Being Sorry

“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.

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30 Responses to Being Sorry

  1. Czessie says:

    This is an amazingly profound read. I imagine many feel similarly, but are not nearly as brave as you to write it out–and so elegantly so. So regardless of the disheartening commentary you might receive when you put on your white coat, or the moments of shame that that you might experience I think in this moment you should be praised for your willingness to reflect and share your innermost thoughts. Because saying sorry is not enough and fails to encompass the emotion I felt after reading this ,I can only say thank you. Thank you so much for writing about this difficult moment Shara, and your fight to not let it harden you. Thank you for fighting–it’s inspirational.

  2. BreadintheBone says:

    My father (who would have been 86 today) was a well liked, highly experienced and highly respected internist, with a large practice. Despite having patients who practically worshipped him (and I am not exaggerating) he also would get very upset by the ones who blamed him. He was physically attacked once while telling a family that he could not save a husband/brother/father who had suffered a massive stroke. He was stalked by a woman who was convinced that every pain or illness she suffered, he was causing. He felt every loss, every perceived failure, very deeply. However, he never stopped studying, updating his medical knowledge, extending himself that bit more. The times he succeeded, the times he diagnosed an unusual condition and treated it, the times he simply listened to an old woman who came to the office more for company than for a cure, lifted him. As I grew up, I sat and listened to him in the evenings, talking about his day; he loved being a doctor.

    Don’t stop what you’re doing. Your skin may grow a bit thicker, but remember the times your work makes a difference for the better. Even the ungrateful and difficult people need care, and someday you will be able to reply quietly to wrath, and explain what you are doing is for the best. It may even work, on the odd accession. I know this sounds trite and overdone – mea culpa – but the fact that you are worried and can express that worry means something.

  3. Heather says:

    I am a regular reader of your excellent posts. As a biologist who works with any number of physicians at many different levels of training and seniority, I can only applaud your self-insight and the capacity to describe your feelings. They will evolve with your experience. You will not allow yourself to be upset by the same things. But every good physician I know, especially the ones I frequent in the research hospital setting, has moments like this. The best ones remember them and learn from them, as you seem to have done. *I* believe you have those good intentions. More importantly, so do you. You still care. Thus you have them.

  4. bratschegirl says:

    New here; a Facebook friend posted a link to this post.

    You articulate these wrenchingly difficult situations beautifully and honestly. This has to be one of the hardest aspects of not only your training, but of the reality of what you’re training for. This will happen again, and it’s an incredibly overwhelming experience when you’re the one in the cross-hairs.

    I’m quite confident that you know this already, but I wanted to point out one small thing. You wrote above “…until he compromised my ability to help him.” That’s not quite right. It was your reaction to him, to his unjustified assault on you, that compromised your ability to help him, and that is a critical distinction vital to the process of learning to manage this. Did he incite and deserve that reaction? Absolutely. Did you react the way pretty much anybody but a saint would have? Sure. Not blaming you in the slightest. But you’ve laid out, with amazing clarity, the costs to both you and your patient of having that reaction.

    You might enjoy and benefit from the practice of mindfulness meditation. Stepping aside from this kind of automatic and completely understandable but unhelpful reaction is what it’s all about. In your copious free time, check out a book called “Full Catastrophe Living” by Jon Kabat-Zinn.

    Finally, I want to say that I get from this entry that you are and will become the kind of health care professional I’d want. The ones who are impervious because they don’t care are the ones to be avoided. You’ll figure this out. Chin up and forge ahead.

  5. Nicky says:

    Your post really hit home with me. I’m a resident in my PGY-1 year right now, so I remember being in very similar situations as a clinical clerk. Often times these situations would be with family members of terminally ill patients who had no other outlet to their sadness and anger other than to berate whoever was around, which often ended up being the very junior members of the team, such as myself. I would let it happen, because like you, I knew it wasn’t personal. But it’s important to remember that even though you need to emphatize with your patients you also have the right to be treated with respect and common decency. It’s tough when you’re alone, but there were times when my staff have told patients/families that their behaviour towards nursing staff/medical students/etc is cruel and unacceptable.

