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A “difficult” patient

Recently, I had an encounter with a patient who wasn’t like me in several ways. He’d had chronic pain for years, and lately had been misusing and lying about narcotic medications that I’d prescribed. He’d nearly killed himself and was now demanding more medication.

I was enraged. The first thought that crossed my mind was, “That one, not like me, not my tribe, kick him out of the practice,” even though I knew that my short-sighted view of him would take a toll on both of us. We were at a stalemate—he, a human being in pain deprived of caring attention and me, unable to fulfill my role as a healer.

Wise words from Walt Whitman

In a mindful moment I remembered a line from “Song of Myself” by Walt Whitman, the great American poet.

Looking straight into the eyes of those whom he might consider “not like me,” Whitman could see a spark of humanness meriting deep regard, respect and humility. He described how he could see himself in the criminal and the victim, the robust and the dying, realizing that his vision of openness and inclusion was at the core of the American spirit.

“I am large,” Whitman wrote. “I contain multitudes.”

Recalling Whitman’s “multitudes,” I considered my patient in a new light. We had one thing in common—he felt betrayed and so did I. That awareness made me curious to get to know and understand him better. I learned that he’d had an unspeakably abusive childhood, chronic pain from a fractured jaw and brain damage from repeated concussions. He was in a cycle of despair, having made bad decisions that cost him his job and his family.

As we talked, I realized that I’d known despair, too, along with the need to be understood. Following that, he was no longer an “other.” Our candid conversation made him more connected to me and I to him. I could see that it was possible to set aside my anger and disappointment. Eventually, he was able to see that he could accept drug treatment.

As a teacher of doctors, I’ve observed how good doctors take care of those who aren’t like them. They’re not merely fulfilling a professional obligation; when doctors are at their best, they embody Whitman’s vision, setting aside judgments and turning towards that which is deeply human in others. In doing so, they also unleash those same qualities, including a self-sustaining sense of purpose and gratitude, in themselves.

Curious and present, the best doctors see each person—and themselves—anew.

Avoiding polarization within the doctor-patient relationship

Of course, attentiveness and inquiry in the face of harsh differences isn’t easy. We’ve all experienced how rhetoric can highlight the differences among us, creating norms of exclusion and crassness.

Humans are fundamentally tribal and we remember negative experiences more vividly when they involve someone whom we regard as “not like me.” These experiences are at the root of bias and stereotyping, and even worse, hate and alienation. Similar polarizing sensibilities can play out in the relationships between physicians and patients.

There’s an alternative, and I’m not just suggesting tolerance or reconciliation. I’m talking about awareness—learning to be aware of your own thoughts and feelings, and to listen deeply. Awareness means unflinching acceptance of our own impulses to avoid knowing those whom we see as different, to treat them as “the other.”

I teach medical students and doctors that it takes effort, resolve and practice to be a healer in the face of these tendencies.

I suggest that before they see each patient, they pause for a moment, hand on the door handle, and mentally set aside their expectations and preconceptions so they can be fully attentive to whatever the patient might bring—beautiful or horrible, expected or surprising. Ask: “What am I assuming about this patient that might not be true?” Smile, as if to say: “Welcome, this is your time; here I am, listening.”

Recognize that we all contain multitudes.

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Ronald Epstein, MD, is a family physician and professor of Family Medicine, Psychiatry, Oncology and Medicine at the University of Rochester School of Medicine and Dentistry. He’s also the author of Attending: Medicine, Mindfulness, and Humanity (Scribner, 2017).
image: Vic (Creative Commons BY)

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