Intern (28 page)

She was tall, frumpily dressed, with wavy auburn hair and narrow-set eyes. “How long have you had back pain?” I asked.

“It started this morning,” she replied. “I heard a pop between my shoulders.”

“Has this happened before?”

“Yes, several months ago.” She had gone to a chiropractor, which helped.

“What did the chiropractor do?”

“I don't know,” she replied, her voice rising. “He manipulated my spine and I felt better.”

“Are you experiencing any weakness or numbness in your legs?” Nerve root compression from a slipped disk (like the one I had had in my cervical spine) was a common and potentially serious cause of back pain.

“No.”

“What about shooting pains?”

“No.”

“Pins-and-needles sensations?”

“No!” she shouted. “How is this important? I just want a referral.”

“Okay,” I replied, but first I had to examine her. I explained that if she had a pinched nerve, a chiropractor might do more harm than good. Reluctantly, she got up onto the examination table. I pressed on her back with my fingers, trying to see if I could localize any tenderness. Back pain was usually benign, but in rare cases it could be caused by an infection or tumor, and I wanted to make sure I wasn't missing anything. After finding the testicular tumor in Jonah, I had become meticulous about physical examination. I raised her straightened legs one at a time, trying to elicit pain, a telltale sign of sciatica.

“You're wasting my time!” she erupted. “Call your supervisor.”

Now my supervisor that day happened to be a calm, soft-spoken doctor who had a nice way with his patients. I called him to my exam room, explained what was going on, and excused myself. In the hall-way,
I listened as my patient inveighed against the clinic and the doctors who had mistreated her. My preceptor's quiet manner and attention appeared to mollify her, because she allowed him to examine her. Then, calmly, they discussed her options. She was not interested in Motrin or rest as therapy. She insisted on a chiropractor.

About fifteen minutes later, he emerged from the room and asked me to please write the referral. I did, and the woman left, looking satisfied.

Afterward, in his office, he shrugged and weakly smiled. “She was a difficult patient,” he said. “In such cases you listen and try to do the best you can. Sometimes patients just need to vent.”

The encounter left me to wonder: Who had been more difficult, the young woman or me? After all, she was the one in pain, and I had presented an obstacle to her relief. Chiropracty was unlikely to do any harm; she told me it had already helped her. Still, for reasons I could not pinpoint, I had created hoops for her to jump through, asking irritating questions more for my own purposes than for hers. The situation demanded empathy, but instead I had been automatic, hyper-rational, and detached. It certainly wasn't the way I had imagined I would be as a doctor. The right thing probably would have been to give her an unfettered referral without asking too many questions, but somehow I had not obeyed this instinct. Part of the reason was to assert my authority. Part of the reason, no doubt, was that I was wearing a white coat. It wasn't the first or last time that I felt my uniform was somehow suppressing my better instincts.

Later that month, the clinic chiefs asked me to present a case at morning report, so I decided to present the case of the young woman. Snickers could be heard in the wood-paneled conference room when I put up my title slide:
Difficult Patients
. I started off talking about a landmark 1978 article in
The New England Journal of Medicine
by Dr. James Groves, then a professor of psychiatry at Harvard Medical School, called “Taking Care of the Hateful Patient.” In it, Groves described certain personality traits that kindle aversion, fear, despair, or even downright malice in doctors. He described such patients as “dependent
clingers,” “entitled demanders,” “manipulative help-rejecters,” and “self-destructive deniers.” Emotional reactions to patients, he wrote, cannot simply be wished away, nor is it good medicine to pretend that they do not exist. Freud called such reactions countertransference—how doctors react to patients, not the other way around—and said these reactions could be used to explore the unconscious conflicts of doctor and patient.

Aversive reactions, I told the audience, are common in any enterprise involving intimacy: marriage, psychotherapy, the battlefield, and so it is with medicine. The difference is that doctors cannot divorce their patients, at least not easily, and for good reason. Entrusted as we are with a fiduciary duty to preserve health, we cannot dismiss patients willy-nilly. But the question demanded asking: If patients can choose their own doctors, why can't doctors choose their own patients?

