Be the bad guy with good intentions

“You’re not sorry.”

Within two days two different patients said this to me, each with hatred in his voice.  Each time I was alone, each time I had known the patient for only a few minutes, and each time the rage was directed at me and only me.

For seven months, I had avoided being the bad guy.  When a patient got upset, he accused my superiors, and I hid behind their authority with relief.  With no power came no blame.  I would offer sympathetic eyes during the blow-outs and weigh how much of what the patient perceived was in line with reality.

The last two episodes were on an entirely different level, not because of their intensity but because no one but me stood there to shoulder them.  Now I see patients alone and project a greater air of confidence, which naturally leads some to believe that I am the one making their decisions.  My usual intellectualization and analysis were non-existent; I experienced a pure visceral response.

The first episode, in retrospect, was merely a preamble.  I walked into the clinic room and was greeted with “You’re 45 minutes late.”  I apologized.  The patient insisted I wasn’t sorry but that I was unprofessional.  I don’t quite remember all the personal attacks he added over the next few minutes because my sympathetic system had taken over: my cheeks flushed, my heart pounded, and all I wanted to do was flee.

I managed to squeeze out that we were running  behind because we spent more time with sicker patients than we had anticipated.  What I wanted to add was that he was setting us more behind.  What I wanted to add was that even though his appointment was only for 20 minutes, we would spend more than 20 minutes with him, like we did for every patient.  What I wanted to add was that his behavior was self-fulfilling: suddenly I wasn’t sorry anymore.

Instead, I withdrew.  I’m fairly certain I took a less thorough history with him than I do with other patients.  I’m pretty sure my plan was more rushed since he questioned my judgment at several junctures.  I know that all I wanted to do was get out of that room and away from an unpleasant person that I had originally wanted to help to the best of my ability until he compromised my ability to help him.

The following day, I was back in the hospital with a much sicker patient.  I walked in to do a physical exam and the patient demanded that I get him food.  I explained that he couldn’t eat independently because he was at severe risk for swallowing the wrong way and having the food go into his lungs and causing an infection.

“You f*cking b*tch,” the patient yelled as loudly as he could with his weakened voice as he tried and failed to get out of bed and reach his food.  I apologized and once again I heard the cutting response: “You’re not sorry.”

Again, I felt the familiar flushing as the patient called me creative names and instructed me to do creative things.  This time, I had no response at all.  After the first minute, I felt sorry that the patient was hungry and couldn’t eat.  I felt sorry that he had such poor hand dexterity that he needed someone else to feed him.  I felt sorry that he didn’t deserve the medical hand he had been dealt.

After several minutes though, my empathy faltered and finally gave out.  My thoughts turned from the patient’s plight to a more inward stance: I don’t deserve this.  That single thought amplified until the hungry patient in front of me no longer existed.  I don’t deserve this.  I knew it wasn’t personal because he would have screamed at anyone who happened to stand in my place.  But at the same time it was personal because it happened to be me.

I didn’t say much and walked out, feeling shaky.  More disturbing thoughts snaked their way into my consciousness and wouldn’t let go.  No, I wasn’t sorry anymore.  No, I didn’t really care what happened to him.  And then probably the worst thought I’ve ever had in my life: in that moment, I didn’t really care if he lived or died.

With that realization, I found a bathroom to cry in for about half an hour while I ignored the page from my resident inviting me to get lunch.

Within an hour, my limbic brain had yielded to my cortex and I was able to analyze what had happened.  Ironically, it was the analysis rather than my raw emotion that brought back empathy.  I reread the patient’s notes, talked to his son, and felt as though I had a better grasp on the reasons behind his intense anger.

Within a few hours, the patient was transferred to the ICU.  (Thankfully, the turn of events was unrelated to the care I did or did not give him.)  Half of me felt sorry but the other half still felt relieved that I would not have to see him again.

During our psychiatry rotation, we had had a lecture on how to think about “difficult” patients.  We were encouraged to think about the feelings of helplessness, uncertainty, anxiety, and fear patients felt, in addition to the destructive medical processes impairing their minds and bodies.  We were told never to forget that context when we dealt with someone whose behavior didn’t conform to our expectations of how a “good” patient should act.  It was a very valuable lecture, and I sat in the safety of our conference room absorbing it.

On the floor, feeling vulnerable and alone, feeling attacked and helpless, I lost sight of that lecture.  I was feeling the same things my patient most likely felt, yet to a fraction of an extent.  Although I didn’t verbally abuse anyone the way he did, my internal verbalizations were probably just as abusive.  Destruction need not be loud and it need not be an action.  Perhaps it begins with a thought,  one that snakes into your consciousness and amplifies.  Perhaps it ends in inaction, with you walking out of the room too early.

