“I’m an adult! If I want to go out for a smoke, then I’m going to go out for a f*cking smoke. And if I’m going to be out there anyway, I might as well just leave the hospital because you’re not doing a g*ddamn thing for me anyway! Useless!! All of you!!!”
With every sentence, G’s pointed finger punctuated the air like a frenzied orchestra conductor. His eyes bulged so intensely, even from across the room I could see bloodshot red streaks ready to burst at a moment’s notice from his agitated blood pressure. Grey hair flew wildly, except for that flat, bare spot on the back of his head, the familiar hairstyle of someone who’s been laying in bed all day.
But he wasn’t laying in bed now.
No, G was towering over me, shifting his weight to his right leg in an effort to keep from putting pressure on his left diabetic foot ulcer, oozing pus on the bandage that was skimming the floor. His haphazard hand gestures only served to throw off his balance, but his mission to tell me how useless we all were was more important than his risk of falling. It was almost comical, seeing this “adult” throw a full blown tantrum like my 3 year old patients.
Still, my calves readied themselves to bolt out of the room at a moment’s notice. Dr. Strange, my old psychiatry preceptor’s words rang in my ears:
“Remember to never let a patient get between you and the door. You’re an easy target.”
Looking beyond G’s behemoth body, I was jolted by the realization that the clock hadn’t even struck 8 am yet.
Your habit of starting off the day “strong” is getting old. Alright M, time to get your big girl pants on and diffuse the situation… it’s what you do best.
Returning my attention back to the room, I finally refocused on his diatribe.
“All you doctors want is my money. But you don’t care about me, you don’t care about anyone! And that damn surgeon… that podiatrist who isn’t even a real surgeon, and trust me, I know because I’m EDUCATED. He’s delaying my surgery because he wants to go golfing. And you probably have your second vacation home that you’re trying to pay off.
Just making money off of the backs of us common folk. And then you wonder why we hate going to you and refuse to see you at these unnecessary appointments…”
For a brief second, the temptation to interject and tell him I was only taking his verbal onslaught in order to pay off my student loans, not my second vacation home engulfed me. But interrupting him would only add fuel to the fire.
He was going to be heard, truth be damned.
Never mind that his reason for being here in the hospital was due to years of untreated diabetes, refusing to go to the doctor to get prescribed that g*oddamn poison doctors receive kickbacks for prescribing. Never mind that he could’ve done something, perhaps changing his diet or lifestyle to lose the extra 250 lbs he was carrying – but no, his jerk of a doctor should never have brought up the weight because that was none of his business. Let’s just gloss over the fact that his chronic foot wound was formed by a Swiss army knife as he tried to dig out a wart on his own. That he had watched it refuse to heal over the last 4 months and only decided to seek medical attention when he’d had enough of changing his pus filled dressings multiple times a day.
But none of that fit into his narrative. Not the one in which he got to play the part of the victim. Not the one in which he was justified in screaming at the young doctor who was currently regretting her life decisions to “help” people.
After all, she was just in this for the money.
“You know, if you don’t let me go out for my smoke break, I guess I’ll just be forced to leave. I hate to do it against medical advice, because I think I’ve been reasonable in allowing that pretend surgeon to talk to me about amputating part of my leg off, even though I deserve a real doctor, but that’s beside the point.
If you don’t let me go outside for my smoke break, I’ll just go home and probably die from this infection. Because there’s no way I’m ever coming back to this scam after this experience. And you know what?
If I die, IT WILL BE ALL YOUR FAULT. All over a cigarette.”
Bulging eyes challenging mine, he crossed his arms and awaited my apology.
Now what?
Scrolling through my scripts internally, an overwhelming exhaustion fell upon me.
How many times had I been in this exact situation over the last 3-4 months? How many times had I served as a verbal punching bag to patients who wanted to place the blame on their preventable chronic illnesses on everyone but themselves? How many variations had I heard of “you’re only in this for the money” and “you don’t give a shit”, even as I prided myself in being the person who would willingly go the extra mile?
It was the same drama, over and over again. The same anger-defusing script, serving up empathetic listening and understanding while quarantining my thoughts in order to keep the peace. In order to avoid a “bad” review.
I could feel the words of my well worn monologue at the tip of my tongue, shoulders preparing to turn inward to make myself small to complement my non-threatening face. Incidents such as this had become so routine, this pacifying stance had become second nature. But today, my lips refused to betray me.
No amount of telling myself, “Hurt people hurt people” was going to excuse his behaviour.
