Pre-rounding was going well; the patients were getting better and the team was making record time. I commented to the resident how satisfied the attending would be with the efficiency of his work. He just laughed and said “look” as he gestured down to his list of patients. I saw the name, and a sense of dread sank in during the rest of the silent walk down the hall.
Having walked the halls many times in the past weeks, I knew exactly how close we were to the room. Fifty steps. Why do I feel this way? I got into medicine to help people. Twenty-five steps left. Why do I feel guilty? Time to focus, we are here. The resident and I paused, and our silence was broken by the creak of the door.
This was the textbook “difficult” patient, the one that I was warned about in my preclinical years. No matter what I did to help, any setback would always be my fault. It was frustrating at times, but I did what was necessary to help her while minimizing her effect on my mood as I cared for other patients. Looking back it is clear that her moods were a reflection of the massive uncertainty that had been suddenly thrust upon her; but in the moment, every time I walked towards her room I could not help but take her and her husband’s distrust personally.
One foot in the door and I was aggressively confronted by the gaze of her husband. I saw her lying tearful in the bed.
What did I do to deserve this forceful confrontation; have I been unkind? Why do I keep getting assigned to this patient? Was it a rite of passage? Was this a form of hazing? Was I somehow making her worse by being here?
“Hello ma’am, how are you feeling this morning? How has your pain been overnight?” I asked. She forcefully gestured to her arm but remained silent. Her arm appeared large and edematous, in stark contrast to her slight frame. Her peripheral lines from the previous day’s surgery were absent.
My guilt shifted to sadness. Did I really do this to her? Was it my fault?
“Well, you gave her a clot in her arm, that’s what,” said the husband. “She said from the start that she didn’t think she needed the IV antibiotics, now look at what you have done to her!” If the look the husband gave us carried the weight of his emotion, we would all collapse like a tower of playing cards.
How can he honestly think that we did this to her on purpose? I was doing the best I could. Why can they not see that I was only there to help?
She let out a soft whimper, her first sound since entering the room; I turned to her to offer comfort. Before I could make a sound, she cried out, “Go get the real doctor, I don’t want any more residents or students. You all are the reason I’m still here! Every time you do something I have to stay here longer.”
Why couldn’t I connect with her like my other patients? I looked towards the resident as he gritted his teeth and smiled; the look in his eyes told all.
“Ma’am, we understand that this is frustrating, but this does happen occasionally,” he said.
“I don’t care! First it was the abscess, now the clot. I thought that you were all here to help me, not make me sicker! I want you all to get out and tell the real doctor to come see me,” she yelled. “GET OUT!”
I silently nodded, turned, and retreated behind the resident, followed closely by her husband who slammed the door behind us.
It would always be my fault. I would be the one who gave her the abscess, sepsis and deep vein thrombosis. I would be the medical student feeding her “false information.” Each accusation slowly chipped at my sense of ability, allowing the doubt in closer.
Until one day…
“We’ve had a tough night,” her husband explained shamefully. “The surgical team came by in the afternoon to break the news.” I caught her gaze once again, but that day the daggers were replaced with a softness that was not previously present in her brown eyes. She did not speak, but her body language was humble and contrite. The attending slowly floated across the room to make therapeutic contact with the patient the way we are all taught in medical school. Did she deserve that sympathy after all she has put us through?
She had been diagnosed with not one, but two forms of cancer. She was the same patient whose words always seemed to cause negative emotions to well up, but the team no longer seemed to mind. There seemed to be an understanding that she now acknowledged our attempts in healing her. It was not to say that the past did not happen, as it will always hang in the air between us, but this change in dynamic seemed to re-energize the team.
The next day dread was not a prerequisite on the walk to the room as the team entered with heads and spirits held high. Why were they all so happy? Do they not remember how rude she was just the other day?
“Good news!” the first doctor in the room exclaimed. “Now that we know what we are dealing with, we should be able to get you home tonight or tomorrow. Your infection has resolved, and we can schedule your follow-up outpatient with the oncologist.”
“Thank you…” she said, “for everything.”
Then it hit me like the first forceful blow of chest compressions, as her first words in days burst through my continuous internal monologue. This isn’t about me.
Realizing that I was the problem, not me personally but my attitude, I stood once again lost in my own thoughts. At that point I should have thanked her, a name and a face never to be seen or heard from again. Before the realization had fully set in I found myself nodding and smiling as I left the room with the team. The next day she was gone, and in a week I would be too.
During the entire time I had spent with this patient, I had subtly been making our interactions about myself, asking why I was to blame, why I was inadequate. Perhaps it was a hunger to learn or a selfish need to prove that I am capable that temporarily overcame my normal character. Lost in my own frustration, I forgot that I was indeed doing my job, and doing my best to be there for her. The disparity between what the patient needed and what I anticipated based on previous patient interactions was unexpected. I had become accustomed to the generally positive interactions with patients as the team laid out the plan of action. Before this time, or in the time since, I have yet to encounter a patient who expressed such powerful raw emotions. While we did not always enjoy being the sounding board for her emotions, the team’s management of her numerous comorbidities freed her to safely explore her emotions without plunging into the depths of her uncertainty.
There is a fine line between patient care and caring for a patient. In our short four years of training we learn about appropriate patient care and effective decision-making. In contrast, caring for patients is something that continues to develop over the lifetime of a physician’s practice. This encounter forced me to really reflect upon my feelings toward this patient and others that I have had like her. I realized that while it may sometimes be uncomfortable, it is important to continue to do what you think is in the best interest of the patient, while tending to the needs of the patient as they work through their circumstances at their own pace. There will come a time in each of our careers where we will face these feelings of self-doubt, perhaps some sooner than I. It is not a race to some great revelation, rather it is more important how one reacts to these feelings and proceeds forward.
Doctors are not more than human. They are not like the glorified actors on television. They have bad days and emotions like the rest of us. But they have them on their time, trained to compartmentalize patient care from their own feelings.
By now she probably hardly remembers the medical student as more than a blip on her radar. This interaction turned out to be one that I will not soon forget. Many of my peers would likely refer to the case as “low yield” because it was a medically straightforward case, but her lessons extend far beyond any test.
Uncertainty is an integral part of medical training. Uncertainty in the differential, uncertainty in the effectiveness of treatment and most importantly uncertainty in yourself.
Trust in your training and welcome opportunities to grow.
Image credit: Grandparents (CC BY-NC 2.0) by Razortapes