In the very realistic fictional world of The White Coat Diaries by Dr. Madi Sinha, a first-year internal medicine resident goes through a harsh initiation into the realities of medical training. Protagonist Norah Kapadia encounters a complication of a penile implant in an elderly patient with end-stage liver disease and dementia. Her senior resident talks her through the problem of causing hematuria as she placed a catheter through an area of scarring in the urethra. The inexperienced intern is concerned that she has harmed her vulnerable patient. The malfunctioning implant issue is dismissed as inconsequential as compared to his liver disease and mental status.
Ethan (the senior resident) shakes his head at me, bemused, “What? He’s eighty-six and demented. He’s not going to remember any of this tomorrow.”
Norah says, “I know, but …”
When Norah re-tells the story of the entire incident to her non-medical roommate, Meryl, she includes dismissive statements and rationalization for her behavior.
Meryl’s glass freezes in mid-air, “Whoa. That’s how you talk about your patients?”Her eyes widen reproachfully.
I’m (Norah) suddenly defensive. “He’s super demented. He doesn’t know what’s going on.”
“So what?” Meryl demands. “My grandpa had dementia before he died, and I wouldn’t have wanted anyone to say something like that about him. What’s up with you? I’ve never heard you talk about your patients like that before.”
“I’m just tired,” I say, which sounds like a pathetically thin excuse, so I add, “And that’s how everyone talks in the hospital. It’s not out of disrespect or anything, it’s just … how we talk.”
Meryl frowns skeptically. “If you say so.”
Of course, I can’t expect her to understand. She’s never pulled a night on call or pronounced someone dead or saved a patient who was on the cusp of death. She doesn’t have any idea what it’s like.
When I came to this section in the novel, I knew that I would have to circle back to it to share a few thoughts. This short section tells so much about the tone of negativity and insensitivity that medical trainees adopt about their patients and their problems. In my book, Changing How We Think About Difficult Patients, I write about the issue. Physicians, nurses, paramedics, and all clinicians naturally adopt a very negative view of our patients.
We are trained to look for what is going wrong and what would be the most dangerous diagnosis facing a person in a given clinical situation. Everyone in the medical workplace shares terrible opinions about certain patients and certain situations. We think we are just observing the facts: That person is demented, this patient is non-compliant, and that family is belligerent. The new staff adopts the entrenched opinions of the more seasoned staff.
As inexperienced Norah encounters the elderly gentleman with a potentially serious and painful problem, her mentor tells her to ignore it because the patient will not remember it. Even though she resists the insensitive conclusion, she takes on her mentor’s view of the situation. He normalizes the bad behavior, and she respects him, so she normalizes it too. When called out on her insensitivity by her friend, Norah caves into the pressure of the group think. She justifies her bad behavior by saying that everybody talks that way.
Not until she registers the reproach of her friend does she hear how terrible her language truly is. She had become desensitized to how mean-spirited her words truly sounded. This incident reflects just one of the many incidents that affect Norah before she finally takes charge of the person and physician she wants to be. The book covers a wide range of demoralizing and challenging intern experiences.
The White Coat Diaries is a romantic comedy with strong empowerment and a coming-of-age message. In so many ways, this book offers a more realistic view of the internship year than most of the non-fiction medical memoirs I have read. Sometimes life and death in the medical wards hold some dark humor. If we didn’t laugh, we would certainly cry. Many times, we do cry.
Gallows humor has a place in break rooms and after our shifts. In the center of a busy emergency department, where other patients and families can hear our banter, we should choose our words more carefully. We have cultivated negative thoughts about that subset of patients we identify as difficult. They either don’t follow the plan, continue their substance abuse, or overuse the emergency department. We blame them for their illnesses, not vaccinating, or not following up with their primary care providers. We label them frequent fliers, drunks, or druggies. It’s them against us, and we’re the good guys.
But are we? We didn’t write those hateful, depersonalizing comments on our residency applications or offer them during our idealistic job interviews. What happened to us? Was it long shifts, under-staffing, exhaustion, or crushing cynicism? I read the comments of young trainees on social media claiming no one told them it would be this way.
They envisioned patients who only came when they had a true emergency and followed all of our medical advice. They dreamed of lovely thank-you notes and bunches of flowers delivered to the ED after a great save. They believed that baby smiles and warm handshakes would be the culmination of every ED visit. That was a delusional fantasy. Do young doctors and nurses in training really think that our interactions with our patients would always go well? Do young parents think that their own beloved children will never anger, frustrate or disappoint them?
Most of our patients are lovely and respectful. Some are frustrated and oppositional, but they are still the minority. We have to struggle to remember that. One start to change how we think about patients who challenge us is by changing the language by which we refer to them. There are no difficult patients. There are people who can’t understand their symptoms, don’t understand how to use over-the-counter medicines, or can’t afford them. Our patients fervently believe that we have a magic wand to wield or a potion to prescribe to make them better now.
The patients and family members who challenge us are still human beings who are suffering and deserve our utmost respect. They deserve an attempt at education and explanation. We can set rules and boundaries for their behavior. If they are stable, we can discharge them. Their symptoms and their experiences, and their lives matter. Even the symptoms and discomfort of elderly patients who will not remember the issue a few minutes later. Even people who seemingly cause their own illnesses. Most truly don’t want to be there, and blaming or shaming them serves no one.
Listening to our break room conversations and reading the messages on our social media sites with more sensitivity could be the start. Many comments are filled with derision and hate. What would an outsider think of our insulting and dismissive banter? They would be shocked, and perhaps we should be too.
Moving in the right direction starts with knowing where we are now. Many of us are in a sarcastic and cynical place. Now that you may hear the tone and note how negative it truly is, don’t beat yourself up about it. It’s the way humans think and speak sometimes to belong to the group with its negative groupthink. We can adopt thoughts that will result in a more compassionate place.
We need to remember that we are here to serve them. Each one of them is someone’s loved family member. Remembering why we chose a career in medicine or nursing in the first place will guide us to choose kinder and more humane words to speak about all our patients. Kindness feels so much better than resentment. We need to become the good guys again. It’s really worth a try.
Joan Naidorf is an emergency physician and author of Changing How We Think about Difficult Patients: A Guide for Physicians and Healthcare Professionals.