No amount of digging into why he was so upset was going to justify this brand of gaslighting.
What did he see as he waited out this silence?
A sweet girl trying to figure out exactly how she was going to fall over herself and beg for forgiveness?
Or a young doctor who just realized she no longer gave a damn?
“Sir, that hurts you more than it hurts me.”
Nostrils flared and back straightened as he registered the absence of my apology. Sputtering, he barked,
“EXCUSE ME?”
Ensuring I was a safe distance out of arms’ reach, I tempered my voice.
“If you were to leave the hospital against medical advice and chose not to address your foot infection, that would hurt you more than it hurts me. You’re the one who would live with that decision.”
A look of bewilderment appeared as he regarded me with a new lens, as if seeing me for the first time.
“Well… I’m an adult. And I make my OWN choices. I’m just going to smoke when I get discharged from the hospital anyway, so there’s no point in stopping me!”
“Yes, of course. It’s our hospital policy that we don’t allow smoking on our campus, but as you said, you are an adult and you are free to smoke across the street if you’d like.
But I also believe it’s my responsibility to tell you that if you continue to smoke, you will have poor wound healing after your surgery, and you may end up having more complications requiring more procedures because of that choice. I, of course, recommend that you stop smoking altogether, but as you’ve said – it’s your choice, and I can’t make that decision for you.
So you can go out for a smoke. But you won’t be escorted by any of our staff and you’ll have to sign a document stating you’re responsible for anything that may happen to you while you go on your smoke break. If instead you’d like to leave against medical advice, I’ll have your nurse bring the paperwork to you. No need to decide right now… just let her know when you’ve made up your mind.
I’ll leave you to think about it, but before I do, is there anything else you’d like to discuss?”
G shifted again, lifting his left foot. The putrid smell of rotting flesh assaulted my senses. I couldn’t get out of there fast enough, but I forced myself to stay still.
Eventually shaking his head, he scoffed and pointed his chin at me.
“I knew it. You really don’t care.”
Arching my eyebrow, I mulled over his attempt to make me backpedal. For a split second, I could hear myself laugh and say,
There’s a reason people like you come to the hospital all alone, with no one to support you. There’s a reason no one forced you to go to the doctor to find out why your foot smells like death.
It’s because you’re an asshole and you’ve alienated everyone in your life. And pretty soon you’re going to push away the only people who are willing to help you now. All for a power play.
What a pathetic attempt to get me to “care”. This obviously was a pattern he’d fallen into again and again, manipulation being the only way he knew how to engage with people. Redirecting the burden of guilt and taking advantage of people’s inclination to be “good” and helpful had worked for him so many times in the past – why wouldn’t it work again?
Unfortunately for him, today was the day I was done playing these games.
“I wouldn’t be here if I didn’t care. Your nurse wouldn’t be here if she didn’t care.”
A satisfied smile started to crest his face. But I wasn’t finished.
“But ultimately, this is your choice. It’s your choice to smoke, your choice to stay, your choice to undergo the surgery. And if you choose to leave, you do so taking full responsibility of your actions. Same thing with smoking and not taking your diabetes medications.
That’s within your power, not mine. But for what it’s worth, I hope you stay.”
With that, I turned around and walked out of the suffocating stench, leaving him holding the bag of his own shit he’d tried to dump on me.
It was never mine to carry.
“It seems to me that part of what contributes to you being emotionally sapped is that you don’t necessarily let go of your expectation that people should behave in a certain way. When said people fail to meet your expectations or – more specifically – piss, shit, and vomit on your expectations in spectacular fashion, it riles you up every time.”
Smirking, I re-read HD‘s email and let it settle in. Once again, my mentor-I-never-asked-for nailed it. This is what made this unlikely friendship work: unfiltered, no holds barred honesty.
But, am I in the wrong to expect that people act like decent human beings?
I understand emotions run high in times of crisis when people come to the hospital or clinic. Fear speaks via confrontation, panic turns into intense outbursts and grief finds its way out by displacing hurt on others. And as doctors, we find ways to navigate this because we understand it’s all part of the human experience.
This, though, is something entirely different.
People come prepared to fight. To teach us a lesson. To make us pay.
We don’t know anything and in fact, everything bad that has befallen them is because doctors don’t know what they’re doing.
We have become the “bad guys”.
In this world of social capital where Press-Ganey scores, Google, Facebook and Yelp reviews reign supreme because the patient is always right, we’ve been indoctrinated to bend over backwards to keep the peace.
Mantras like The patient always comes first come with the unspoken understanding: And you come last.