There are guidelines for when a doctor can dismiss a difficult patient, and usually only the most egregious misbehavior qualifies, including threats, violence, and noncompliance. For example, courts have ruled that kidney specialists do not have to provide dialysis to violent or disruptive patients, even those who need it to remain alive. In 1987, Dr. John Bower, a kidney specialist at the University of Mississippi, was sued after dismissing from his practice a patient who regularly missed dialysis appointments, verbally abused nurses, and even threatened to kill Bower and a hospital administrator. Bower cited medical noncompliance and violent threats as grounds for terminating care. The Fifth Circuit Court of Appeals, in New Orleans, agreed with him, ruling that doctors can refuse to treat violent or intransigent patients as long as they give proper notice so that the patient can find alternative care. Forcing doctors to treat such patients, the court said, would violate the Thirteenth Amendment, which prohibits involuntary servitude.

To prepare for my talk, I had gone through the “administrative files” on ten patients who had been dismissed from the clinic over the past five years. The reasons for expulsion were noncompliance with
medical advice, threats, verbal abuse, and physical violence. One patient had punched another in the waiting room. Another patient had forged her doctor's signature to get painkillers.

After my presentation, the fifteen or so residents and attending physicians in the room weighed in with some of their own tales of difficult patients. A resident told of an obsessed patient who showed up at his clinic every week and even once followed him home. An attending physician said that he had once been conned into prescribing long-acting morphine to a patient with lower back pain. The patient claimed to have had an extensive workup by another doctor, but when the attending checked, he discovered that the other doctor did not exist. “Always do your own workup,” he warned the group. “Set strict rules, and stick to them.” Another physician said that his patients were “hypomanic” and rarely on point. He didn't agree with the conventional wisdom of letting people talk out what was on their minds. Another attending compared difficult patients to Bloomingdale's shoppers. “Give me a thousand Kmart shoppers for every Bloomingdale's shopper,” he said to murmurs of agreement. “Kmart shoppers have their insurance, they don't pay cash, they're not going on the Internet, they don't ask a lot of questions, they don't have a bunch of doctor friends second-guessing your decisions.”

The atmosphere had the charge of catharsis, as one anecdote led to another. The stories were fascinating in a baroque sort of way, and I felt pleased that my presentation had engendered such a robust discussion. (Evidently, sometimes doctors need to vent, too.) But then a dissenting voice was heard. It was Sheila Jones, a young attending with a slight frame and a wispy voice. A few months back, I had helped care for one of her patients in the hospital, a young woman who had been troubled for years with abdominal pain and a psychologically abusive boyfriend. The patient had been in and out of various hospitals, undergoing X-rays, ultrasounds, CAT scans, and so forth, all of which revealed nothing.

She was angry and afraid, and frequently came to the emergency room demanding hospitalization and painkillers. Doctors who cared
for her had grown weary of her constant complaints and started giving her morphine. Then she became addicted, and no one cared about her enough to ensure that she got the psychiatric help she sorely needed, including, in retrospect, me. It was easier to abdicate responsibility than to deal with her.

She was the quintessentially difficult patient. After a while, hers was a room we avoided. Her needs were bottomless, her pain unremitting. In the constant buzz that is ward life, time seemed better spent on other patients. Nothing seemed to be physically wrong with her, at least not anything to explain the severity of her pain. Yet she relentlessly demanded morphine. Try as best we could, it was hard setting limits. A tough approach alienated her. A conciliatory approach simply got her more drugs.

But Dr. Jones knew how to handle her. Though she had been her doctor for only a few months, she had developed an effective style with this patient. She was not afraid to be strict: if the patient yelled, sometimes she yelled back, or she was kind, as the moment required. Though somewhat unconventional, she grasped her patient's psychology like no one else, and she truly cared for her. She eventually managed to discharge her without morphine.

