Not Too Bad

Dr. Javier Ortega had been a consultant surgeon in Aberdeen for exactly four months when the complaint arrived. It was not, the clinical director assured him, a formal complaint. It was "a bit of feedback". A patient's daughter had written to say that Dr. Ortega had told her father, within ninety seconds of meeting him, that the scan showed a tumor, that it was large, and that without an operation he would probably not see the summer. All of which, Javier pointed out, was true.

"Nobody's disputing that," said the clinical director, a mild woman called Dr. Fiona Grant who had a habit of agreeing with people right up until the moment she didn't. "It's not what you said. It's the order you said it in, and the speed, and the fact that he was still in his coat." She suggested, very gently, that he might like to shadow one of the senior nurses for a few clinics. "Just to pick up a few local habits," she said. "We do things a wee bit differently here."

In Valladolid, where Javier had trained, bluntness had been a form of respect. You did not waste a frightened person's time. You told them what was wrong, what you were going to do about it, and what the odds were, and then you answered their questions. Softening the news struck him as a kind of condescension, as if the patient could not be trusted with the facts of their own body. He said as much to the nurse he was sent to shadow, a woman called Morag who had worked on the ward for twenty-six years. Morag listened, nodded and said, "Aye, well. Come and meet Mrs. Gauld."

Isobel Gauld was eighty-two, a retired primary school teacher from Stonehaven, and she had been admitted the night before with abdominal pain that she described, when Javier asked her to rate it from one to ten, as "a bit of a nuisance". Her notes suggested that it was considerably more than that. When he asked how she was feeling, she said, "Oh, not too bad, Doctor," and then winced so sharply that she had to hold the bed rail.

Javier had studied English for years, and he had passed every exam with ease. Nothing in them had prepared him for a country in which "not too bad" could mean anything from "perfectly well" to "in considerable agony", in which "I'm not sure that's ideal" meant "absolutely not", and in which "it's a bit chilly" might be said, as he had personally witnessed, during a snowstorm. At first he found it maddening. Then, slowly, he began to suspect that it was a language with rules of its own, and that he had simply not learned them yet.

Over the following days he spent more time at Mrs. Gauld's bedside than his schedule strictly allowed. She asked him about Spain and told him, with great precision, which of her former pupils had gone on to disappoint her. When the results came back, they were not good: there was a growth, it would need to come out, and at her age the operation carried real risks. Javier rehearsed, in his head, the way he would once have said it. Then he sat down, which he had not always done, and waited until she had put down her newspaper.

"Mrs. Gauld," he said, "I'm afraid the scan has shown something we need to talk about." She looked at him steadily over her glasses. "Is it the kind of something," she asked, "that people bring grapes for, or the kind they bring flowers for?" He hesitated, and in that hesitation she read the answer. "Ah," she said. "Well. That's a bit of a blow." And then, after a moment: "You'd better tell me all of it, son. I taught eight-year-olds for forty years. I can cope with anything."

So he told her all of it. He did not leave anything out, and he did not make the risks sound smaller than they were. But he told it in a different order: what they had found, then what could be done, then what might go wrong. He paused when she needed him to pause. He let her ask the questions rather than answering ones she had not yet asked. And when she said, at the end, "So it's not great, then," he found himself replying, "No. It's not great. But it's not hopeless, either," and realizing that it was, in its way, the most accurate sentence he had spoken all week.

"You see, Doctor," she said, "you think we say these things to avoid the truth. We don't. We say them so that the other person can choose how fast to walk towards it." She patted his hand, as though he were the patient. "Honesty's not a bucket of cold water. It's a door. You can kick it open, or you can knock." Javier wrote that down on the back of a drug chart the moment he left the room, and later had the good sense to copy it somewhere more permanent.

The operation took four hours and was, as he told her daughter afterwards, "as successful as we could reasonably have hoped". It was not a phrase he would have used a year earlier. He had once regarded such phrases as evasions; he now understood that they could be the most honest thing available, because they told the truth about uncertainty itself. Mrs. Gauld spent eleven days on the ward and was discharged, at her own insistence, in time for her great-grandson's christening.

Some months later, a card arrived at the hospital addressed to "The Spanish surgeon, Ward 209". It showed a picture of the harbor at Stonehaven under a gray sky. Inside, in very neat handwriting, it said: "Feeling not too bad. Which, as you now know, means very well indeed. Keep knocking. I.G." Javier pinned it above his desk, where it remains, and where junior doctors occasionally ask him what it means. He usually tells them it is a long story. Then, if they have time, he tells it to them, slowly, in the right order.