On the first episode of Scrubs, one of J.D.’s first patients passes away suddenly from a pulmonary embolism.  He narrates.  ”I’ll never forget that moment.  The way he looked exactly the same only completely different.  The shame that all I could think about was how hard this was for me.”  Seven months after I have started this thing called hospital medicine, I have finally felt that shame.

Before I wrote this post, I checked on that patient’s status.  He had recently passed away.  I hadn’t known.  It hadn’t been an expected event.

I wonder if I had known how close he was to death if my thoughts of him would have changed in that moment when our lives intersected.

I also know that the answer shouldn’t matter.

Here’s to the start of being the bad guy with good intentions.  Here’s to the start of trying harder, of keeping those good intentions during the most difficult moments–those when no one else believes you have them.

Note: Certain patient details have been changed to preserve anonymity.

Shara Yurkiewicz is a medical student who blogs at This May Hurt a Bit.

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  • azmd

    Here’s a question:
    When is it OK to set limits on a patient treating you abusively? When they start to physically assault you? What makes it acceptable for a patient to be verbally abusive?

    • themedstudent

      She’s a rich, greedy doctor (er.. med student… same difference) so she deserves it. Should have been a nurse if she really wanted some serious respect.

      • azmd

        Although I realize that the saintly martyr doctor archetype is an important part of our medical culture, I think when the patient is so abusive that it distracts you from providing decent care, the interaction is unproductive and should be terminated until the patient can regain his composure.

      • blynn29

        that’s really low. and how do you know she’s rich or greedy?

      • Jimmy John

        What? Nurses don’t get the respect they deserve. What planet are you from?

    • blynn29

      i have been a registered nurse for 32 years and i am very aware of a patient’s helplessness, fear, and lack of control and have strived to give them a feeling of as much control as possible to alleviate those feelings. But no one has the right to heap abuse out on me. Everyone, in healthcare or otherwise, has the right to tell the person ‘ i am not comfortable, (or i don’t like, or i won’t stand for,) with you calling me names, cussing me out, (whatever) and i will return if and when you can control yourself’.. and then walk out. no ONE deserves to be cussed at or yelled at.

      • http://www.facebook.com/wendy.hanawalt Wendy Belgard Hanawalt

        I have found that when I say it just as you said it — “I understand how you feel, but I don’t deserve to be spoken to in that way” — nine times out of ten, the person apologizes.

        • blynn29

          YUP

    • Suzi Q 38

      Sure you can.
      Of course if it rarely happens, you can pass it all off as an errant, “crazy,” patient. There are those, you know.
      On the other hand, if it is happening more frequently, maybe you are projecting a lack of empathy or poor attitude.

      I remember that I needed to know if I had M.S. or not. The results were in, and I had asked the doctor to call me or have his nurse call me with the results as soon as possible, as I was very worried.

      Not only did they forget to call me, but they did not respond to my TWO phone calls for information. I assumed since no one called me I had M.S. I decided to go to the hospital and find the doctor, who was not working that day. His nurse was working at another part of the hospital. I decided to get the nurse at that unit to call the other nurse or my doctor. She wanted to know in front of a room full of patients why. I told her: “I have been waiting for a week as to whether or not I actually have M.S., DO YOU MIND??? I am not leaving until I have an answer.” My next stop was the patient advocacy department. I didn’t know what else I had left to do to get my answers.
      After all of that, I learned that my results were negative, and they could have saved me a lot of grief and heartache with just one phone call or following up on my TWO phone calls. Maybe a diagnosis of M.S. is no big deal for a neurologist and his nurse, but it was a big deal for me.

      You may be doing your jobs to the best of your ability, day in and day out. Ditto for night work.

      For us, our health is our lives. what is not a big deal to you, may be a big deal to us on top of a series of unfortunate events in and out of your control.

      In other words, that day may be that you were late. Maybe, that was merely one little thing that happened on top a litany of big and little things that have happened to that particular patient. So he or she decided to let it all out on y our particular visit. Sad for you.

      I think it is rude for a patient to say: “You’re late.”
      What is that supposed to prove? That he/she did something wrong? My PCP used to always be late.
      Now I make my appointment at 8:30 AM, 2:00PM, or 4:00PM.
      I only have to wait about 10 minutes if I do that.

