What difficult patients can teach us

Several years ago, I was taking care of Emma. Or, at least, I was trying.

Emma was in her mid-forties and unemployed, I suspect because she could never find a position that matched her greatest skills – histrionics and passive aggression. Consequently, when she wasn’t physically in the office, she passed her time by contacting the staff and pushing more buttons than an accountant during tax season.

On nights and weekends, she would visit our local ED, often precipitating next-business-day phone calls by exasperated physicians insisting that something needed to be done about her behavior. (Though sympathetic, I had similar exasperation in trying to get these docs to understand that I was Emma’s PCP, not her father.) With Emma, I observed one of the most time honored superstitions of my medical training years: I would not say her name, lest she appear.

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One morning, just as the clinical session was getting into full swing, my office manager, Cathy, approached me with a grim look. Employing one of her favorite greeting catch-phrases, she said, “Morning, Glory. Guess who’s burning up the phones already?”

“Delores?” I conjectured. (Hey, we all have more than one “Emma.”)

“That would probably be better. Try Emma.”

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We sighed in unison, then she continued. “This is just ridiculous. We have people with real problems who need to be seen, and we’re wasting our time with her. She’s torturing the front staff, she’s tying up the nurses, and she’s not even in the office. I’m fed up. But it’s your call. If you want to destroy your morning and work through lunch, I’ll get my crow bar and squeeze her in.”

Here I will pause.

Next: Finding yourself frustrated and overwhelmed in clinic?

I am fortunate enough to have been mentored by one of the greatest teachers of family medicine in the twentieth century, Dr. B. Lewis Barnett. Dr. B., as all who know him affectionately call him, had a gift for redirecting irritated and exhausted residents in the most difficult circumstances back to their raison d’etre – the patient. When I am frustrated and overwhelmed in clinic I use a variation of a traditional Christian technique for centering oneself; I ask, “What would Dr. B do?” It almost always helps, but on this particular day, I felt an unusually intense connection with my old instructor, almost as though he were in the room with me.

“You know, Emma really is sick,” I said to Cathy.

“What? Have you gone off the same rocker she did?”

“Think about it. Would you want to live your life like Emma? There is obviously something she needs that she is not getting outside of this place. How miserable would it be to live your life constantly worrying about when you get to see a doctor again? I don’t know about you, but I hate being a patient. And being a patient is the best part of her day.”

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She looked thoughtful for a moment. “I never considered it that way.”

“Yeah, I have to remind myself of that quite a bit, too. So,” I sighed again, “guess we better get the crow bar.”

I don’t have specific memories of the content of Emma’s complaints that day (though I have some pretty good ideas–headaches, insomnia, weakness, dizziness, and edema only she can see), but I do remember that my perspective was different. As general office busy-ness whirled chaotically through the halls outside, there was a calmness within the exam room that I did not associate with the usual Emma visit.

Instead of closing the encounter in the usual Emma fashion-stepping backward toward the door while speaking, leaving no dead air for a new complaint to arise-I moved toward her and shook her hand. Emma remarked, “Thanks for working me in and listening.”

Next: We all have our big moments

Perhaps she had said it before, but it was the first time I really heard it.

A few years later, I was speaking with Cathy at a social gathering. She no longer worked in our office, so we were re-hashing old times. “Do you remember Emma?” she asked.

“That’s a rhetorical question, right?”

She laughed. “Right! Well, do you remember that day you told me that she truly was sick? That has really stuck with me. Made me think about patient care completely differently. Powerful stuff.” As it turns out, thanks to Emma, Cathy and I made a connection, too.

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Dr. B used to say that if every patient takes a little something from you, you’ll burn out in no time; but, if you can figure out how to get a little something for yourself from every patient, you’ll last as long as you want.

We all have our big moments-grand epiphanies, tears of gratitude, congratulations from peers and superiors for a job well done. However, those are generally too few and far between to keep us running in the patient care marathon. Rather, it’s the connections we make-or at least, CAN make-every day that will keep us going, including connections back to those who made us who we are.

Even in these days of electronic medical records, accountable care organizations, prior authorizations, and the like, it is, as it always has been, the connections we make in our day-to-day professional lives that rejuvenate us.

David Switzer, MD is a family physician in Luray, Virginia.