A WELL-DRAWN CHARACTER
K. Patrick Ober, MD
Mark Twain was interested in almost everyone he met, and he met just about every type of person imaginable in his years as a riverboat pilot on the Mississippi River. "When I find a well-drawn character in fiction or biography," Twain wrote in Life on the Mississippi, "I generally take a warm personal interest in him, for the reason that I have known him before – met him on the river."
Physicians have the same privilege of being able to meet just about every kind of person there can be.
Many of the people we meet are memorable in the best of ways. We readily take a warm interest in them, especially the ones who are personable, interesting, kind, appreciative, brilliant, insightful, admirable, and inspirational.
Then there are the other ones.
They are the ones who drive us just a little crazy. They are the ones who are excessively demanding, the ones who try our patience to its limits, the ones who waste our time with their unreasonable requests.
They are easy to recognize.
They make us feel uncomfortable, primarily.
We don’t know why we feel so uncomfortable. We just do. And our inability to know why we are uncomfortable makes us even more uncomfortable, and our discomfort builds on itself.
They are the ones who don’t seem to stay around for long. We may notice [if we are attentive to things like this] that such demanding patients rarely come back to see us for a second visit, and we may feel – transiently, mistakenly – grateful for their disappearance from our lives. The discomfort they brought with them goes away when they are gone from our lives, but something that is vaguely and oddly and intangibly good seems to have disappeared too with their departure…was there something else we were meant to discover?…possibly something of value?…whatever it is, it is gone, with them…
How did that happen, their abrupt disappearance? Perhaps they sensed the same personality mismatch we did, and chose of their own accord not to return. Perhaps they picked up on our nonverbal cues that signaled our insincerity even as we went through
the motions of caring. All we knew was that our day was already too long, our clinic too packed, and our wait list for appointments interminable. They become a "no show," and our day improved.
Our ability to chase off the bothersome ones, without appearing to be doing it, can be an art form.
It is easy to rationalize, too. Why should we work so hard to connect to this single overly demanding human being, when there are so many others where the connection comes easy and the fulfillment is natural?
Sometimes, though, for reasons inexplicable, we invest some extra time, extra energy, extra compassion, and we find a way to reach out this human who now sits before us.
Our reward is a second visit.
[Our reward is our punishment.]
Predictably, we will be the recipients of more demands, more infuriation, more vexation, and more weariness.
We knew that at the start.
And, yet, on that return visit, it starts to feel like a good thing has happened, even though it doesn't make any sense to us at all why we should look at it as a good thing.
When I was out of commission in early 2013 from multiple pulmonary emboli, Dr. Xanthia Samaropoulos was one of the wonderful colleagues who stepped in to take care of my patients.
During my days of convalescence, "X" sent me a note to bring me up to date on the status of one of my more difficult patients, Polly Henderson [a fictional name]. Polly tends to be a challenge for any doctor she encounters. She typically comes across as obstreperous and uncooperative and abrasive, and she can be overtly hostile when she is having a particularly bad day. Most of the days of her life have been particularly bad days.
I was sorry that Xanthia was going to have to deal with her – I considered Polly my personal burden – but I was also curious about how it would all play out.
Polly’s background and mine are considerably different, as are our life experiences and our worldviews. Polly and I have had to travel a long rocky road together for a couple of decades to get to where we are now, a place of shared understanding and mutual respect. I think we have both learned a lot from each other by toughing it out together, though the learning curve has been steep and thorny.
I used to dread seeing Polly’s name on my clinic schedule, once upon a time.
Now I almost look forward to it.
But I felt bad that any of my colleagues would have to be blindsided by meeting her without me to buffer the vitriol, or at least be warned.
Polly still overwhelms and intimidates anyone who meets her for the first time, and that alone makes it extremely challenging to take care of her. She seems to be aware of this tendency, too, on the infrequent occasions she seems to have a speck of insight [not that she has ever made any effort to change her ways]. If she needs a doctor when I am away, she will usually wait things out for a few days until I come back. She knows how badly it always goes for her with a new doctor [including me, when I was her new doctor], and she does her best to avoid the bilateral emotional trauma of starting over with a stranger.
In January of 2013, I was going to be out of action for a good while, and Polly needed an endocrinologist. She couldn’t wait it out until I returned. The stage was set.
All of which leads us up to the story of Polly’s arrival on a surgical subspecialty service with messed up blood sugars.
It was predictable that Polly might leave behind a trail of traumatized victims.
Dr. Xanthia Samaropoulos told me the story.
Xanthia started the tale by sharing with me the progress note written by the resident on the endocrinology consultation service after they were summoned by Polly’s surgical team to help in regulating Polly’s out-of-control diabetes.
SYNOPSIS: Endocrinology was consulted for glycemia management. Briefly, Polly Henderson is a 47 y/o F w/ PMH significant for Type 1 DM.... With regards to her DM, she is followed in clinic by Dr. Ober. Most recent HbA1c was 9.0%.... She is very reluctant to receive advice on her DM management from anyone other than Dr. Ober...