  6. Marcia says:

    My father passed away this year, and as her daughter I can only say to you that, although saying that you are not sorry, we are always thankful to you for being doctors.

  7. Phil Grimm says:

    I can relate to your dilemma. I too was an introspective and sensitive medical student, struggling with my own personal failings and worried about which skills I needed to learn and how to deal with ungrateful or angry patients .

    But life caught up to me, and I became an interventional radiologist. In private practicem, there was no one else but me to stand in front of the patient or his family, and after a dozen years I had been pushed into performing my technical skills on many suboptimal patients with many unreasonable expectations.
    I didn’t just help people or occationally snatching them from the jaws of death, there was enough of that to give me positive re-enforcement, but I also killed people. I don’t mean murder, I mean iatrogenicly caused death during the course of a normally performed procedure. People who walked into the xray suite a for a regularly scheduled outpatient procedure and who were wheeled out, two hours later, in a box.
    This is when my introspection was destructive. Having each of these deaths reviewed and excepted by the QA or PIP committees did not help my distress, because I wanted to be perfect and I certainly did not want to be the responsible party for a death. But the body count never went down and no mater how much I emotionally shielded myself, occasional disasters were always lurking, and second guessing my performance only increased my distress.
    I let other, less sensitive people perform the more dangerous procedures and I ironically went on to chair the QA and PIP committees for another dozen years. I had to council other physicians both when there was a procedurally acceptable death and when there was real incompetence. It wasn’t easier dealing with these events as the all-knowing external auditor than it was to be the perpetrator.
    I can remember the faces of those who died as I practiced my craft, I watched as the body counts mounted for both my partners and myself and for the various surgeons in our tertiary referral center. I have become extraordinarily passive-aggressive when dealing with families who want us to do anything or everything that could possibly be done to Grandma. I am no longer willing to be anyone’s executioner. I can deliver a mean PARQ speech.

    Gradually, over the years, I learned to accept these deaths, I’ve watched enough tragedy and I’ve suffered enough personal tragedy that I have come to accept these events . I no longer envision myself or any other of the hundreds of physicians that I know, as anyone’s savior… We are just doing a job, to believe that we do anything more than that is just a delusion.

  8. APatient says:

    Interesting post, thanks. I was struck by this paragraph:

    “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.”

    From the other end of things, since I’ve been needing far more contact with healthcare professionals I’ve often found myself needing to remind myself of context when dealing with ‘difficult’ doctors or nurses. It’s too easy to forget that people are doing stressful jobs as part of a complex – and sometimes flawed and frustrating – system when they are involved in ‘bad’ behaviours ranging from mistakes and sub-optimal practices which pose a (small but non-trivial) risk to my safety through to impoliteness which I really hope I’ve never shown to people I work with. I must admit that I’ve become rather snippy about apologies at one hospital: because professionals usually don’t apologise when something goes wrong and, even when they do, they often repeat the same mistakes again and again.

    I hope I’ve remained polite – I’ve certainly never berated anyone, and I’ve been esp careful not to scare the v young-seeming junior doctors! – though I can become a bit abrupt over time. I guess an understanding of why all involved in medical relationships can behave ‘badly’ at times can be useful (though understanding obviously doesn’t remove the need to deal with problems and errors).

    By the way, interesting that the topic of ‘difficult’ patients was dealt with under psychiatry. Schools I’ve known have taught this more as a social science topic – I’d be very reluctant to medicalise ‘difficult’ behaviour. On the contrary, this can be perfectly healthy behaviour for patients – e.g. if someone is rude to you or endangers your safety, it’s not unusual to get irritated. Behaviour that professionals perceive as ‘difficult’ – for example, checking drug doses or asking people to wash their hands – can also have definite benefits for patient safety. In a way, I think I might have avoided some problems had I been more ‘difficult’ when I first got ill!

