health facility to initiate free anti-tuberculosis treatment. They walked out with a very disturbed and depressed mood. Despite my repeated encouragement and reassurances, they left the clinic very depressed.


We walked out of the clinic after we finished and were standing at the bus stand awaiting the bus. In the nearby tea shop, the young boy and his father were sitting sipping their tea. They still had the depressed countenance. As I stood there wondering what I had said or done wrong, the whole clinical encounter ran in my mind. I realized suddenly that I had indeed said an inappropriate thing. I had told them that what the young boy had was the same thing that the father had. I was not sure if that was the most appropriate thing to say. What I had said could have implied that the father gave his son the bad illness. It could have made the father terribly guilt-ridden. It could have made the son angry at his father for giving him the illness. I had only said that statement to make the diagnosis sound familiar, reassure them that ‘you have done this once already and have come out successful, you will do this again very well’, and help them understand that it is curable. But little did I realize that it could have the implication of blame, stigma, guilt, and anger.


As I started narrating this incident to my colleagues, one of them narrated an anecdote that she encountered today with a patient of hers. This was a young 12-year-old girl child who was brought by her mother, as the child had whitish discharge from her private parts. It is not usual for a young 12-year-old prepubescent girl to have white discharge from the genitalia. It may indicate some kind of forced sexual activity or abuse. So, my colleague carefully and sensitively approached the topic and spoke to the child as well as the mother. She was convinced that there was no evidence of any sexual abuse. But at the time of eliciting this history and having a conversation about this, she learned a very bad experience that the girl and her parents had with a previous doctor. The previous doctor had asked the child in her mother’s presence, “have you had sexual intercourse with anyone”. The child was completely shocked to hear this question and had started crying. The mother had expressed her displeasure at the way the doctor had asked the question and had taken her daughter out of the clinic. After that, both the child and the mother had been too traumatized to visit any doctor. They both had felt comfortable talking to my colleague as she had approached the topic gently and in a very friendly, non-intimidating manner. The other doctor had probably had the same intention as my colleague, to understand whether there had been any abuse. However, the other doctor had approached the question in a manner that sounded like judging a very young 12-year-old girl for indulging in precocious sexual activity. The intent was to help the girl, but the doctor did not know the right thing to say or do.


This is not only true in medicine. It is true in everyday life too. I recently had a small spat with a friend of mine. After a bout of heated argument, I had gone quiet. My friend texted me an apology message in which she said, “I am sorry. You are in a bad mental state, so I should have acted more mature”. It was not at all the right thing to text. The apology here was offered because she thought I was in a bad mental state. Not because of a genuine regret about all the bad things she had said in the argument. She probably meant to genuinely seek an apology, but what she typed in the text, implied something else.


It is not always possible to know exactly the right thing to say. Developing a keen sensitivity to other people’s feelings, empathizing with people and understanding that communication can often be tricky are the first few steps of being a sensitive communicator. My grandfather always said, “nothing comes out of the mouth that has not passed through the brain”. He meant that there is no excuse for saying things that we will regret later. In other words, he emphasized the importance of always processing everything in the mind before saying them out loud. This processing should be seasoned with a lot of emotional intelligence, empathy, sensitivity, and humility. Knowing the right thing to say and saying it sensitively comes with practice.