Soon after I began my clinical rotations in medical school, I started to see it. It was subtle. At first, I didn’t even notice it. It usually happens during hand-over, when the night team fills in the day team on overnight events, including any new admissions. There is usually a pause, an interruption in the patient updates. As soon as they reach the new patient, the “difficult” one, the tone shifts.
In medicine, there is a narrative of the “difficult” patient. This is often manifested by talking about a patient’s “non-compliance” with a treatment plan or “non-cooperative” attitude in general. These language choices are subtle, but they are insidious. I see this narrative play out fairly regularly now that I am on clinical rotations, but it isn’t new; I experienced it even before I started medical school.
Fresh out of college, I accepted a job as a case manager at a local non-profit organization. My degree was in psychology, and I knew I eventually wanted to go to medical school. However, my coursework had done little to prepare me for my new task of helping clients navigate the unnecessarily complex network of American social support programs. I walked into my first day of work, naively and unrealistically confident in my abilities. I would quickly realize how out-of-my depths I actually was.
One afternoon not long after I was hired, my supervisor came into my office. He sighed. “I have a guy I’d like you to see.” His voice faltered. Apparently, this client had a history of multiple discharges from services due to lack of engagement. And yet, he kept coming back. After explaining this history, my supervisor began to back out of my office. “Also,” he added as an afterthought, “he has an anger problem.” With that, my journey with my most “difficult” client began.
It was rocky from the start. The first time I called him, he immediately started yelling: “What do you mean I’ve been assigned another new case manager?” My sympathy quickly turned into a muted frustration. I spent the next five minutes dodging personal attacks, but eventually, we settled on a time for me to pick him up for our first appointment.
Driving to his house the following Monday, I tried to ignore lingering doubts in my abilities. After parking and finding his door, I braced myself and knocked. Seconds went by, and I knocked again. No answer. Peeking tentatively through the blinds, I called him, but his number was disconnected. “Well, at least I tried,” I thought to myself. Though I am not proud to admit it now, a part of me back then was relieved.
A week later, he greeted me one morning with an angry voicemail, distraught that I had “forgotten” his appointment. I called him back, but the new number, too, was disconnected. We played phone tag for a couple of weeks before we finally made contact again. This time, however, he came in to see me.
Face-to-face for the first time, I found myself fighting the urge to match his frustration, and I could tell that he sensed it. Although skeptical and reserved at first, he eventually opened up and I hesitantly began to write down each of his requests. We decided to tackle getting him an ID first. We drove to the DMV together, mostly in silence. Waiting in line, he suddenly started talking — about his new job, his grown children, his best friend — and once he started, he did not stop. It was only later that I realized he was starting to give me his history — his real history, not the truncated version I had heard prior to our first meeting. After posing for his picture, ID in hand, he looked up at me and smiled. It was the first time I had seen him smile.
We met monthly after that and he never missed an appointment. Even when we did not have an appointment, he often left me voicemails just to update me on his life: “You don’t have to call back, I just wanted to tell somebody.” On one such voicemail, he proudly revealed to me that he had started going to Alcoholics Anonymous (AA) — and then he thanked me.
At that point, it might have been easy to be self-congratulatory, but I had not done anything special; I didn’t even remember talking to him about AA. I realized that he had never been angry at me — he had simply not trusted me, at least not at first. And why should he have? For years, he was tossed around from case manager to case manager, bearing his story anew every time he stepped foot through the agency doors. What he needed, more than support, was consistency, and we had failed to give him that.
During our last appointment, we talked for almost an hour. As he talked, I reflected on my year with him. What had started as a contentious relationship had blossomed into one of mutual respect. Without me realizing it, he had become my favorite client. When he left, he hugged me and patted me on the back. “Good luck, little buddy,” he said, and then he walked out. I never saw him again.
Years later, I still think about him often, especially when the weather outside dips below freezing or during the blistering summer heat. Where is he living now? Is he still going to AA meetings? I carry these thoughts and concerns with me as I visit patients every day. Sometimes I see someone that reminds me of him, and I smile.
I am in my third year of medical school now and plan to train in psychiatry. Since starting this clinical phase of training, I’ve seen how easy it is to get caught up in the minutiae of patient care and forget about the people behind each door. When we walk into a patient’s room, though it may be our first visit with them, it is not their first visit with us. Most patients have complex relationships with the health care system and carry that narrative with them each time they enter the hospital or clinic. As providers, it is our responsibility to look past any surface-level emotions that might be masking a patient’s deeper insecurities, borne out by a history of mistreatment or distrust in the healthcare system. Like it or not, we as providers are a part of this narrative. How we contribute to it is up to us.
Image credit: Shadows (CC BY-NC 2.0) by ana branca
Contributing Writer
University of Oklahoma College of Medicine
Zachary is a psychiatry resident at the Medical University of South Carolina. He graduated from University of Oklahoma College of Medicine in Oklahoma City in 2023.