After I declined to prescribe him stimulant medication, one of my favorite patients became angry and began to raise his voice.
It was the last appointment of the day, and the clinic was largely empty. I shifted back in my chair, leaning away from him, subtly trying to protect my pregnant belly and hide my fear and disbelief.
“You’re just going to make me start using again,” he said, his face becoming red. “What’s the point if you’re not helping me!?”
I thought I was.
Despite being trapped in a vicious cycle of poverty, my patient was working hard for himself. He had been doing well in recovery from his opioid use disorder and we had been diligently working for several months to address his other mental health concerns.
I brought my full self to each encounter — an open heart and an open mind. In the words of David Foster Wallace, my work was “morally passionate, passionately moral.” His progress made me feel as if my care mattered.
But then he turned on me and our shared goals. All at once I felt betrayed, defensive, confused, and hurt.
Was I caring too much? Was I in too deep? I made a mental note about the danger of growing fond of my patients: You risk having it thrown back in your face.
My patient no-showed our next appointment and neglected to return any of my calls. And then I went on maternity leave.
I couldn’t help but worry about him the entire time I was away. Would I be responsible for his fatal turn back to heroin or fentanyl? Were his choices his or ours?
I tried to remind myself that his life was not my life. But it was clear his life was impacting mine. As I cradled my newborn baby, I’d angrily rehearse what I’d say to him about my duty to do him no harm. I worked up the nerve to stand my ground and brace myself for the many difficult conversations that lay ahead.
“I’m not doing too good,” he lamented, when we finally met again. He had lost a loved one to an opioid overdose just three days before. His pain had not yet dissipated. It was right in front of me. Inescapable, raw, and real. My silent resolve instantly shattered.
We spent most of that appointment sitting in silence. Holding back the tears that were desperately trying to escape my eyes, I just kept telling him how terrible this was and that I was so very sorry. “Thank you, Dr. O,” he said.
I was equal parts sorry for his loss and that I’d steeled myself toward him. Our sorrow was not only an anticlimactic end to the fight I had spent months preparing for, but also a blindsiding knockout I didn’t see coming. How do we honor the call to medicine without becoming undone ourselves?
Throughout my training I’ve watched mentors and fellow trainees turn away from complex clinical work because this balance is elusive. As I care for an increasing number of patients, I’ve learned that the work of medicine, the real work, is remaining emotionally within reach. When exhausted by the emotional ricochet of our patients’ triumphs and tragedies, it’s tempting to simply walk away.
Moving away from paternalistic styles of practice, my profession preaches humility, a modest view of my own importance in the doctor-patient relationship. Perhaps humility frees us from the gravity of these intense feelings by giving us permission to stand back and look away when the embers of humanity burn too bright. After all, it hurts to look directly into the sun.
Should I be humble about my feelings and their impact on my ability to provide good, sustainable care? Perhaps, but I wonder if downplaying the emotional labor required to tend to human suffering is what makes burnout an inevitability.
Neither standing back nor denying my feelings satisfies. Nor do these two stances respect the emotional investment that separates doing a job from getting a job done. As I start my last year of residency training, I’m desperate to find a style of practice that will allow me to truly engage in my work.
There was something poignant between my patient and me. I am no longer full of the unjaded enthusiasm that made me feel like a good doctor to him, and there is stress in that loss. There is also an uneasiness as I look to answer the call that will come from the next patient.
I have to believe by continuing to show up, I will be good enough.
you have favorite patients? i love it when psychiatric professionals talk about favoritism
Sound like he needs some medication. Ive been in that guys shoes and he wont be back unless hes on probation. Either way that guy’s in need of someone who can identify whos been in his shoes and hes probably afraid hes gonna die and i cant believe im alive but half my family succumbed to addiction plus mental health. You were trying to help and ironically ADHD untreated made me unable to function and if not for the stimulant i had zero chance id be dead or prison. ADHD is for some is hell and thank god my meds were kept locked away from me until i slowly . If that guy does have adhd he needs someone to administer 1 at a time. Thanks for sharing now I remember a level of despair it would honestly kill me and many people die
In the pit before the spiritual realm decides to offer u life yet death was so close it grabbed my brother and I never had to die anymore ive lived every day for 3 and a half yrs and everyone i grew up with faded 1 by 1 and alcohol is so powerful it was so painful to begin life in its rawest at 31 alcohol was harder than the heroin and paws ripped me to shreds for a year and MAT saved me the brain damage and im alive and continue my way to the next level. Thanks for helping me cleanse a little of the past making room for whatll b new.
Don’t lose hope. You win just by walking through the door.
As a Surgeon, we recognize all cuts and lacerations and what may have caused them. I saw very fine razor blade self cutting scars on a preteen girl’s belly getting her appendix out. She seemed to be well adjusted as her friendly outgoing personality masked a dark secret. I point blank asked about her self cutting and she denied it at first but much later admitted, although she was popular with lots of friends, she felt tremendous pressure and anxiety being popular. This was her alleviation of stress. I referred her to a colleague and later on reflection, realized that even the cool kids don’t have it all together.
After 30 years of doing oncology I have learned that the most difficult thing is to have empathy and support your patients without drowning with them. It is not easy and it is a personal journey. My trick has been to delve more into the studies of humanities to try to understand the human being as a social being not as a patient.
You will need to learn to separate yourself enough from these events so you do not suffer from burnout
Thank you for your open and honest expression of struggles that most of us share, but are either afraid to express them or simply suppress them because they may show us up as weak
Good, heartfelt story for sure… I have to admit I am curious about why you did not prescribe the stimulant.
Thank you for your sharing your experience and your truly caring for your patient.
Balance is elusive. Wisdom emerges from experience.
Questions raise interesting challenges such as the one raised in your commentary, “How do we honor the call to medicine without becoming undone ourselves?
The answer lies within the question!
The journey to answer the question will result in the experience one seeks.
There is a growing body of literature on the psychological benefits of meditation. “Different techniques produce long-lasting changes in attention, emotion, cognition, and pain perception, and these correlate with both structural and functional changes in the brain.”
Compassion and patience appear to be teachable skills, and the way we think directly influences our experience.
Learn about compassion vs empathy, mindfulness without attachment, and the relative impotence of each of us to change how another person thinks/feels/behaves. Much of this is counter to what you learn in medical school…now learn from the people who have worked in psychiatry and manage to care without getting burned out. Might be the pt care tech, or the SW, or the nurse. Read Elissa Ely.
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