We hear this messaging again and again in our medical training, chronic staffing shortages, even the way our electronic medical records are built. We hear it in the system’s lackluster responses when we report verbal and physical abuse, only to be directed to a de-escalation video module and mandated to answer a 5 part questionnaire to prove we watched it. Even worse, at times it’s yelled at us behind closed doors when we’re asked,
“What did you do to deserve this? We know it was you.”
So we take it.
We shut our mouths and tell ourselves it’s just part of the job. We make sure there isn’t a disgruntled patient or family member following us to our cars in the parking garage at the end of our day. We thank the powers that be that no one knows how to actually pronounce or spell our last names, just in case they contemplate tracking us down.
Eventually we learn to ignore the daily 20+ security codes called overhead in the hospital. We roll our eyes at the shooter response video we’re mandated to watch every year, now a standard part of our annual compliance training. We shrug our shoulders as we exchange looks after being scolded by an unhappy customer, let out a collective sigh and carry on with our day.
Meanwhile, healthcare systems wave around phrases such as Evidence based medicine like feel good pieces of marketing, all while ignoring the data that actually shows the most satisfied patients are more likely to die and incur more expensive medical care.
They sweep other metrics under the rug, like these statistics put out by the Joint Commission in April 2018:
“According to the Occupational Safety and Health Administration (OSHA), approximately 75 percent of nearly 25,000 workplace assaults reported annually occurred in health care and social service settings and workers in health care settings are four times more likely to be victimized than workers in private industry.”
As egregious as these numbers are, they likely only represent the worst assaults, not the verbal abuse we see and normalize on a daily basis.
Get over it
Maybe HD is right.
Maybe I’m just too sensitive and easily offended.
Maybe I’m a little too late in coming to the realization that I was supposed to set the bar low for my fellow human beings a long time ago.
Perhaps I was too presumptive to believe if I cared that much about strangers to spend 12 years of my life learning everything I could to help them get better, then maybe they would at least muster the effort to pretend to be decent for 15 minutes.
How silly of me.
As much as I’ve resisted, I must come to terms with the fact that the whole concept of “serving the greater good” has been hijacked, now used as a shiny fallacy to leverage our caring natures against us.
We are being manipulated, exploited and gas-lighted by both the people we set out to serve and the systems we serve them in.
Somehow, we’ve allowed ourselves to become their whipping posts when in reality, the flagellation belongs to them. In doing so, we’ve become the ultimate enablers – taking on the consequences and pain of their actions while absolving them of any responsibility.
And it won’t stop until we stop playing the roles they’ve given us.
We must unlearn the Pavlovian nature of our training. The years of jumping through hoops and figuring out how to get stamps of approval from our preceptors have only conditioned us to salivate at the prospect of an administrator dangling a useless, potentially dangerous metric above our heads.
But this goes both ways – our self-abandonment has only reinforced everyone else’s belief that they can treat us like garbage and get away with it. We want to be so well-liked and helpful, we’ve effectively given our self-respect away.
Serving others doesn’t mean you have to stand there for 15 minutes as they lambaste you in a never ending tantrum.
Being kind never meant giving them permission to treat you like a diaper, just waiting for their shit to roll downhill into your open arms.
Putting the patient first never meant to also include: At the expense of yourself.
The time has come to stop being martyrs for people and systems who time and again show us how little they value us as human beings through their words, actions and policies.
If society is going to demand that we help everyone, then we must in turn demand better behaviour from hostile, confrontational individuals and safe working environments.
I’ve been yelled at, cussed at and threatened. I’ve had clipboards thrown at my head, eyeglasses broken by a swung arm. Nurses have anxiously watched a patient’s closed fist while I examined them, just in case.
I’m over it.
Enough is enough.
***
Have you been verbally or physically assaulted at work?
Join the conversation in my Instagram stories HERE.
#silentnomore
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“I went in this for love… now I’m wondering why.”
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Picture taken by J via drone photography of the Oregon coast at sunset.
This is exactly the advantage of being an independent provider. You can train patients to behave a certain way. I have spent 20 years building the practice I have always wanted. I dictate what insurances I take. I also have a lot of self-pay. Patients know it is my house and they play by my rules or they don’t come back. I have 3 simple rules: be respectful, pay your bills, be compliant (includes keeping appts). My patients say thank you and sometimes give me gifts. This is how it is supposed to be!!! If they don’t like it, they are free to go elsewhere. I live in nowhere USA but I wouldn’t have it any other way. I am extremely busy and am financially independent. Looking to go part time once I recruit the third doc then eventually FIRE when I’m ready to call it quits. However I love what I do, so I don’t know when that will be.