  9. jeff says:

    Thank you for sharing this. I’ve had many of those same things said about me, and I was just working at a fast food restaurant. People are just jerks sometimes, and it helps to remember it’s got nothing to do with you (regardless of what unreasonable flip-out they want to have).

    Feel bad if there was a 20min wait because you got out of bed late after a night of drinking … otherwise it’s not worth pondering.

  10. AP says:

    ‘Difficult’ patients are also ‘difficult’ people: they are the entitled ones, the ones that failed to take care of their health for years on end, and want miracles with no effort on their part. They want a magic pill to lose weight, lower cholesterol, reduce blood sugar, control blood pressure, etc! Providers are not magicians. I tell my patients that the majority of my job is to educate them about their condition and help them make better choices, but there is no sense on my prescribing meds if they are not willing to do their part. Have I’ve been subjected to abusive patients, demanding patients, moronic patients, entitled patients? You betcha! But mostly, I’ve been blessed with the ability to practice a profession that is rewarding. Painful, yes, but being welcomed into a patients inner circle, to share joys & pains, is to be human. I wouldn’t have it any other way!

  11. Carol Trongeau says:

    As a patient, I don’t care what the doctor thinks about me nor do I care how the doctor acts towards me other than that they are extremely competent and motivated to do the best possible medical job. The best doctors I’ve ever had were total jerks, but they knew their stuff and they would go all out to do an excellent job, not because they liked me or hated me, but because of their pride in their work. I have had extremely arrogant surgeons and specialists, but they were almost universally great in their performance of their job – one surgeon spent 14 hours doing an operation that was originally expected to last 4-5 hours because he was a perfectionist and wanted to dissect away as much scar tissue as possible and be very cautious not to rush. I spoke with the assisting resident surgeon and he told me how painstaking the attending surgeon was in his work and that most surgeons would have given up because of the difficulty and done a less good job (which would have had negative long term consequences) because they wouldn’t embark on such a hard challenge and spend 14 hours in the OR, screwing up OR room scheduling and his own workload. That surgeon was a complete ass. And I love him for being the way he was, because I’ve noticed an inverse correlation between competence and compassion in the medical field. Our dermatologist spends maybe 1-3 minutes tops and two sentences – then writes the chart and leaves – zero interpersonal skills – but the moment he saw my mother he diagnosed a very rare and unusual drug reaction as the cause of a rash (that 6 other doctors missed!) – and solved her problem and was out of the office within 3 minutes. He knows his stuff and doesn’t waste time with small talk. I like that.

    Give me a horse’s ass who knows his stuff every time over a mediocre doc who is charming and compassionate. I don’t want a friend, I want a cold-headed logician who knows his stuff and wants the best outcome – not because he cares about me, but because he cares about his own expectations of perfection in his work.

    I’ll take a Dr. House any day!

  12. Nathan Weber says:

    Shara: Wonderful, sincere heartfelt post. You’re the kind of doctor I hope I’ll have access to when I need one.

    I am astounded at Carol Trongeau’s comment that there is “an inverse correlation between competence and compassion in the medical field.” My experience as a patient has been the exact opposite of hers: the more of an arrogant asshole my physicians (and other medical personnel) are, the lousier they are at their jobs; the more swollen their egos, the less competent their skills. Two weeks ago I had a malignancy removed from my right kidney. At the ago of 70, hearing that I had cancer was terrifying to me. (Eight years ago I lost my sister to lung cancer.) But my surgeon was kind and very patient, putting up with my overwhelming anxiety, my constant interruptions and misunderstandings of what he was explaining (at one point he turned to my wife and asked with a smile ‘Is he always like this?’ She nodded vigorously.). After the surgery, which went well, I had excellent care by the nurses, aides, and everyone else who had to tolerate tending to a cranky patient. I sent them all–surgeons, associates, nurses, etc.–thank you cards. So, Shara, never give up your sensitivities. The fact that you are so open to your feelings, so in touch with your humanity and vulnerabilities will make you a much better doctor in both the long and short run.

