If I Am Ever Like You, I Need A Break
Clutch quote from an OB resident 3 weeks ago that’s still been bothering me, in reference to a patient with metastatic cancer who was in pain and needed a CT scan but was refusing contrast:
“I am so sick of these patients. Just suck it up already and deal with it. God.”
If you’re ever working with me, and I ever say anything as remotely cruel and disgusting as that about a patient, especially one with metastatic cancer all over the place, please, please, sock me in the gut, or slap me, or something. There’s ranting, and there’s bitching, and then there’s just plain inability to have any sort of compassion or caring for your patients.
I feel guilty that I didn’t speak up and put the resident in her place. Granted it was 3 residents versus one med student, but I wish I would take the right path rather than the easy one a little more often. Sigh.
I hear ye. I know doctors can often be under a lot of stress and deal with a lot of frustration, but still, it’s important to put that in perspective. Any frustration we feel is peanuts compared to what a lot of patients have to deal with: they’re the ones with the real pain and suffering. I’m lucky so far to have worked with patient attendings and residents, and I haven’t really been in this sort of situation yet. When that situation does come along, I hope I can remember your experience and find the courage to say: “Hey, give her a break: she has cancer. It isn’t easy to deal with that.”
Good post.
that is heartless and down right mean!
Trust me, Apollo, you don’t need to say that. Your attendings and residents are not monsters and there’s no need to embarrass them.
By the way, it is perfectly natural to be irritated by even your really sick patients every now and them. Some of them are irritating. That’s all there is to it. You just have to maintain your serenity and say, “I can go home at the end of my shift…I can go home at the end of my shift…I can go home at the end of my shift…etc.” and you’ll be okay.
Not every patient is undergoing pain and suffering. Many present for nothing, what we call a “weak admit” or a “bogus complaint” and cause more pain and cause a lot more pain and suffering to the ED staff than they are experiencing.
I agree with Apollo.
You have to be patient no matter what. Especially when someone is dying. Whatever you ‘re going through can’t be worse than his. You shut up and keep your worries in you. If you can’t then GO WORK IN A LAB. I have seen such stuff in the hospital and it’s unforgivable- end of story.
Let me give you a real life example and not something dramatic like cancer.
I am on call tonight and I have just now (0530) cleared the board of admissions. And I am not exaggerating in the slightest when I say I have been working continuoulsy with no breaks and hardly a chance to sit down since about 4PM yesterday. So I’m beat. I’d like to lay down but no sooner do I close my eyes when the pager goes off.
It’s about an 79-year-old demented woman with every health problem under the sun including renal failure requiring hemodialysis who has had runs of VTach all night and is now in A-fib. She is asymptomatic as far as anyone can tell and her vitals are stable. Hell, her heart rate is only 100 or so which ain’t bad.
But I still have to get up there, assess her, decide if anything needs to be done, write a note, write orders, and even talk to the daughter who is sleeping in the room.
For God’s sake. She’s got CHF, kidney failure, dementia, five stents, a CABG, an artifical mitral valve, and health problems that are just a blur at 0530. What the hell do they want me to do? Fix her? make it better?
So if I curse when I put down the phone and somebody scolded me, particularly a medical student or a volunteer…well…use your imagination. Technically they would be correct about patient care blah blah blah but is this really such a goddamn emergency that it can’t be seen by her team just two hours from now?
And it’s not the patient in this case who’s demanding but her daughter. Good Lord. What you want to say is, “Lady, your mother is dying. Why don’t you accept it and stop making us do the little ACLS monkey dance with her every few weeks? Maybe when you have seven hospital admissions in the last three months it’s time to throw in the towel.”
I’m not sure what they wanted done, Panda. It might help to ask the daughter next time, or take the time to have the conversation with the daughter–or call a social worker, so the cycle of admissions stops.
Plus, if you’re so beat up that you can’t do the job, you should declare yourself temporarily unable to work, to ensure proper care for the patient. And if you’re not that beat up, you’ve always got the possibility of assessing the situation as not in need of immideate attention and let it be ’till later.
