Category: Uncategorized

It was close to 6pm and, as usual, the uptown F train was crowded. People on the platform glanced at the subway as it pulled into the station. One of the cars had plenty of standing room. When the doors opened, several people rushed out. Some people walked in, then walked right back out again.

Two ladies rushed through the turnstiles and, upon hearing the announcement, “Stand clear of the closing doors, please,” they dashed into the car. They smiled at each other in congratulations and then looked around.

Seated near the end of the car was a man who appeared to be asleep. His thin frame was lost in two dirty jackets and baggy jeans with tattered hems and a hole in the crotch. Bits of food were caught in his scraggly beard. His legs were splayed out in front of him and his hands, soiled with dirt, were resting on his lap. The odors of sweet alcohol and fetid sweat emanated from him.

New passengers looked at him, their noses crinkled. Saying nothing, they moved as far as they could to the other end of the car. Often this meant taking a mere two steps away.

One of the two ladies was wearing a golden mink coat. An Artsy GM Louis Vuitton bag hung from her wrist and strappy heels that bore the intersecting letters of Chanel were on her feet. She turned to her companion, clad in a white Marc Jacobs Balmacaan raincoat and Jimmy Choo Cosmic platform shoes, and waved her hand in front of her nose.

“It smells terrible in here!” Mink Coat exclaimed, shaking her head. Her dark tresses shifted on her shoulders. “He smells so bad!”

The train rattled as it entered the dark tunnel. A few people turned the pages of their magazines.

Raincoat glanced at the man and stuck out her tongue in disgust. “I know. I don’t think I can stay in this car!”

A man at the other end of the car sneezed. The subway lurched to the left.

“Let’s switch cars at the next stop,” Mink Coat suggested. “It’s hard for me to breathe.”

A woman looked up from her Kindle and glanced at the two ladies. The man next to her suddenly snapped his eyes open when he realized that he was listing to the right.

“That’s a good idea,” Raincoat said, vigorously nodding her head. “He smells worse than trash. I wish the train would hurry up.”

The young man leaning against the door marked with the words “Do not lean on door” plucked his mp3 player out of his pocket and glanced at the screen.

“This is 42nd Street, Bryant Park,” the automated voice announced as the subway burst out of the darkness into the illuminated station. The subway suddenly decelerated. Someone mumbled apologies as he inadvertently bumped into his neighbor.

“Thank God,” Mink Coat said, getting as close to the door as she could. The sleeping man quietly burped.

“Gross,” Raincoat mumbled.

“Do you want to go left or right?” Mink Coat said as the subway came to a halt.

“It doesn’t matter. Just get us away from the stink!”

When the doors slid open, the two Coats stepped out quickly, sighing loudly. The sleeping man shifted in his seat, his chin dropping to chest.

“Stand clear of the closing doors, please.”

Kevin, MD, posted a commentary about encounters with “difficult patients”. He correctly notes that physicians themselves contribute to these interactions. To reduce the likelihood of these encounters, he suggests that physicians would benefit from more training in “psychosocial skills”.

Kudos to Kevin for adjusting his own language by the second sentence of his post: He makes the distinction between difficult patient and difficult encounter.

A vital step in decreasing the likelihood of difficult encounters is recognizing the language we use for these events. The words we use affect our perceptions. Compare:

• “That’s the liver guy. He’s a complete train wreck!” versus
• “That man has liver cancer. He has an infection in his blood, needs a mechanical ventilator to breathe, and now he might be having a heart attack.”

The phrase “difficult patient” automatically suggests that the patient alone is responsible for any conflicts or problems during the appointment. Uncomfortable emotions, like helplessness or anger, that the physician may feel are attributed solely to the patient. If only the patient would change, then everything would be fine!

As a result, the doctor may then feel absolved of any responsibility to alter his own behavior to improve the interaction. The assumption is that the physician is right and the patient is wrong.

If we instead label the interaction—rather than a single person—as difficult, this can help both patient and physician to step back, assess what each is contributing to the situation, and work together to resolve it. The assumptions doctors and patients have about each other are often inaccurate and impede cooperation. Using the time to understand, rather than blame, the other person can decrease the likelihood of these difficult interactions.

Doctors, like most people, often assign adjectives to patients because it can be hard to identify and then acknowledge emotions. It is much easier to say, “She is such a difficult patient! She is never happy with her care!” than to say, “I feel angry and helpless when I see her because it seems like nothing improves her symptoms!” Leaving out the subjective “I” gives the illusion of objectivity and professionalism.

Physicians are only human. Sometimes we have bad days; sometimes our “psychosocial skills” aren’t well developed. However, we must do our best to engage and build rapport with patients to provide optimal care. Watching what we say and choosing our words with care is a valuable first step.

His secretary had cancelled two appointments for the following week. When the geriatrician asked her why, she simply said, “They died.”

