[acb-hsp] Being Sorry

[Mmorrowfarrell at aol.com]

Ironically patients are indeed never patient.  At some time in our  lives 
we have been on both the giving and receiving end of annoyance.  May  we be 
at peace no matter what in knowing that our feelings or those of others  have 
been heard.  That in itself is enough.  No guilt needed. ~ M.  
Morrow-Farrell, Philly PA
 
 
In a message dated 12/8/2012 12:45:50 P.M. Eastern Standard Time,  
paltschul at centurytel.net writes:

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.
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