  13. gp says:

    “one more person….”

    oscar schindler.
    (from the movie of course)

    if every experience makes us look more within than without, then i think progression is positive :)

    am a pediatric resident. here, the reactions are very different from what u have described. the kids feel the same pain, the same distress, but their responses to it are not directed at or against other people, u know be it doctors or their own parents. that makes ur own emotional involvement much more intense in terms of both joy and sorrow. the kid will cry, but he/she wont say u r or anyone else is responsible for it. see the difference between our reactions to “u r not doing enough for me” to “i am feeling pain”. only because our egos are called to play when the same feeling is directed with respect to a particular person and not “simply” expressed. of course, we get the same kind as u have said from the parents, sometimes its easier to think of the kid simply in a provocative situation to get back to sanity.

    so, just a bit more heart i suppose. :)

    bid u good times n good learning

  14. The lack of personal accountability in this piece is stunning. The first patient had every right be to angry about being kept waiting for 45 min. Doctors routinely keep people–very ill people–waiting. This isn’t behavior we tolerate from the other professionals in our lives. (I’d hazard a guess that it doesn’t happen to you often, doctor and when it does you too feel put upon and disrespected.) Treating people’s time this way is insulting and the only justification I hear is that you have to spend more than the 20 allotted minutes dealing with patients, thus the timeline gets out of whack. This scheduling is not your job, I’m aware, but being a part of the organization that perpetuates this unworkable system you certainly bear some responsibility. Also, you genuinely do not sound a bit sorry about it. Rather than blaming a patient irritated about being left to linger endlessly in a sterile room, why not blame the system that stacks up appointments in such an untenable way. You seem to feel that the mere fact that you’re trying to physically help this patient excuses you and your practice from treating him and his time with a little respect, but you’re wrong.

    The second run in is on an entirely different level. Equating them isn unfair and inaccurate. This man was clearly feeling stripped of all dignity and personal power. Your bedside manner left him feeling even more disempowered. You don’t deserve to be castigated for simply doing your job, but don’t go congratulating yourself on your empathy. It sounds to me like your people skills are in serious need of work. You aren’t a psychiatrist, but that doesn’t excuse you from from trying to relate to patients as people rather than a set of symptoms. It’s possible that no matter what you said to the hungry man he would have exploded. It’s equally possible that you handled it poorly, igniting his sense of futility and deep fear.

    Commenters her are so eager to congratulate you for “feeling” so deeply. But what I hear is the beginning of a process of dehumanizing your patients and shifting blame. You say about the first patient that “he comprised your ability to help him.” You could just as easily say that you compromised his trust in your competence and humanity by keeping him waiting for an inordinate amount of time.

  15. @Orli Van Mourik – your tirade against the author of this piece (who just so happens to be my sister) is full of gross extrapolations, assumptions, and strawmen. Nowhere did Shara imply the patient who waited for 45 minutes had no right to feel angry about it; nowhere did Shara “blame” the patient. Instead, Shara apologized. As she should have.

    You then go on to say that the “The second run in is on an entirely different level.” Well, yes – and Shara acknowledged that directly: “The first episode, in retrospect, was merely a preamble.” Then, she went on to explain calmly and professionally why the patient was not being allowed to eat. And, she apologized for it. The patient became angry. It was understandable. He was suffering. Shara recognized that. Your presumptions about her bedside manner are backed by nothing in the piece. From the ad hominen attacks in your comment, it’s more likely they reflect your own biases.

    Orli, throughout your comment, you are looking for someone to blame. What I took from this piece is that dealing with frustrated and angry patients is a difficult situation – for everyone involved. The best efforts from all sides are not enough to guarantee a smooth outcome without pain and hurt feelings. It is possible to reflect on that reality without pointing fingers. I am glad this piece did so.

    Keep up the great work, Shara. I know you know this already, but I’m very, very proud of you.