He frowned, though he wasn’t surprised. One patient was in his seventies and the other was in her eighties. People don’t live forever and the odds were simply greater that his patients would die sooner rather than later.

The male patient was a self-proclaimed curmudgeon. Though he often complained during his visits with the geriatrician (“Are you trying to kill me with all of these medications?!”), he was consistently punctual to his appointments and bought a box of chocolates for the office staff every Christmas.

The woman said little. She answered his questions, but balked when he asked anything she thought was intrusive. (“You don’t need to know anything about my memory. I’m fine, thank you.”) In her large purse was a small notebook. At the beginning of every appointment, she fished the notebook out and asked the questions she had written down before their meeting.

He felt sad. He missed them.

“When you do you want to see Ms. Smith again?” his secretary called out.

The geriatrician glanced at the calendar. There was a holiday the following month. More than five weeks would pass if he saw her after the holiday. Though she was close to 90 years old, Ms. Smith was generally healthy. Today, she showed him photographs of her new great-granddaughter. She laughed with energy and enthusiasm.

What if she dies in the interim?

“Before the holiday,” the geriatrician answered.

Keith Johnstone wrote an excellent book called Impro:

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I’m remembering [the psychotic teenaged girl] now because of an interaction she had with a very gentle, motherly schoolteacher…. We were in a beautiful garden (where the teenager had just seen God) and the teacher picked up a flower and said: “Look at the pretty flower, Betty.”

Betty, filled with spiritual radiance, said, “All the flowers are beautiful.”

“Ah,” said the teacher, blocking her, “but this flower is especially beautiful.”

Betty rolled on the ground screaming, and it took a while to calm her. Nobody seemed to notice that she was screaming “Can’t you see? Can’t you see!”

In the gentlest possible way, this teacher had been very violent. She was insisting on categorising, and on selecting. Actually it is crazy to insist that one flower is especially beautiful in a whole garden of flowers, but the teacher is allowed to do this, and is not perceived by sane people as violent. (p. 15-16)

Though Johnstone’s book is ostensibly for students of theatre, his text is immensely useful for teachers of all types. Furthermore, the chapter “Status” might teach more concrete information about human behavior and dynamics than psychology and psychiatry textbooks.

I still firmly believe that improv classes (and partner dance classes—really) help train people to become better doctors. Both employ the “Yes, and…” strategy, which encourages engagement, rapport, and collaboration. Doctors must cultivate those three skills to make health care work well. Otherwise, we, too, might engage in gentle violence.

During the third year of medical school, students are released into hospitals and clinics to interact with actual patients, doctors, and medical systems. On our first day as third-year medical students, my classmates and I each received a key card. It was a light shade of grey, had an uneven surface on one side, and easily slid into the sleeve that held our identification.

The hospital administration admonished: “Keep your key card in a safe place. Do not lose it.”

The key card unlocked all of the doors in the hospital. Just 24 hours prior—when I was a second-year medical student—I had to register as a hospital visitor and wait for people to guide me through the building. Now, things had completely changed.

After tapping the key card against the electronic panel outside of the trauma surgery ward, the lock on the door disengaged. I pulled the door open and inside were patients with various limbs elevated, wrapped in gauze, with metal rods and screws sticking straight out of their flesh.

The heavy doors of the intensive care units automatically swung open with the tap of my key card. The sighs of mechanical ventilators and various beeps from heart monitors greeted me. I spied silent, yawning people sitting by unconscious patients. Tubes jutted out from their slack-jawed mouths and numerous clear tubes trailed from their bodies to the IV poles towering over them.

The key card allowed me to step into the maternity ward. No one cast a wary glance at me when I peered at the rows of newborn babies in the nursery.

With that key card I learned that the entire hospital, with all of its sacred spaces, was open to me. I felt both terror and delight. Did they not know that I had no idea what to do? Couldn’t everyone sense that I did not belong there? I avoided eye contact with all other human beings and hastened my gait to assure everyone I was not loitering. I didn’t want to give anyone the impression that I was trying to take care of patients.

No one noticed. In some instances, I used my key card to open a door, took literally two steps into the area, then walked right back out again. Doctors and nurses seemed to look straight through me.

At the end of the day, I used my key card to leave the hospital through an unofficial exit. The heavy heat of the July evening immediately walloped me, along with a humbling realization: Now that my classmates and I were allowed into these sacred spaces, we had power and privilege.

Doctors often forget that patients can invite us into the sacred spaces of their lives. They share their physical and emotional vulnerabilities with us. We learn about their health, illnesses, fears, and hopes.

We, however, do not automatically receive key cards to patients’ lives when we first meet them. We can only earn these invitations through respect, professionalism, and competency. We must remember that, as with hospital key cards, we should do our best never to lose those skills.