Jones told the now-silent group that she had several difficult patients in her practice. “Like any doctor, I do not seek them out. But they are not that hard to treat, once you figure out what is bothering them.”

Patients don't always come right out and say what is wrong, she said. Sometimes they hedge or obfuscate. Often the key to treating them is to look a little deeper.

“Most doctors are reluctant to take on difficult patients,” she acknowledged. When these patients are ready to leave the hospital, “business cards get tucked away and doctors duck into the shadows.” Consciously or not, doctors create hoops for these patients to jump through, marginalizing them even more. “And then we say these patients were ‘lost to follow-up,' ” she said.

There wasn't much more discussion after Jones spoke. Soon people filed out of the room. That night, I thought about how different the real
doctor-patient relationship is compared with the idealized one that had been presented in medical school. Then the emphasis had been on the heartwarming stories, the enduring intimacy. But in reality the relationship is neither simple nor neat. Every human enterprise has its share of conflict and reconciliation—and medicine is no different. I don't know what surprised me more: that there was such a divide or that it had taken me so long to see it.

Even now, years later, it remains a mystery to me exactly why one doctor can relate to a difficult patient, and another can alienate her. Another reminder, perhaps, that medicine is a field of specialties. Some doctors are better at treating certain diseases; some at treating certain patients.

If you are hidebound with prejudice, if your temper is sentimental, you can go through the wards of a hospital and be as ignorant of man at the end as you were at the beginning.

—W. SOMERSET MAUGHAM,
THE SUMMING UP
, 1938

 

I
f internship was about being a secretary, second year on the wards was about being a manager: ignoring the small details, seeing the forest for the trees. During internship, thoughtful reflection had been all but impossible, but being able to delegate changed all that. Now I was the one in charge of my students and interns. At one time I couldn't have fathomed delegating duties, but on the wards I discovered that I loved having interns around, and it was as easy for me to dump on them as it probably had been for my residents to dump on me. No longer was I the team's shock absorber—the one who got pimped first, blamed first, thanked last. I had always found it fundamentally unfair that the people who got interrogated on rounds were usually the least equipped to answer questions. That disparity continued, of course, but it was no longer working against me.

At the same time, individual patients started to fade from view. No longer was I the first doctor paged in a crisis. Part of me missed being more involved in the life of the ward, but I also appreciated having some distance, operating remotely from the workroom, staring at a computer screen, reading through charts one by one, scribbling a short
“chart-round” note, a tiny drizzle of ink to show that I had been there. I got very efficient at finding lab results or medical records, minimizing computer time because I knew exactly where everything was. The clerks would still dress me down for hogging the charts or for getting in their way, but for the most part they were much nicer to me, and I was no longer afraid of them. At lunchtime someone would call out, “Anybody want Mexican?” and I would respond, “Count me in!” like I belonged. Fellowship descended on the ranks. As junior residents, we could afford to be congenial because we were no longer carrying the burden of the hospital on our shoulders. Even sign-out wasn't a frenzied rush to get out of the hospital. In fact, most of the time, we didn't even attend because our interns took care of it for us.

Not long ago, I had dinner with one of my classmates from residency. He was now a chief resident at a major teaching hospital in the Northeast. Over the meal, we chatted about the transition from internship to second year. “In internship, it's like, ‘This doesn't make sense,' ” he said. “When you think about it, as interns we were making, like, a hundred and fifty decisions a day, and as second-years we were, too, but the difference was that you knew why. As an intern, you didn't know why, which is why it was so hard. You had to collect the data, process it, massage it, fit it into an existing plan. It was psychologically exhausting.

“Another difference was that second year there was more responsibility. If they criticized you, you took it more personally. You had more invested because you had gone through internship. You were more a part of the community; you worried about what people would say. You wondered, What will happen if people discover that I'm not as smart, efficient, or competent as they think?”