Breaking the vicious cycles in medicine

He was known to the hospital as someone who would try to manipulate his caregivers. And I fell for it anyway.

Frequently admitted for pain crises associated with a chronic illness, he spent most of his hospital course avoiding eye contact with the team. So, too, were avoided answers that involved more than a few words. Providing care for him was business-like; we knew better than to expect pleasantries.

The day of his discharge, the nurse informed me of a change. “You might want to go talk to him. He’s pretty angry right now.”

We had planned to send him out with a prescription for pain medications at a pharmacy half a mile from his home address. But now, he was insisting, we were sending him out too early. He has no pain meds left at home and no way of getting to the pharmacy to pick up more. So he is going to stay right here until he is ready to go, continuing to receive the meds through his intravenous line.

I concocted several workable scenarios, trying to solve what seemed to be an unsolvable problem. Because every time I suggested something, it seemed like new problems kept cropping up. Walking to the pharmacy was too painful, and a cab was too expensive. What about a family member, neighbor or friend? He squirmed. No, not that either. Meanwhile, the conversation was punctuated by bursts of anger, accusing me of not understanding and not helping.

I went to my senior resident to see if there was anything else I was missing that we could do. “He’s a grown man. He needs to figure out how to get to a pharmacy by himself.” Her patience was clearly wearing thin, though unclear if with him or with me. “Staying today was already above and beyond. OK?”

OK.

When I returned to his room, he was on the phone. “Here,” he said, pushing it into my hand. “Talk to my advocate.”

Before I could say a word beyond “hello,” the voice on the end was yelling at me. That we were mistreating him. That we didn’t understand. That we were disconnected and uncaring. He has no one, she explained. I understand, I replied, and though my superficial conscious wanted it to be true, deep down I was aware that — not in pain, not suffering a chronic illness, and not alone — there existed a chasm between us that kept me from truly comprehending.

Frustrated with the situation, frustrated with how my hands felt tied, and frustrated, yes, with how this was now keeping me from doing my other work, I managed to get him a taxi to take him from the hospital directly to the pharmacy directly to his home that same day, free of charge to him. Because I was tired of arguing. Because I wanted to smooth the path for even a hint of an alliance in the future. But mostly because I simply felt sorry for him.

A few hours after he left, I called the pharmacy for another patient and decided to check in on how everything turned out for him. Had he been able to get the meds today? Yes. And, by the way, he had picked up the same prescription just a few days before, and it was for a substantial number of pills. The date they mentioned was the day before his admission to the hospital. Meaning there was no way he could have used all of them. Meaning he had plenty left at home. Meaning this was anything but the very urgent situation he had presented it as.

Are you sure? I asked. They were sure.

I told this to my team, and no one was surprised; the only part they were surprised about was that I was surprised. My resident thought there was something vaguely adorable about it all, fitting my reaction into a narrative of a young, naïve medical student discovering What Things Are Really Like in this cold, cruel world we live in.

But I don’t think it’s that simple.

I had been deceived before, both in and out of the hospital walls. But it never bothered me as much as did then. There was something about how he did it. It was as though his plea was carefully constructed to play off my empathy. To tap into basic human compassion and twist it into a desired outcome. I wasn’t angry. In some strange way, that I couldn’t fully understand at first, I felt hurt.

Maybe it was because when you are duped, you learn from it. You shift a little towards the opposite end of the spectrum of whatever quality flaw did you in. If someone plays off a lack of intelligence, perhaps you get a little bit sharper. If shyness a factor, you become a bit more assertive.

What bothered me is that if I were to learn from this situation, my lesson would be to become a little meaner.

I had trusted — trusted that a patient was in need and that I had the ability to help that need. Our interactions with all patients are based on that trust, and we usually yield to it unthinkingly. I enter each encounter with a presumed belief that the patient and I are on the same side, working toward a shared goal of improving his or her health.

Maybe the next time, I wouldn’t trust so easily.

On his end, I imagine that trust was violated long ago. How many times had he encountered a provider who truly didn’t want or try to understand? How many times had he come in pain and been met with disdain? How many times was he denied medically indicated painkillers because of pre-conceived biases? I imagine it happened. I imagine it happened more than once. And every time, I imagine trust was chipped away at, bolstering the face he had presented to me then: that of a patient who avoided eye contact, and who was uninterested in forming any sort of relationship with a new provider.

How many times had the advocate picked up the phone and spoken to a voice that was dismissive? How did those interactions shape her diatribe and hone the arguments she had leveled against me? Perhaps each time, she became a little less likely to give the unseen caregiver the benefit of the doubt, and a little more likely to open with accusations instead of questions.

How many times had I been manipulated by a patient?

Just once. For now.

But instances accumulate into habits that accumulate into systemic barriers to care. And every time a caregiver is lied to, I worry that change happens on our end, too. We become a little less likely to believe. A little less likely to give.

And we become trapped in a cycle that with each new encounter becomes a bit harder to break.

The doctor-patient relationship is not the only relationship vulnerable to vicious cycles. They’re everywhere, composing a hospital dynamic that perpetuates itself and over time gets taken for granted as entrenched. Perhaps there’s a certain ward known for hostile interactions between nurses and doctors. Perhaps there is an operating suite where medical students are regularly not allowed to participate in procedures. So when trying to build rapport with nurses, I realize that I’m fighting not just my reputation, but that of dozens who came before me. And when I ask for more autonomy, I’m advocating not just for myself, but for future generations who will or will not be handed the scalpel depending in part on how I perform.

I’m not saying any of this is fair. But I can see how a cycle that sustains itself like this is a cycle that will continue until somewhere, somehow — someone becomes intentionally “naïve” and chooses to break it.

It asks for when individuals to trust, even when there is no reason to. Even when all our experiences and all the evidence suggest we shouldn’t.

This is an incredibly difficult thing to do. Foolish, even, some might suggest. But if there’s any lesson I want to learn from this experience, it’s that I don’t want to learn from this experience. I don’t want to be filled with so much doubt.

Because what choice do we have? The alternative is that things continue to get just a little worse — for all of us.

Certain details of this story were modified slightly to protect the privacy of the patient.

Ilana Yurkiewicz is a medical student who blogs at Unofficial Prognosis.

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