[acb-hsp] Being Sorry

[peter altschul]

Being Sorry
  By Shara Yurkiewicz December 7, 2012
  "You're not sorry."
  Within two days two different patients said this to me, each 
with hatred in his voice.  Each time I was alone, each time I had 
known the patient for only a few minutes, and each time the rage 
was directed at me and only me.
  For seven months, I had avoided being the bad guy.  When a 
patient got upset, he accused my superiors, and I hid behind 
their authority with relief.  With no power came no blame.  I 
would offer sympathetic eyes during the blow-outs and weigh how 
much of what the patient perceived was in line with reality.
  The last two episodes were on an entirely different level, not 
because of their intensity but because no one but me stood there 
to shoulder them.  Now I see patients alone and project a greater 
air of confidence, which naturally leads some to believe that I 
am the one making their decisions.  My usual intellectualization 
and analysis were non-existent; I experienced a pure visceral 
response.
  The first episode, in retrospect, was merely a preamble.  I 
walked into the clinic room and was greeted with "You're 45 
minutes late." I apologized.  The patient insisted I wasn't sorry 
but that I was unprofessional.
  I don't quite remember all the personal attacks he added over 
the next few minutes because my sympathetic system had taken 
over: my cheeks flushed, my heart pounded, and all I wanted to do 
was flee.  I managed to squeeze out that we were running behind 
because we spent more time with sicker patients than we had 
anticipated.
  What I wanted to add was that he was setting us more behind.  
What I wanted to add was that even though his appointment was 
only for 20 minutes, we would spend more than 20 minutes with 
him, like we did for every patient.  What I wanted to add was 
that his behavior was self-fulfilling: suddenly I wasn't sorry 
anymore.  Instead, I withdrew.
  I'm fairly certain I took a less thorough history with him than 
I do with other patients.  I'm pretty sure my plan was more 
rushed since he questioned my judgment at several junctures.  I 
know that all I wanted to do was get out of that room and away 
from an unpleasant person that I had originally wanted to help to 
the best of my ability until he compromised my ability to help 
him.
  Two days later, I was back in the hospital with a much sicker 
patient.  I walked in to do a physical exam and the patient 
demanded that I get him food.  I explained that he couldn't eat 
independently because he was at severe risk for swallowing the 
wrong way and having the food go into his lungs and causing an 
infection.
  "You finincking binintch," the patient yelled as loudly as he 
could with his weakened voice as he tried and failed to get out 
of bed and reach his food.  I apologized and once again I heard 
the cutting response: "You're not sorry."
  Again, I felt the familiar flushing as the patient called me 
creative names and instructed me to do creative things.  This 
time, I had no response at all.  After the first minute, I felt 
sorry that the patient was hungry and couldn't eat.  I felt sorry 
that he had such poor hand dexterity that he needed someone else 
to feed him.  I felt sorry that he didn't deserve the medical 
hand he had been dealt.
  After several minutes though, my empathy faltered and finally 
gave out.  My thoughts turned from the patient's plight to a more 
inward stance: I don't deserve this.  That single thought 
amplified until the hungry patient in front of me no longer 
existed.  I don't deserve this.
  I knew it wasn't personal because he would have screamed at 
anyone who happened to stand in my place.  But at the same time 
it was personal because it happened to be me.  I didn't say much 
and walked out, feeling shaky.
  More disturbing thoughts snaked their way into my consciousness 
and wouldn't let go.  No, I wasn't sorry anymore.  No, I didn't 
really care what happened to him.  And then probably the worst 
thought I've ever had in my life: in that moment, I didn't really 
care if he lived or died.  With that realization, I found a 
bathroom to cry in for about half an hour while I ignored the 
page from my resident inviting me to get lunch.
  Within an hour, my limbic brain had yielded to my cortex and I 
was able to analyze what had happened.  Ironically, it was the 
analysis rather than my raw emotion that brought back empathy.  I 
reread the patientbs notes, talked to his son, and felt as though 
I had a better grasp on the reasons behind his intense anger.
  Within a few hours, the patient was transferred to the ICU.  
(Thankfully, the turn of events was unrelated to the care I did 
or did not give him.) Half of me felt sorry but the other half 
still felt relieved that I would not have to see him again.
  During our psychiatry rotation, we had had a lecture on how to 
think about "difficult" patients.
  We were encouraged to think about the feelings of helplessness, 
uncertainty, anxiety, and fear patients felt, in addition to the 
destructive medical processes impairing their minds and bodies.  
We were told never to forget that context when we dealt with 
someone whose behavior didn't conform to our expectations of how 
a "good" patient should act.  It was a very valuable lecture, and 
I sat in the safety of our conference room absorbing it.
  On the floor, feeling vulnerable and alone, feeling attacked 
and helpless, I lost sight of that lecture.  I was feeling the 
same things my patient most likely felt, yet to a fraction of an 
extent.  Although I didn't verbally abuse anyone the way he did, 
my internal verbalizations were probably just as abusive.  
Destruction need not be loud and it need not be an action.
  Perhaps it begins with a thought, one that snakes into your 
consciousness and amplifies.  Perhaps it ends in inaction, with 
you walking out of the room too early.
  On the first episode of Scrubs, one of J.D.'s first patients 
passes away suddenly from a pulmonary embolism.  He narrates.
  "I'll never forget that moment.  The way he looked exactly the 
same only completely different.  The shame that all I could think 
about was how hard this was for me."
  Seven months after I have started this thing called hospital 
medicine, I have finally felt that shame.
  Before I wrote this post, I checked on that patient's status.  
He had recently passed away.  I hadn't known.  It hadn't been an 
expected event.
  I wonder if I had known how close he was to death if my 
thoughts of him would have changed in that moment when our lives 
intersected.  I also know that the answer shouldn't matter.
  Here's to the start of being the bad guy with good intentions.  
Here's to the start of trying harder, of keeping those good 
intentions during the most difficult moments-those when no one 
else believes you have them.