  16. Old Geezer says:

    I don’t know you, so I certainly shouldn’t judge or characterize you or your comments. That said, I do believe I have met people like you, both in a clinical setting and at the local coffee emporium. You certainly carry a lot of ire and umbrage about matters you only slightly know and understand. To suggest, 1) that the author bears responsibility for what you misconstrue as a scheduling problem rather than the fact that some patients require more time than others and that time cannot be magically accounted for by schedulers, and 2) that the author is treating the patient with a lack of respect because she gave respect to the previous patients she visited – thereby allowing the “schedule” to slip, shows a shocking lack of empathy for either the author or the patient. I have been taught that one does not DEMAND respect, one earns it by showing the same respect one would desire.

    I hope you are not injured when you come down off of your high horse. You might face an unacceptable wait in A & E.

  17. Shara Yurkiewicz says:

    Thanks so much everyone for your replies and sharing your experiences. It’s nice to know that these feelings are common, on both sides of the doctor-patient relationship. What I hope to do by sharing things publicly is to humanize the journey: voicing thoughts–sometimes good, sometimes bad, sometimes open to interpretation– and analyzing their context so that perhaps a reader can relate or understand better.

    APatient: Although we did learn about “difficult” patients during psychiatry, the emphasis wasn’t on medicalizing those behaviors. I think the physician decided to give that lecture because psychiatry is a field in particular where you run up against these issues more frequently, is all.

    Orli Van Mourik: I politely disagree with your comment. I certainly don’t go around congratulating myself on my empathy; in fact I wrote this because I recognize that it was my lack of empathy during difficult moments that could affect care. I hope with time I can temper my reactions somewhat. Also, I chose those two examples because what was angering each patient was truly out of my control: 1) as a student, I only volunteer at that clinic once each week, and I don’t set the schedule or tempo of the appointments, 2) and the second patient exploded at me almost immediately after I told him he couldn’t eat, so I don’t believe it was my bedside manner in that case.

    Thanks again, and hope to hear more!

  18. From Both Sides says:

    Curiousity speaking….Did the patient who ‘exploded’ possibly have some low blood sugar? Ever missed a meal and felt grumpy?

  19. Shara Yurkiewicz says:

    Yes, there could have been physiological reasons underlying the patient’s behavior. However, to protect privacy, I keep details very vague and change some of them.

  20. DocHuman says:

    There’s another aspect to this from which the author is apparently still being shielded. ‘Grown up’ doctors, fully fledged specialists who’ve finished their training long ago, are routinely called in to the principal (an MBA or Nurse administrator ) and chastised for all manner of things. One of these things is ‘patient dissatisfaction’. For example, if you don’t cave into patients demands for addictive substances, they will complain, make no mistake. If you do cave in, you’re not practicing medicine, you’re being a drug dealer (and will likely lose your license and DEA eventually). There’s no way out of this dilemma.

    A real life example of this was an active IV heroin user I consulted on once upon a time when I was working as a C&L psychiatrist somewhere in the Midwest. He was given as an outpatient alprazolam (xanax) and ritalin, crazy things to give a person with active addiction. When in the hospital I stopped the ritalin and switched him to clonazepam, assuring him that if he’ll feel any withdrawal symptoms or any discomfort, he should let the nurses know and I’ll adjust the medications accordingly. He stared at me hatefully. Naturally, he complained, and I was ‘called in’.

    You see, in the American medical system over the past 20 years, patient complaints always ‘win’, no matter how ludicrous, no matter how much you worked hard for them, no matter how much you tried to work together with with, no matter that you did the right thing. As they say, no good deed goes unpunished. Now that there are Press Gainey (satisfaction surveys) even in psychiatry, complaints will lower their numbers. People with personality disorders and drug addiction need to be kept happy at all times (which is impossible).

    Needless to say, this is not only insulting, demeaning – and shocking, it makes it impossible to do your work.

    So that’s the future you mostly likely have to look forward to – you’ll be attacked not only by patients but by the institution, sometimes by your doctor supervisors, more often by non-physician admins. You’ll be attacked for trying to be a good doctor.

    That’s the dark reality of medicine in the United States.

