Opportunities for grace

Actually, a more accurate statement is that I hate the way I feel about myself when I have negative emotions about some of my patients. The shame and guilt that accompany this quiet struggle have been my companions since the beginning of my career but struck me hardest in residency.

My savior complex in full force and my identity wrapped up in an idealistic version of me, by the time I hit my second year I'd developed a reputation for having great capacity to work with "problem patients."

Yet what could I say? My fear of seeming anything less than compassionate kept me alone, juggling all my conflicting emotions - a sense of obligation to these patients, who often victims of themselves and terrible circumstances, pride over being good at it, anger that I was always getting "dumped on," but most of all, the guilt over wishing a given patient would self-combust and disappear (or, at the very least, no-show).

Now that I've been practicing internal medicine for five years, I still have a reputation of working well with difficult patients. Though time and experience have somewhat tempered my perfectionism and self-judgment, I still find myself struggling at times. I often worry that the energy I spend dealing with my more difficult patients might leave me a shell of myself for the vast majority of the people for whom I care. This struggle has led me to try to figure out exactly what helps me do this very necessary aspect of being a physician. Though I've distilled many concepts from my experiences, my first lesson stands out the strongest, as does the patient who helped me internalize it.

AN UNWELCOME PATIENT

When I saw Anna for the first time, she didn't seem all that unusual. I'd been warned she was tough to deal with, and reading her chart before seeing her had scared me to death. This quiet, conservative-appearing. middle-aged woman seemed innocuous enough, however. She sat primly in her seat, in a nice skirt suit, legs crossed at the ankles and clutching her small purse in her lap. I'd almost exhaled in relief, and then she looked up at me.

Through her large, thick-framed glasses, her eyes locked on mine, and I was caught by an expression that I've since learned to recognize in the face of some people who have been severely traumatized and left emotionally bereft. There was a calculating greediness in the way she looked at me, as if she were sizing me up and deciding whether I was going to be able to give her what she needed. At that moment I was sure of two things: I had no idea what she needed to find peace in this world, and regardless of what it was, I would be unable to give it to her.

Anna carried bread-and-butter diagnoses of diabetes, hypertension, and high cholesterol. She also carried the diagnosis of depression and the label of having borderline personality disorder. The latter may have been true, but, looking back, she truly had post-traumatic stress disorder as a result of many early years of physical and sexual abuse.

As a first-year internal medicine resident, I did not have the skills to even begin to help her process her tragic past and the damaged psyche that remained. I saw my goal as trying to care for her medical problems despite her emotional and psychological problems, as if I could compartmentalize the issues that felt manageable to me, and somehow the rest would be left outside the exam room door.

Of course, I quickly learned that her psychological issues were no more easily separated from her than a vital organ. She was manipulative. She cried at least once at every visit. She was sexually inappropriate toward me. I felt physically ill whenever I knew she was on my schedule. I never spent less than one tortured hour with her at our appointments, and in the end, she was no better, and I was closer to giving up medicine and becoming a toll booth worker (the monotony and routine of it always seemed so soothing to me).