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Breaking Boundaries and Finding Love in Patient Care

On a recent visit to my parents’ home in Upstate New York, just as the snow had finished melting and our tulips were beginning to sprout, my dad and I went out for a walk. As we made our way down our driveway to the railroad tracks-turned-walking trail that runs through the woods near our house, we bumped into one of my dad’s patients. With a hearty grin, the middle-aged man proudly told my dad how his morning blood sugars were improving. My dad beamed, and gave him a big high-five. Later, as we walked along the trail, he told me how thrilled he was to see this patient getting the exercise that would help treat his diabetes and high blood pressure.

As a medical student training at an academic medical center in Boston, I’ve learned to interact with patients in a different way than what I was used to seeing growing up in the household of a family doctor in a small city. As a first-year medical student, I was taught to set firm boundaries with patients. Many of the boundaries our medical ethics faculty instructed us in seemed completely reasonable: don’t have sex with your patients, don’t accept large gifts or cash, don’t try to diagnosis and treat your family members. These kinds of boundaries exist so that we won’t abuse the power that comes with being a physician or let our personal ties to a patient cloud our judgment.

Yet, in this extensive talk about boundary setting, we are also given the unspoken message that forming any personal connections with patients may be dangerous. Taking this cue and hoping to live up to the expectations of my professors, I practiced setting boundaries with the patients I saw in the hospital as a third-year medical student. I hesitated when patients asked me questions about where I was from or what medical school was like. I made sure to wear my white coat and drape my stethoscope around my neck for each patient encounter. I was polite and warm with patients, but rarely chatted about topics outside of medicine or tried to make my patients laugh. I didn’t go out of my way to follow up with them after they left the hospital.

After completing my third year of medical school — my first year on the wards — I was exhausted, worn thin and questioning whether medicine was the right path for me. I decided to do a rotation in a primary care clinic, hoping that I would again find something that I loved in medicine.

During that month, I paid a home visit to a woman in the early stages of dementia. As I drove to her home, I imagined what I might find. I was worried I would find her home dirty and in disrepair. I wondered if she was safe there, if she had enough food, if she might trip and fall. When I entered the woman’s home, I was transported back in time to a more youthful version of her world. The apartment was furnished with deep red velvet couches and adorned with crystal figurines. On the walls hung portraits of Frank Sinatra, Pope Paul VI and the woman and her now deceased husband posing in front of their Volkswagen bug. In the middle of her living room was a baby grand piano.

After she showed me where she kept her pills and how she kept track of her doctor appointments, I asked her if she would play the piano for me. She hesitated, but I persisted. As a violinist, even after months away from my instrument, when I play it again I feel I have come home. I hoped that in returning to her piano she too might find that homecoming.

The skin on her hands was paper-thin and each of her knuckles, deformed by years of arthritis, looked like a knot in a tree branch. When she sat down at the keyboard, she touched softly on a few keys, but seemed unable get her bearings. As she fumbled, I worried that I had pushed her too hard, forcing her to face the cognitive abilities she had lost. But she was steadfast. And in a few minutes, her fingers were dancing the full length of the instrument.

As I walked to my subway “T” stop after my last day at the primary care clinic, I was surprised by how sad I felt. After each of my prior rotations, no matter how much I had enjoyed parts of it, I was always relieved that it was behind me. As I tried to make sense of my sadness leaving the primary care clinic, I realized what I had valued so much about my time there: my patients had let me love them.

It’s scary to think of loving a patient. When we have been counseled repeatedly on boundaries and professionalism, love seems to have no place in medicine. In American culture, or at least my slice of it, we use the word love in funny ways. In one sense, we use it describe our romantic love. In another sense, we use it to express our enthusiasm for simple pleasures, like “I love mint chocolate chip ice cream” or “I love watching House of Cards.” Rarely do we use the word love to capture how we might feel towards strangers, casual acquaintances or patients. I was so uncomfortable with this idea that I might love my patients that I tried to get rid of that word and find other descriptors to express how I felt.

One evening after volunteering at a family medicine clinic, I, for some reason, Googled the name of the wise and energetic attending physician I had worked with. I stumbled upon a blog post she had written entitled “Doctor Dares To Use The L-Word.” In this essay Dr. Kirsten Meisinger acknowledged the same discomfort that I felt with using the word “love” in medicine. She too was taught the supposed necessity of rigid boundary setting in patient-care. Yet as a family doctor caring for patients as whole people who are part of families and communities, her perspective evolved. Reading her essay, so did mine.

She wrote, “I love my patients passionately. I think about them in the middle of the night. I worry about their kids and wonder how the last week of school went after I made them promise to study more. I feel the crumbling inside me when they talk about the children they left in a faraway country, the ones they talk to every night but have not seen in 10 years. I want to care for the children of the babies I delivered. Primary care docs care for you for life, over your entire family’s lifespan. What does it mean to be there for them for a lifetime without love?”

Loving my patients does not mean that I always like them, or that they don’t sometimes frustrate me. Instead, it means that I strive to speak to them and examine their bodies in ways that acknowledge them as human beings. It means that when they occasionally raise their voices at me, I hear that they are frustrated and asking for my help, rather than allow myself to become angry in return. It also means that I am not afraid of forging a connection, of making jokes, of laughing at their jokes, of telling them how awesome I think it is that they quit smoking. It is my way of signaling to patients, we’re not so different from each other.

In the emergency department on a chilly fall evening, I was preparing to suture a laceration on the leg of a middle-aged hiker. With my supplies, I brought out a big, 60-cc syringe which I would use to draw up water to wash out the wound. When my patient saw this big syringe, he focused on it for a moment and then asked me what I was going to do with it. I reassured him that it was just for water. He sighed, shook his head side-to-side and laughed to himself. He suggested that the next time I see a patient who needs suturing, I should show him that big syringe and, as a joke, tell him that’s what I would be using to poke him. I opened my eyes wide and I told him I would never do such a thing. Then, hesitantly, I told him that sometimes my dad plays pranks on his patients like that. I confessed, it made me a little nervous.

He laughed again, shrugged his shoulders and said, “When doctors act like themselves, I trust them more.”

Author’s note: Patient identifiers have been changed to protect patients’ identities and privacy.

Colleen Farrell Colleen Farrell (1 Posts)

Contributing Writer Emeritus

Harvard Medical School

Colleen Farrell is a fourth year medical student at Harvard Medical School. She is a member of the Student Leadership Committee of the Harvard Center for Primary Care, a guest editor of the AMA Journal of Ethics, and plays violin in the Longwood Symphony Orchestra, Boston's medical community orchestra. She is currently writing a memoir about her medical education. She plans to pursue a career in primary care.