    Btw, the most likely to complain are people who are on disability and medicaid but are not actually disabled. Usually they’re drug addicts, but not the sort who’re trying to fight their addiction and get back to life. The least likely to behave this way are the working poor and the professional class. These people respect your time and effort and will show appreciation.

    All in all, is it worth it? Absolutely not.

    The attacks from patients taken on their own are difficult, but can be dealt with. You learn to take a deep breath and you learn to make your off hours as fun and light as possible.

    Being attacked by the system for trying to be a good doctor – that is intolerable.

    Again, is it worth it? There might be some specialties where patients are more appreciative, but all in all – no. If you’re a caring and conscientious sort, practicing medicine in the United States in this day and age will bring you to an early grave. It is not worth it.

  21. R E G says:

    It wouldn’t surprise me to find myself starring in a “patients from hell” story one day. Not because I waited 45 minutes, or couldn’t get anyone to help me eat.

    I like to live in the illusion that I am reasonably smart and competent. That illusion blows up in my face every time I encounter the medical system I am sincerely trying to follow directions, keep appointments, not bother the wrong people, etc. etc. But somehow it never works out.

    The whole system is like the Twilight Zone to me. I have been accused of not going for a test because the result is not in my file. I have had a doctor and nurse bicker over scheduling while performing a procedure on me. ( I wanted to point out it was not very professional but they were holding sharp objects.) I was once referred to a very charming young lady who assured me she could arrange x, y and z … I only needed to ask. She didn’t return my 5 or 6 calls, and when I finally reached her, she informed me that was not her job.

    So far my frustration has mostly taken the form of ” I’m sorry for the misunderstanding…what should I do next?” even though I am just following directions. After all, the doctors, nurses and others are caught up in the crazy system too. But the frustration, the confusion and the helplessness – and the delays – it causes are grinding me down.

  22. Kate says:

    Try this substitution:
    “Rather than blaming a doctor […] why not blame the system that stacks up appointments in such an untenable way. ”
    I suppose you think doctors should walk away in the middle of treating a patient if the allotted appointment time runs out, to make sure they get to the next patient on time. That’ll work.

    Yurkiewicz talks openly, with courage, about feelings medical staff aren’t supposed to admit to. It’s important to understand how normal human feelings – of failure, humiliation, rage etc – affect professional performance. Everyone with normal human emotional structures has these feelings – they’re not particularly deep, but they are important, and very difficult to deal with unless uncovered. Without such admissions, nothing will improve.

    Isabel Menzies Lyth wrote a powerful paper in 1959 about the impact of unacknowledged feelings ‘The Functions of Social Systems as a Defence Against Anxiety: A Report on a Study of the Nursing Service of a General Hospital Defense.’ The UK NHS learned a lot from it – about how to support staff faced with illness, death and other emotional challenges stemming from being held responsible for the lives and deaths of others, which it repeatedly forgets and has to re-learn. It may be 50 years old, but medical systems haven’t improved so much that they can’t learn from finding out what actually happens, what people in these situations actually feel like, rather than idealising and blaming.

  23. NYEngineer says:

    Doctors do not need to apologize for being late, while engaged in the activityof saving human life. I had some surgeries in 2011. Out of 8 appointments I made with surgeons, typically two or three weeks in advance, 3 were canceled. Two were on the day of the appointment for emergency surgery. I was just happy not to be the person who needed the emergency surgery.

    It’s tough when you are sick. No one can help you, really. Your situation is worse, and while it will improve, it most likely will not go back to what it was before. It’s inevitable that people will take it out on doctors, and the doctors need to forget about it.

    As DocHuman points out, making the goal of medicine “patient satisfaction” is ridiculous. Financial corruption and treating the patients as “customers” probably plays a role here.

    I agree with Carol Trongeau that I want the technically competent doctor, and with Nathan Weber that many of the best doctors are also the nicest.