Yes. I took this for granted when I was in primary care as I was part of a private practice, and now that I’m a hospitalist and HAVE to see everyone on my list, I see how valuable that was. Hindsight is truly 20/20.
I’m happy to hear you still love what you do! I would like to think I’d still practice medicine if I could go part time, perhaps finding a job where I could minimize the things I dislike and do more of the things I enjoy. The thing is, I only see that as a possibility if I hang my own shingle somewhere. Maybe some day I’ll join your ranks as an independent physician!
Very well said. Especially the stuff from that HD fellow – he sounds like a modern-day Socrates. 😉
When I’m dealing with a difficult patient, I tend to frame the encounter this way: is this “benign” crazy or “malignant” crazy? In either case, I understand that crazy doesn’t want to change, so I’m going to conserve my energy for those I can truly help. While I can listen empathically and try to give benign crazy whatever support they’re looking for, I can only walk out on malignant crazy. And that’s OK, because you’re right, M. We don’t need to “put the patient first” in a fashion that sacrifices our safety, dignity, sanity, or even the limited supply of empathy that we have to dispense on a daily basis.
The question is, how can we continue to function in an environment where we are defecated upon daily. Is the answer to lower our expectations of our fellow humans? Try to focus solely on the fact that they’re hurting, while ignoring their inappropriate reactions? Employ a liberal strategy of walking out of the room, telling them you’ll be back when they’re ready to be civil? All of the above?
So did you intend on ending your soliloquy with Socratic questioning, or was that just a happy coincidence? 😂
I’m not sure what the answer is, but it’s probably somewhere in the middle – as is most things. The trick is to figure out which technique is most useful in different situations and that takes a lot of effort in and of itself to stay that engaged.
Another option you didn’t mention was to walk away from this altogether, something a lot of us choose to do. You know I love my nuclear options 😏
This holds true to what most physicians deal with every day. It’s sad that new doctors who really have the passion to serve have to, to a variable extent, succumb to this toxic industry.
It’s soul-crushing. To have this ideal of what you thought doctoring would be in your head for YEARS, just to face this day in and day out on the other side.
Are you sure you don’t work in the ER, M?
It can be profoundly depleting to care for people when they act toward you in a way their mother would not permit at her dining room table. We’ve started to enforce behavioral contracts with patients we formerly tolerated abuse from, and it’s been an empowering step in the right direction, if not a panacea.
At the same time, we see a lot of these people because they have no place else to go and no one cares for them.
Or put better by Robert Frost:
‘Home is the place where, when you have to go there,
They have to take you in.’
In the ER (and, by the sounds of it, the wards you walk) we are the final home for the deplorable, the self-destructive, the pathetic, the lonely.
Sometimes our only solace as airbnb hosts to the damned is bearing witnesses to their absurd, enraged, amnipulative forms of self-induced suffering.
It’s an extreme form of bird-watching – you see things hidden from most eyes, you understand more fully than most the glorious and heartbreaking spectrum of human behavior with a specialty in hurt and loss, you take some punches because they have been hit so often by so many all they can do is lash out at the first person who stops to help – you, and me, and anyone else who makes the mistake of stepping between that speeding train and the brick wall it hurtles toward.
I recall being an intern – my black female ER attending informed me that a white supremacist juvenile delinquent in custody had declined to let her examine his laceration – so she sent me, a latino Jew to take her place. Sometimes that laughter, a little bit of gallows humor no one else would understand, is all we have.
And when it harms us and scars us too deeply makes us want to lash out like they do, we need to put down the stethoscope and move onto something (creating art? rescuing kittens?) that we know to be an unqualified good in the world.
I don’t have the tolerance for abusive patients I once did. But I am proud of those times I could provide the only bit of dignity or human kindness someone encountered in their day (even when it went unreturned; especially when it went unreturned, because that was the hardest moment to sustain).
I like to think I made a deeply broken world infinitesimally less broken with my imperfect, flawed practice of medicine.
Feeling your hurt, loud and clear,
CD
CD,
I have such an immense amount of respect for you and what you do. Emergency medicine has become the catch all for all of society’s ills, and you truly see the worst of everything.
For you to still be able to hang on to that thread of humanity just speaks to the kind of person you are.
I can only hope once I become as seasoned as you to still see the beauty in caring when we know those moments will go unappreciated.
M
I am a veterinarian. Remember, you can’t care more about their health…than they do.
So much truth in this statement.