  • http://www.facebook.com/shirie.leng Shirie Leng

    This sort of scenario has happened to all of us doctors. It also happens to waiters, bank clerks, bus drivers, anyone who encounters the public on a regular basis. While we are professionally obligated to treat all our patients with respect, we are not obligated to sustain physical or verbal abuse. Everyone has the right to a certain level of respect. I see nothing wrong with walking out on such a person and finding someone else to provide care for that person. It is impossible to do a good job under such circumstances, and any error or omission is likely to be blamed on the physician. Everyone talks about patient rights, but doctors have rights too.

    • http://www.facebook.com/people/Jason-Simpson/100001631757606 Jason Simpson

      I agree. I worked at Taco Bell as a high school student and now I am a doctor. I took much more abuse in the Taco Bell drive thru than I did as a physician. People would throw food thru the window, curse obscenities, try to grab you thru the window, etc.

  • AuthenticBioethics

    It has been said that people say and do things to communicate something other than what they say and do. If I offer my wife a cup of coffee, it’s more than about the coffee. The patient’s reaction was less toward the doctor as the doctor, than to the doctor as the personification of everything that is wrong with his world. The exclamation “f-ing b-tch” was not about the doctor, but about everything else, with the doctor as the latest occasion of frustration. And even if the patient really wanted to eat, the request for food represented more — it’s a test the patient used to prove to himself that everything is going wrong for him. And in this case, the doctor unwittingly affirmed that, and hence the patient’s reaction. When we are on the receiving end of such words, whether one is a doctor or a waiter, it is VERY hard to see them in this context.

    I am not a doctor, but I have had to deal with irate clients — and who hasn’t dealt with an upset friend or relative? But if we can try to see what is really bugging the other person, then we can see that the apparent abuse is often really directed at a third thing. We don’t take it so personally and we can actually take the other’s side and become an advocate. We can begin by solving the immediate demand — by passing the test — if the food was in the room (he tried to reach for it), why not call in someone to feed the guy? We all tend to think that everything is about “us” — but sometimes what seems to be about “us” is really not, and it sometimes hurts our egos to know we are not really so important – that we’re not really who the other is mad at, that we’re not really the problem, that we deserve to be treated better by someone whose life is falling apart. I find it helpful to go into these situations with the attitude, “it’s about the other, not me.”

    • azmd

      There is a certain point past which behavior is unacceptable, even if we are able to understand it as directed not at us, but at some other circumstance about which the patient may be distressed.

      Doctors are not robots. We have feelings, and they legitimately include the feeling of being flustered and upset if a patient is verbally abusive. A doctor who is flustered will not be able to function effectively, and so trying to tolerate an abusive patient is not in that patient’s best interests.

      A doctor is there to provide medical care for the patient, not to serve as a vessel for bad feelings that the patient may have at that particular moment in time. It is condescending to our patients to assume that they are so ineffective that they need us to process their feelings for them.

      • AuthenticBioethics

        I basically agree with you of course. But I am not justifying abusive behavior or saying patients have a right to be abusive. But the question is, What do you do in the face of that behavior? Say to yourself, I don’t deserve this (which is true)? He shouldn’t treat me like this, even if he is in pain and his life is falling apart and hes afraid of dying (which is also true)?

        It seems to me tha in those moments it isn’t very effective to dwell on the fact (yes, fact) that one is the victim. As the recipient of an injustice, one can either let it pass or demand justice.

        A lot also depends on circumstances. Someone becoming abusive over the doctor being 5 minutes behind for a routine blood pressure check up is way less understandable than a dying, pain-wracked fellow.

        I’m not saying its easy., either.

  • jsmith

    As the doc shortage hits big-time, this will get worse. Have you considered cosmetic dermatology?

  • PoliticallyIncorrectMD

    You should NOT be sorry. Behaviors like these are the result of twisted culture of entitlement and political correctness. They are inexcusable. Walk away and help those who want and appreciate your help.

  • Doug Capra

    People get out of control. As others mentioned, it’s not just in hospitals and directed toward doctors. Sometimes it’s because of physical and emotional issues related to their illness. Sometimes it may because they’re jerks, and regularly act that way whether they’re sick or not. But consider this: consider the number of patients every day who feel they way your two patients did, and may be saying such things in their minds, but hold back — because they’re basically decent people and know it’s wrong. Or, consider those patients who may be in pain or vulnerable or sick and dying who say nothing when they should say something — they say nothing because they’re afraid that what will happen is precisely what you describe — the doctor will withdraw, eventually feel no empathy and that will affect the quality of their treatment. No one deserves to be abused as you describe, especially providers who are trying to help people. But sometimes — and this is very contextual and hard to define — some communication, even any communication, is better than no communication at all. There is almost always a message, a subtext behind the words themselves that may be worth listening and responding to.