I’m not so beat up I can’t do my job. I showed up at the patient’s room with my best “doctor face” on, assessed the situation, and, as you correctly deduced from the history, temporized by doing nothing (stable vitals, no symptoms, etc.) because her team would be rounding in an hour or so. But generally you have to at least get up and physically see the patient.
Which is why I cursed. And made a cutting remark to my colleagues who laughed at me when I went back to the resident’s lounge.
As for declaring yourself unfit secondary to fatigue, it can’t be done. Although it varies by rotation, we are, unfortunately, in charge of the at night. I am the senior resident on some services (ICU) for example.
And I think anyone who reads my blog knows how I feel about call.
I know exactly what the daughter wants. She wants her mother kept alive at all costs. The other thing is, and you guys need to take this to heart, it’s not the social worker’s parvue (sp?) to discuss end-of-life issues with the daughter except after the daughter decides to give it up. She’s not qualified and to give her the authority is to give up some of your responsibility to a person who doesn’t rate it, is not medically trained, and has no business discussing anything remotely medical.
thanks for the post, graham.
you guys shouldn’t kid yourselves that patients and families are oblivious when the doc is angry or frustrated or in a bad mood. trust me, we notice. we can pick it up in your facial expression, your tone of voice, the words you say.
maybe you think we’re just meat, but i ask you: would you want your parent, your spouse, your child, to be the target of someone else’s bad day?
not saying it’s not ok to vent, because we all get frustrated and angry sometimes. but try to save it until your shift is over. because if you don’t, it’ll inevitably scorch every patient you have contact with. and often it’s the nicest people – the ones who appreciate you the most and wouldn’t dream of complaining – who get mowed down in the crossfire.
I don’t think you’re just meat. And I never have a bad day. That’s because I have self-discipline. Not only that but patients and their relatives often tell me that they’re going to write the hospital to tell them what a wonderful doctor I am, praise that I don’t deserve because all I have over better doctors is a good bedside manner, which, as much as it really effects the patient’s health, is terrifically over-rated.
In other words, medicine is something of a beauty pageant where doctors are judged on completely superficial things.
I also want to point out that gallows humor is a old as the medical profession and you guys are going to be extremely disliked by the majority of your colleagues if you are prudish about it.
You know who’s the worst? OB-Gyn. Those chicks are merciless, especially if they have had children themselves. Even I am shocked and scandalized listening to their humor. I’m Patch Adams by comparrison.
But Graham, I love your blog. I agree with nothing you say but nobody could ever accuse you of not being able to say it well.
The other thing is, why should a doctor always be in a good mood? Some patients are irritating. Period. Maybe the frequent fliers come in so often because we are too nice.
Just throwing this idea out there. I’m always nice because I’m a nice guy always. But not everybody is and it is hard for some to make the herculean effort to confront patients who are, frankly, idiots without betraying a little frustration.
Now I know that we worship at the altar of customer service and the new paradigm is to, when in doubt, kiss the patient’s ass but do we really need to be bland empathy automatons?
Well panda bear, welcome to the dark side.
Every doctor has moments where we say such things. But they are short lived and fleeting. Unless someone has done a residency, I think they should shut the hell up!!! No one can know what it’s like who hasn’t!! Any medical student who hasn’ been there should definitely keep their mouth shut and not offer their lame “opinion”.
To Mike and Panda Bear:
You may have to stay awake for days on end, deal with frightened, uneducated and annoying patients, and be at the mercy of nurses/residents/fellows/attendings, but it all results in benefit-ultimately-to you.
I’ve done all those things–as the parent of a pediatric cancer patient. So please don’t tell me that “bedside manner” is overrated, or that expressing compassion is superficial. It might be the only “treatment” that does any good.
Dot, with all respect, losing sleep is useless and doesn’t train one for anything, not even going without sleep. They make you lose sleep because residents are low-cost, almost slave labor to most academic hospitals, many of which are so strapped for cash they’d collapse without the house staff.
The AMA itself called residency training the last legal sweatshop in America.
