‘Good’ Patients, ‘Bad’ Patients
He was the kind of patient I went to medical school for.
By the time I met him, he had had a rough go of it. After learning the previous year that he had lymphoma, he was fortunate enough to receive a bone marrow transplant — only to have his body promptly reject it. On three separate occasions in the past six months, he had deadly antibiotic-resistant bacteria coursing through his blood. He was just recovering from a bout of pneumonia when the meningitis struck.
Last night, his nurse saw him crying quietly in the corner of his hospital room. She asked our team to meet with him to evaluate whether antidepressant medications might be helpful to bolster his mood. When I entered his room, he greeted me with a smile — weak and pained in his emaciated body, but warm and genuine. I introduced myself as the medical student on the psychiatry consultation service and asked him how he was holding up.
“I’d be lying if I told you it hasn’t been tough,” he said. “I get down sometimes, but I have so, so many things going for me.”
We spoke at length about his family. His twin sons had just graduated from college and had initially planned to work for a nonprofit organization in Nepal, but opted to stay close to home given his medical condition. His daughter (“all grown up now!”) was being recruited to play softball at a local college. His wife had been tending to their small restaurant business during his long hospital stay.
“I consider myself to be an incredibly blessed person,” he said. “I know I’ll get through this.”
His body was sick, yes, but his spirit was unyielding.
At the end of our conversation, he expressed his deep gratitude for his caregivers over the past several months: “You guys have made this bearable. Thank you, doctor.”
I started to correct him — technically I wasn’t yet a doctor — but thought, ah, forget it. Our interaction had left me energized. The next evening I donned my white coat and strode into the bustling emergency room with renewed confidence, ready to heal.
I started my shift with a woman in her mid-20s who sat cross-legged on a stretcher in the hallway, bouncing up and down with a wide-eyed, unhinged look on her face as she vacillated between singing and crying. As I approached to introduce myself, a viscous ball of saliva and mucus left her mouth and landed squarely on my left cheek.
“Be careful: She’s a spitter,” a nurse advised as he rushed past. “PCP and alcohol. Give her a few minutes to calm down.”
I moved on to an elderly man who was lying on a nearby stretcher and moaning, and I softly asked what had brought him to the hospital. No response. I shook him gently and asked again, louder this time. He opened his eyes just enough to see my face and muttered something entirely incomprehensible.
Suddenly, behind me, the spitter let me know she wanted to leave. She took off her socks and started flapping them about. “I’m ready to go.”
I began to feel frustrated and disengaged, a far cry from the feelings I’d had the day before.
Across the room, a thin, disheveled man hunched awkwardly over the edge of his stretcher. He had strange cuts and bruises scattered across his face and arms and had been waiting to be seen for almost an hour. According to the chart, he was 47 years old, but he looked at least 60. He had come to the E. R. in withdrawal from alcohol, as he had once every few months.
I asked my supervising physician if he had time to accompany me to see the man. Rushing away to see a new patient, he looked over his shoulder and said, “I’m not going to check on a drunk while he’s throwing up.”
I was shocked by how bluntly and callously he spoke. But I wondered whether this was the kind of calculation that busy doctors make all the time. Are we constantly shortchanging patient encounters we find difficult, troublesome or otherwise unrewarding?
As I approached the patient, he was calm but tearful. “I don’t want to live like this anymore,” he whispered. He told me how frustrating it had been for him to struggle with alcohol, how he had tried, time and again, to quit. He had worked in construction but lost his job last year. His girlfriend left him a few months later.
“It seems like you’re going through a tough time right now,” I offered.
“I’ve been going through a tough time for 14 years,” he responded — ever since his daughter died in a car accident.
Like many of my classmates, I entered medical school with an idealized notion of medicine. But I will leave with the knowledge that the reality is far more complex. There are patients who don’t listen, who can’t listen; who try, who don’t try; who smile, thank and love; who steal, curse and hate. Each of these patients deserves the full extent of our respect and abilities. But too often those most in need of our compassion are least likely to receive it.
The balancing of complex emotions, time constraints and limited resources will only become more difficult with the influx of millions of previously uninsured people into our medical system. As we continue to carry out the Affordable Care Act and enter an era of tremendous change, we must confront our natural tendencies to favor patients we find pleasant — especially when it comes at the expense of those we find less so. We must recognize that sometimes the patients who behave the worst are those who are hurting the most.
Dhruv Khullar is a student at the Yale School of Medicine and the Harvard Kennedy School, where he is a fellow at the Center for Public Leadership.
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