April 21, 2019
To be a good doctor is a noble thing. Each of us applied to medical school with lofty dreams of helping those in need, and I trust that we will all spend our lives doing that to the best of our abilities. However, in third year, I’ve learned that we are all fallible with our own suites of insecurities, difficulties and biases that dull our senses and hamper our ability to steadfastly walk the path. Like blood sugar in a diabetic patient, if we allow our human weaknesses to go uncontrolled, we will lose the mental proprioception that informs us about how to be effective as physicians.
My family medicine preceptor is one of the best physicians I have ever worked with. He is energetic and efficient in his office, but kind, calm and imperturbable when he is with his patients. He throws himself enthusiastically into the day’s schedule with seeming disregard for trivial things like his lunch break or personal time. I can see the affection his office staff have for him in the way they roll their eyes with a smile or throw up their hands exasperatedly as he pops out to ask for a battery of things that the current patient needs to ensure his or her healthcare maintenance is on track, despite the fact that it’s 12:27 pm and he will still need to eat lunch sometime.
Last week, a patient threw a slipper at him and then proceeded to verbally abuse him, criticizing everything my preceptor did and said, blaming him for all the health problems the patient experienced. I felt respect ballooning in my solar plexus as I watched my preceptor smile and nod through it all good-naturedly. When the patient turned to me and asked, “He’s so stupid, isn’t he?” I couldn’t help it, and I burst out laughing. In answer to the patient’s inquisitive look, I asked, “Are you always this ornery?” and the patient’s face broke into a snaggle-toothed grin as he laughed and looked momentarily bashful. The rest of the visit went a little smoother, in my opinion.
There was one patient in particular that defined my respect for Dr. FM. We could hear her voice through the wall as she was checked in. She spoke with hoarse, reedy insistence and shrill demand. She had just left the last hospital AMA and I was warned that she was a difficult patient, but that my mission was just to make sure that she was not imminently in danger of cardiovascular or respiratory failure. Her myriad other medical and socioeconomic problems were not my concern today.
I don’t know exactly what I expected when I walked into the room to see her, but whatever I expected was not what I found. I knew that she had severe skeletal disability, opioid-dependence and was a hoarder, wheel-chair bound, but when I walked in the first thing I noticed was her eyes. They were as shrill and piercing as her voice and they watched me distrustfully under unruly white eyebrows and stringy gray hair. Her small, frail frame was hunch-backed and tilted awkwardly in her wheelchair, and the jarring mismatched patterns of her clothes belied the stillness of her posture as she gazed at me with what felt like an impassive accusation. My nose twitched imperceptibly at the smell in the room as I walked in, but I straightened my skirt and shook her hand warmly as I introduced myself.
I asked about why she had gone to the ER in the first place. Her husband had been in the hospital and hadn’t heard from her in a day or so, which prompted him to call emergency services. When EMS showed up, they found her unresponsive in the front entry way of her crowded home. There were 7 fentanyl patches on her back and the assessment was unintentional overdose with subsequent respiratory depression. Apparently, she had also been covered in chicken poop and had been scratched in multiple places by her hungry cats. She was in the entry way because she was confined to her electric wheelchair and the rest of the house was too full of junk for her to go any deeper into the recesses or even to close the front door. The details of the story were disjointed and bizarre enough that sorting them out fully seemed quixotic. Common ground was sparse and I could feel that this encounter was not going the way I wanted.
She told me about her book about mafia in Hawaii. Her eyes darted shiftily to each side as she confided in me that she suspected powerful people were out to kill her and that it was absolutely impossible she could have applied the fentanyl patches to her back. She usually put them on her legs. Her hunched spine and cramped, wasted frame seemed to support this assertion and I decided to ask instead about the duration of her hospital stay. She had been admitted for acute respiratory distress and CHF exacerbation secondary to fentanyl overdose. Because she was incapable of moving without her wheelchair, she had developed a bed sore during her weeks in the hospital. It was painful and the doctors at the last hospital had been deaf to her complaints. She rambled on about the ways in which the world was out to get her, but her story always circled back to her book. “It’s the only thing keeping me alive,” she rasped, as I finally realized her book was the key to connecting with her. I began to structure the interview around the book and organize healthcare goals for her that would allow her to finish her writing, and I felt a flutter of hope that this visit might be a chance to do some good after all. I thought I had identified what this patient wanted.