  24. Shara Yurkiewicz says:

    I am astounded by the diversity of viewpoints here. We can’t agree if a doctor should apologize for being late, if competence and compassion are related, how much patient satisfaction matters, etc. No wonder there’s so much tension. I urge everyone to keep this in mind–that people have vastly differing expectations–the next time they feel themselves getting frustrated with the medical system. Maybe it can help…

  25. Peter Traber says:

    Shara, I just discovered your blog and your insights are wonderful. Over my career I have been Chair of Medicine and Dean of two medical schools. When I trained the only thing to read on training experiences was the “House of God”, also from Harvard. Your blog is a clear evolution to a much higher plane of commentary. Keep up the good work, continue to struggle with the issues, and continue to have a good cry at times. When you stop crying, you have lost your edge. Peter

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  27. Susan says:

    As a health care professional and someone who suffered from undiagnosed B12 Deficiency for 5 1/2 years my advice is do not take it personally, do not judge the patient and most importantly use it as part of your assessment of the patient. 5 1/2 years and seven physicians later I had no idea why I was in physical pain daily, suffering fatigue, memory loss, confusion, angered easily and many other symptoms. It was only on finding out that the serum B12 test that had been used to rule out a B12 Deficiency multiple times over the 5 1/2 years is very unreliable. One study found that up to 50% of patients B12D was missed when using only the serum B12 test. It should only be used to rule out a B12D when used along with MMA and tHcy. An Active B12 test is now available but MMA and tHcy should be used with that as well. Different labs in the US and Canada have different lower limits usually ranging from 138 (my lab) and 200 pg/mL. Neuropsychiatric symptoms have been shown to occur anywhere below 500-550 pg/mL (Japan’s lower limit!) I was bedridden for many months and quickly heading towards dementia at 41! B12 is required for neurotransmitter, enzyme, hormone and DNA synthesis. B12D commonly shows up as fatigue, nominal aphasia, IBS, headaches, peripheral neuropathy, depression, anxiety, irritability, insomnia and balance problems. It is very important to catch neuro symptoms within a few months as these can become permanent. I have been injecting B12 daily for 10 months (along with 5mg folic acid and a B Complex) but I am still left with peripheral neuropathy, tinnitus and fatigue due to being undiagnosed for so long. Anyway, my point is a patient’s reaction may not be about you it may be an easily correctable vitamin deficiency. There is a wonderful international charity that helped me through my B12D called the Pernicious Anaemia Society. They have an American delegate that I am sure would answer any questions you have about B12D or PA. My personal goal is to raise awareness of B12D and hopefully start a Canadian charity in the near future.

  28. Melody says:

    I have found my way to your blog via White Coat, Black Art on the CBC. I will go to your sister’s blog and read there, also.

    I am currently going through a health odyssey that started with an incorrect diagnosis of Cancer. My experiences with the medical system and with health care professionals spans a great breadth. I am a curious and collected patient when in interaction with people who are compassionate – and can be quite fierce when I deal with people who are callous or arrogant to the point that they cannot instill any confidence in their abilities. If I do not feel/ think that someone sees me as a person, how can I trust that they have my true best interests at heart? I was recently reduced to not only a horse, but a common pony by an infectious disease specialist. Conversely, my thoracic surgeon (not the possessive) has instilled confidence in me through his ability, thoroughness, and great, and I mean GREAT compassion. When we all thought it was lung cancer, he spoke to me with tears in his eyes, as did my GP. These people acted in such a way that I felt safe, cared for, and cared about, during a time of great turmoil and fear. The ID Doctor acted in such a way that I felt medically abandoned; frightened to both stunned silence and profanity.

    I am still on my journey, and committed to advocating for my life, my health and humane treatment. Sometimes this means calling people out on their behaviour, and challenging callousness and a broken medical system. I want to learn to be more humane, and for others to learn. I decided early on that whatever illness I am facing needs to have meaning.

  29. Howard Ovens says:

    Re; the patient who demanded food and shortly thereafter was in ICU – irritability and dis- inhibition can be early signs of hemodynamic instability – hypoxia, hypotension, hypoglycaemia etc etc. rule those out first before analyzing emotional context etc…..

    Thanks Howard

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