“Great,” I thought, as I stood at my desk, looking at my patient list early in the morning. She was coming in today. “She” was a patient of mine in her forties, with newly diagnosed triple-negative breast cancer, without nodal involvement. Our first meeting had been several months ago, and it had not been a good one.
I had asked about her history, how she presented; she had been fairly surprised I did not have that information. “You mean, you don’t know?” she had asked. “I would’ve expected you to at least have read my chart or talked to my surgeon,” she said. Then, with a sigh, she had recounted how she got to this point—finding a mass, the normal mammogram, the ultrasound-guided biopsy, receiving her diagnosis. Then surgery, more results, culminating in a referral to me. Every question I asked was met with a furrowed brow, as if I were interrupting her.
“It must be really shocking to be here. No one our age expects something like this to happen,” I said.
She had gotten angry at this. “Just concentrate on the facts, please. I don’t need your pity. What I want is your expertise.”
We launched in to a discussion about her diagnosis, stage, and natural history of the disease. She questioned everything we discussed: “Are you sure your statistics are right? From what I read, it’s more like this . . .” I remember getting defensive, as if each question back to me was a personal attack on my competence as a physician, as an oncologist. I remember feeling flushed as we talked, trying to get my point across as clearly as possible, yet feeling that she did not (and was never) going to “believe” me.
We then discussed chemotherapy—both standard treatments and those available on clinical trials. She had even more questions:
“Why should I get doxorubicin? I heard I’ll be throwing up all day. Are you sure I need it?”
“How is a clinical trial better for me? There’s still a 50% chance I can get doxorubicin, so why is this even an option?”
We covered alternative approaches—ones that did not involve doxorubicin and were available off a clinical trial. I then rendered a recommendation taking into account her tumor, her priorities and beliefs, and what the evidence told me. We talked some more and I fielded additional questions; then I asked her if there was anything else she wanted to discuss.
“Not for you.” She said. I looked to the floor and left the room.
As time passed, I resented having to see her and take care of her because despite what I perceived as my best efforts, I felt we had no real doctor-patient relationship. Each subsequent meeting was tense because I felt more and more certain that (a) she didn’t trust me and (b) she did not like me. I had expected her to find a new doctor—within my practice or somewhere else—but she did not. Indeed, I remember being surprised (and anxious) each time she showed up.
On that day she showed up on my list, I confessed something to my partners: “I don’t like this woman,” I said. They looked at me, shocked. “You should not say that,” one had said. “It’s not her fault she has cancer, and people cope in very different ways.”
Although much time has passed, this patient stays with me because it was perhaps one of my most difficult patient relationships—not because she had questions, but because, as sometimes happens, I felt we did not “connect,” despite my trying really hard to make her like me, and to see that I was a good and decent doctor.
As I developed this blog, I decided to show it to a very dear friend, Dr. Barbara Rabinowitz, whose advice and guidance have been important to me on a number of occasions, particularly when we served on the board of a national organization together. I had wondered what she thought of my experience.
I do believe we hold high and sometimes unrealistic expectations of ourselves. In spite of your usual ease and rapport with patients, the experience you describe above is far from unknown. According to Haas et al., studies have shown that about 15% of the time physicians experience working with “difficult patients.”
In my experience, health care providers often feel trapped by the resultant negative feelings of these non-satisfying relationships. Though not in this case, difficulties may arise in the physician-patient relationship stimulated by pressures from the health care system itself (time allotted for visits, etc.), from undiscussed differences in expectations between the patient and physician, and the patient’s own previously held (and perhaps undiagnosed) conditions (e.g., personality disorders, etc.). Not uncommonly in cancer care, the free-floating anger at having been diagnosed with cancer may also be aimed at one or more members of the cancer care team.
I believe there is an even greater pressure to “like every patient” in cancer care than in general practice, as in this case, as exemplified by the reactions of your colleagues to your frustrated admission.
Ultimately, I clarified something with my partners: “I did not say anything about having cancer being ‘her fault’—I said I did not like her.”
With that, I realized that even with our white coats on, we possess our feelings, likes, dislikes, and personalities. Medicine requires us to do what is in the best interests of our patients, to “do no harm.” It does not compel us, however, to “like” everyone we treat. As a result, I experienced something interesting—almost liberating. I found that subsequent discussions and encounters with this patient became easier and that I was able to listen to her questions and answer them without getting defensive.
I realized that when I stopped trying to make her like me, I was able to take care of her. The pressure of wanting to be “liked” faded. It dawned on me that I was working so hard to make her like me (and vice versa), that it was affecting my ability to care for her. Once I admitted to myself that it was okay to not like a patient, I was able to do what she wanted me to do—to be her doctor.
At the end of the day, doctors are not a deity—omnipresent and omniscient. We are people—we are fallible, prone to our prejudices and our preferences, insecurities, and biases. I have learned that to become a good doctor, one must be honest with one’s self and exert introspection in order to become self aware; to admit that maybe the difficult patient is perceived as difficult not because of who or what she says, but rather the pressures we put on ourselves to “like” everyone we treat.
To close, I thought I’d ask Barbara to share her final thoughts:
It is important to recognize the unrealistic nature of expectations (on the part of the physician and also of the patient) which, if recognized, can help resolve this issue in some measure. Knowing you so well, I am not surprised that you were able to work this through. However, it is not at all easy to do this.
It is my belief that the very stressful work in which we find ourselves in health care can be aided by having peers who are willing to provide support when we experience any of the difficulties we face, including facing the patient whom we find difficult and whom we “do not like.”
As an administrator who sought and brought “Kenneth B Schwartz Center Rounds” (www.theSchwartzCenter.org) to my health care system, I feel strongly about the value of having a forum where health professionals can meet on a regular basis to discuss the “emotional realities” that frequently surface in health care and that may impact our ability to be the best we can be. In these usually monthly forums, where professionals come from all disciplines, the conversation is not about the clinical realities of the case, but on the sometimes unexpected reactions that the health care person presenting had and how it played out for them and their patient/patient’s family. This most often led to others recognizing and sharing similar experiences and to discussing what they learned and are learning from reflecting on the circumstance.
While this structured program is not available in every setting, finding colleagues with whom we can speak and seek support should be available to all. There are some articles and brochures regarding working with difficult patients, and reading can be helpful both in the release of the pressure that comes from knowing one is not alone and in receiving “helpful hints” for managing such relationships. However, it is my opinion that nothing trumps sharing openly with a trusted colleague to help work through feelings we may not have anticipated when we moved into a helping profession.
For more information, Dr. Rabinowitz suggests the following articles:
Haas LJ, Leiser JP, Magill MK, et al. Management of the Difficult Patient. Am Fam Physician. 2005; 72:2063.
Novack DH, Suchman AL, Clark W, et al. Calibrating the physician: Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 1997; 278:502.
Peteet JR, Fremonta LM, Miovic MK. Possibly Impossible Patients: Management of Difficult Behavior in Oncology Outpatients. Jrl Oncol Pract. 2011; 7:242.