My minor victory was short-lived and I started to feel my biases encroaching on the corners of my mind, rasping like dry sandpaper on plexiglass as she continued to purposefully define why she was here to see us. First, she wanted us to fill out a form for the insurance company, falsely asserting that her electric wheelchair was improperly sized and that she needed a new one. Since she’d already had this one for a year, she would be able to keep it for her husband to use and would also be given a brand-new motorized chair. She described the intended fraud without a hint of remorse, seeming proud of the way she’d discovered to game the system. Second, she needed to find placement because someone was allegedly trying to kill her. At the last hospital, they had found her placement and were set to get her there when she left. All the work they had already done was wasted and she wanted us to start afresh.
I felt like Alice falling down the rabbit hole.
I value personal accountability and my biases show up most vividly when I perceive someone’s story as coming from a place of victimhood. I resented her for creating problems in her own life and then wanting us to lie to the insurance company and fix all the mess she had created by being a bad-tempered, difficult patient. I warned her that we would have a hard time making the case to the insurance company for a new wheelchair if there wasn’t reasonable medical cause. She scowled and then launched into a story about the social worker who went to get gloves before looking for the paperwork in her house. She requested that he get her some McDonalds while he was gone. She didn’t understand why he never returned. When I asked her whether she thought that there was anything she was doing that was making it so that others were less inclined to follow through on her care, she said, “No, I think it’s because I don’t live in a nice house anymore.” I was frustrated and put off by her lack of motivation or accountability for the things happening to her. Next she told me about her friend that came over and brought her a milkshake. Since she is lactose intolerant, the milkshake gave her explosive watery diarrhea and in her limited state, she was unable to adequately clean herself. She’d had four massive bowel movements in the last day, and she described the color and texture to me in gleeful detail. The helpful friend had also said that she should make sure that we cleaned her up when she came in to see us.
I don’t like unpleasant smells. I do not like poop. My heart sank as I listened to her dairy diary and imagined the disastrous diarrhea. There was a plastic grocery bag hanging on the arm of her wheelchair and she started to go through it, describing the way she used the scissors inside to cut off her soiled Depends and the tongs to pick up the soiled mess off the floor. I deeply regretted touching the bag with bare hands earlier when she had needed help finding the insurance form. As I prepared to retreat and call for back up, she started back on the subject of the terrible, incompetent doctors at the last hospital that essentially held her prisoner and hadn’t even noticed her sore buttock. I do not like butts. I needed help. With as much grace as I could muster, I excused myself so that I could prepare to face the furies.
I could feel my facial expression drooping like candle wax in the hot sun, as though my smile muscles were on a leave of absence, as I tried to describe what materials I’d be needing to the office staff who were blissfully warming up their lunches. My presentation to Dr. FM came out in a flustered torrent of insurance scams, disposition issues, bed sores and milkshake diarrhea diapers.
“Great!” he said. “Let’s go see her.”
The pressure ulcer was the size of a fist, an angry reddish gray-brown surrounded by irritated erythematous flesh. The eschar had the texture of a singe mark on the industrial carpet of a junior high classroom. I never would have expected to be grateful to be in a cramped exam room filled with the smell of human feces, but that day I was. Dr. FM was cheerful and pleasant as he greeted her and his demeanor never slipped. He rolled up his sleeves and laid his ID badge and stethoscope down by the computer before we helped her stand up from her wheelchair. For the next 30 minutes he kept a good-natured stream of light conversation with her, while he was on his knees in an island of chux pads gently cleaning her backside and shaving away the necrotic flesh of the ulcer. Eventually she was too tired to stand any longer, so we bundled her back into her wheelchair, clean, dry and bandaged. As she left, Dr. FM cheerfully asked the staff to schedule appointments for her every day so that he could continue giving her the care she needed.
Patients come to see us for different reasons. Some want medications and treatments, others just want a sympathetic ear, information, reassurance or someone that will hold them accountable for their health. Then there are patients that truly need our help in a way that we are uniquely able to provide. In talking to the patient, I got lost in her words and missed the most important things. She was in pain, helpless and dying, and I forgot my compassion because I let my ears, eyes, and nose cater to my personal bias that interfered with my values. I was humbled and filled with awe as I watched Dr. FM provide exactly what she needed most without complaint. To be a good doctor is a noble thing.