As for your experiences, there is a vast difference between a pediatric cancer patient, a drug-seeker, and the family of a dying patient who want everything done so they don’t lose the social security check.
in the end we are all human with human emotions and flaws. with fatigue and frustration, these feelings will come to surface from time to time even in the most self controlled. it happens to residents and staff a like. as a med student, you are not their moral thermometer.
i look at this as a learning experience for you. (everyday is a school day) we learn both positives and negatives throughout life and medical training. you have just found a negative that “you” would not like to repeat. remember this when you are in the same situation and try not to repeat it.
Apollo/graham,
First, kudos for your kindness.
Second, sometimes the best way to control this kind of attitude, as understandable as it might be under the circumstances, is simply to say nothing. Sometimes a little silence can show a tactful amount of disapproval, allowing the other person to save face and to think about the hollow, ugly dong her words leave. I’m not saying I don’t understand her frustration or need to vent; however, I’m sure once she said the words, she regretted them. (At least, I would give her the benefit of the doubt.) Perhaps in an effort to prevent little vents from turning into out-of-control departmental patient-bashing free-for-alls, a little tactful silence can do the job.
Third, the comment about the OBs gets me thinking about a wider issue that may be pertinent here. Pregnant ladies, particularly first-world pregnant ladies, are besieged, absolutely besieged, with informational garbage that their practitioners have to put up with all the time. This naturally extends to all patients, though it may be nowhere more concentrated than it is in obstetrics. For instance, did you know that labor pain is all “in our heads,” epidurals can impair mother-infant bonding, IV lines “tie you down” and make you a decidedly unemancipated woman (tsk tsk), and your evil doctor is just chomping at the bit to give you one of those “unnecessary C-sections”? These are the kinds of myths and half-truths that people are shoveled, that we bring into the office to greet doctors with, all the time. I think they can be a much more formidable (and irritating), if not insurmountable, foe than any individual patient.
I guess you know all this, but … I wonder if doctors and nurses may sometimes benefit by asking themselves, “Is this patient irritating because he’s just an irritating fellow” (which of course is sometimes the case), “Is this patient irritating because he’s frightened and sick and obviously not at his best” (which I would guess is almost always the case) or “Is it not so much the patient as the societal crap/misinformation that’s irritating?” (perhaps very often the case). Might help put it into perspective.
You know some where along the way, some Drs. lose sight of the fact that it is our (patients) bodies that have to go through all these tests and procedures. As far as I know we are still basically, regardless of illness, some what in charge of what we want to go through. If someone has Breast ca mets and doesn’t want contrast then why should anyone get mad at her for it?
I have the greatest cancer doc’s alive. When I am going through chemo, or any treatments, they tell me up front, “If it gets to be too much, just tell me to stop this roller coaster and let me off”…It is our bodies going through all this. Im sorry Panda, but you dont own your patients, they are not your children and you are not the boss. You have every right to make medical suggestions and they have every right to either accept or decline.
Some doctors have such hugh ego’s that they cannot stand the thought that some one might actually challenge them.
Huh? Why do you think I want to own my patients? After I get done with you and we have arrived at a plan of care, when you are discharged you are on your own. I am usually completely ambivalent to whether you want to do what I tell you or not. I get paid the same either way and I have long, long ago lost any relish I might have had to try to control other people.
I just want a piece of pie.
Unfortunatley, however, we do own you while you are in the hospital as we are completely responsible for everything that happens to you. If you don’t like it, you can check out AMA. I’m not happy about this situation, of course, but that’s the way it is. In other words, you come in for a particular therapy suggested by your doctor. If you don’t want it nobody is twisting your arm to either come in or stay. It’s not as if people just casually wander in, hop in a bed, and we have long negotiations with them to arrive at a thrapy which is accepatable to them. There is and has to be somewhat of a “take it or leave it” mentality.
As for making medical suggestions, I had a patient who didn’t want to take anything with nitroglycerine in it because his frineds told him it was an explosive and his heart might explode. You can make suggestions but try to be reasonable.
Panda, I agree that when in the ER then of course the doctor is in charge. I was referring more to the subject of this post. A cancer patient refusing to have constast with a scan. That is not something any doc. should get worked up and nasty over. You do reach points, in cacner treatment, where you just want it all to stop. Where even thinking about spending one more hr on a damn scan table almost makes you sick to your stomach. When that happens then everyone should just let the patient deal with it.