  • http://www.facebook.com/wendy.hanawalt Wendy Belgard Hanawalt

    Frankly, the first example kinda IS your fault. I remember once my cardiologist left me waiting for an hour. Yes, he was held up by an unavoidable emergency. But there was nothing preventing his staff from letting me know that as I cooled my heels in the waiting room. I worked five minutes from the doctor’s office. I could have gone to work for an hour and THEN come back to see him, or I could have rescheduled. At minimum, I would have felt that my time was being respected if the information and the apology had happened a hell of a lot sooner. And sorry, but if you’re constantly running behind because you’re spending a lot of time with your patients there’s a problem with your scheduling that you need to address. If you’re scheduling 20 minutes per appoint and spending 30, you need to stop deluding yourself and start scheduling 30. As for the second patient, I can only think of a job I used to have in customer service where people would yell at me all the time. The store manager said to us, “Just remember, it’s never ever personal. They don’t know you from a hole in the wall. They’re angry with the store, they’re angry with their family, whatever. But it’s not personal.” You might want to get over yourself just enough to realize that someone who is very sick and in the hospital, someone who’s hungry but can’t even eat, might not be in a great mood. It’s not appropriate, but neither is it personal.

    • azmd

      I think perhaps you should have read the piece more carefully before using your comment to unload your personal frustration over being kept waiting by your doctor. The writer is a medical student in a clinic. She has absolutely no control whatsoever about how the clinic schedules its patients. She is basically a volunteer, there to provide the free labor that keeps the clinic running. With respect to the second example, it is unacceptable to call someone a “fucking bitch.” Period. It’s not “inappropriate,” it’s unacceptable.

      As for your frustration about being kept waiting, a trick I use that is remarkably effective is this: I call ahead and ask the office staff how far behind the doctor is running and what time they think I should be there. When I arrive, I ask again how far behind the doctor is running and I (very nicely) let them know if I am under any time constraints which would force me to leave before the doctor sees me. I highly recommend this approach.

  • petromccrum

    You have to look at these situations from the patients perspective.

    Its bad enough that we are sick but then you have to wait hours for treatments, tests, medications,etc. The total lack of sympathy or concern is distressing. And some doctors also treat their patients like we are stupid. I have a college education don’t talk down to me. Just remember its a two way relationship. I know some of these problems are not the doctors fault but they also are not the patients fault either.

    • WhiteCoatRants

      I agree with you.

      Just the other day I screamed at a patient and called her a “f***ing bitch” because she wasn’t taking her medications as I prescribed and she was ten minutes late for her appointment. She’s lucky I didn’t physically throw her out of my office when she complained about paying her co-pay. Then she had the nerve to complain about my attitude? What gives?

      I wish more people would realize that my actions really aren’t my fault. Obviously I’m acting this way because I’m stressed over more and more government regulations in medicine, decreasing insurance payments, increasing paperwork, and PATIENTS COMPLAINING ABOUT CO-PAYS!” AAAAAAAAUUUGH! Her total lack of sympathy or concern for my problems was distressing.

      Yeah, the argument you make doesn’t work this way, either.

      Nevermind.

  • Jimmy John

    Too true. Thank you for truthfully acknowledging what goes on in your head, that the rest of us can relate to. Unfortunately, it happens all too often where a patient’s rude attitudes affects the ability of others to help them, including all staff.

  • http://twitter.com/texasgrandmom Mary Templeman

    I doesn’t matter where you are in the pecking order of an organization no one deserves to be treated like that by another
    .I really like the idea one of the nurses who posted here said, say to the person who is verbally abusing you that you’ll return when he/she calms down and behaves like a reasonable adult..
    We have become a culture of rude and inconsiderate people and only collectively change it by just not putting up with it and demanding civilized behavior of our fellow humans.

  • http://twitter.com/riotofcolor1 riotofcolor

    Do continue to say you are sorry if you cannot help a patient regardless of their response. When I was in emergency with a broken limb waiting for a specialist, I asked the nurse if I could have a drink of water. The sharp, gruff “no” in response was baffling. It would have been awfully nice to have heard “I’m sorry, but I can’t give you anything do drink because it may cause problems later when you are given morphine.” Thoughtful kindness means a lot, even if not everyone appreciates the gesture.

    Also, were those hostile patients drugged? A friend of a friend did nothing but curse the whole medical staff while hospitalized and on morphine She was horrified about having done this later, no longer on morphine.