Seen and examined today. No events overnight. Blood sugars continue to be elevated... Discussed need to increase insulin regimen, however patient declines. She states that only Dr. Ober can make adjustments to her insulin regimen.
Ms. Henderson is a 47 y.o. female w/ PMH significant for type 1 DM. Endocrinology was consulted for glycemia management. Ms Henderson is quite particular and prefers for her insulin to be adjusted only by Dr. Ober (who is unfortunately unavailable). As patient has medical decision-making capacity, we must abide by her wishes.
The resident's note created a strange sensation in me. I was accustomed to being bludgeoned by Polly in person; it was odd to learn that she was using me as her cudgel to beat upon other doctors in my absence.
After listening to the resident's presentation of the situation, Dr. Samaropoulos went to see Polly in person and introduce herself as my colleague. Her goal was to calm Polly's misgivings about my absence, and to try to gain some trust and buy-in to work for better regulation of her diabetes.
Xanthia encountered a feisty lady full of opinions, full of assumptions, and full of big plans...and full of cuss words.
"X" described her first colorful meeting with Ms. Polly Henderson:
When I first entered Ms. Henderson's room she was on the phone with a family member -- she was yelling into the phone and I caught the last bit which went something like "I'm going to make them discharge me today whether they agree or not because with what you are doing, you are going to KILL my d*** cat!!"
Xanthia wisely withheld her curiosity:
I wanted to ask what was being done to the cat, but thought better of it...
Dr. Xanthia Samaropoulos explained that she was my colleague, filling in for me in my absence until my health improved. This news only magnified Polly’s ire, and she ventilated it all to Xanthia:
She told me that once she "got out of this d*** hospital" she was "going to call Mrs. Ober and come over to Dr. Ober’s house to help make him better faster" or else she "was a lost cause" in regards to managing her diabetes.
Xanthia spoke of her concern for me:
I do hope your number is unlisted...
She also reached a practical outcome, in typical Xanthia-style:
By the way – we were able to get the sliding scale correction that "Dr. Ober handwrote for me!" that she keeps posted on her refrigerator door and she is much happier for it...WHEW!
So there you have it, a glimpse at a patient we might generously classify as a "difficult patient."
Mark Twain would call her "a well-drawn character," and suggest she is one of the people we are fortunate to meet on the river of our life’s journey.
They drive us crazy.
They often enrich our lives.
They may even deserve a tribute.
A TRIBUTE TO A WELL-DRAWN CHARACTER
I have taken care of her for many, many years. She is a sad soul who has had a hard life, and I suspect she has been treated badly by many people on many occasions, in ways we can only guess. She distrusts almost everyone, and if half of what she says is true, she distrusts with good reason. She distrusts doctors particularly, and has had bad interactions too numerous to mention. Her technical care has been good each time, I believe, but it is the emotional work of connecting with her that is overwhelming at times [possibly at ALL times?].
She wears her anger on her shoulder. I was surprised that she came back for her second visit to see me, years ago. During the first visit, I felt I was being flogged without mercy, and I didn't know where I had sinned. The first five minutes of each visit, even to this day, are typically laden with undirected anger [which, for many years, I thought was directed at me, for reasons unknown to me, until I understood her anger was at the world at large]. And yet…she kept coming back. I finally realized that I was the person in her life who would listen to her and honor her as a person, without judgment, for those 5 minutes of introductory tirade, blasted out of the same cannon she fired at Xanthia. I had no choice but to listen [I had NO idea of WHAT to say!], and that turned out to be what she was really looking for. I don't think I treated her with honor because of a wish to appear to be noble. As I remember it, my goal was simpler than that…I simply hoped to survive the encounter.
She seemed to be a person in pain back then, and she still does. Her approach to life is to be in a constant attack mode. She is like a rattlesnake, always rattling the rattles, to scare off potential enemies before they get closer to her [not realizing that she also scares off potential friends]. In a life where experience has taught her that the number of potential enemies outnumbers the number of potential friends, the risk/benefit ratio of chasing off EVERYONE works to her advantage. [Or at least that is the approach to life she has developed...]
Her only relative is her adult daughter, who apparently has serious psychiatric disease [or so I have been informed on numerous occasions], and they are frequently estranged.
Her cat is her sole companion most of the time. We often talk about her cat during clinic visits. It's how I can get her to be cheerful, happy, upbeat. [She does have a good sense of humor, veering toward the cynical end of the scale...].
I am sure it is the untrusted daughter who was looking after the cat.
Her diabetes regulation, as is the case for so many of our patients, has less to do with insulin doses and more to do with everything else in life. She actually is a "good patient," in the bizarrely physician-centric way in which we use that term: she takes her insulin reliably, monitors her glucose routinely, sends me results weekly...even though the numbers are always an uninterpretable roller coaster whenever I try to spot any patterns.
Whenever I call and try to find out about details surrounding the erratic numbers, I discover that each of the 300s and each of the 30s on her paper is the result of an unanticipated life event. I can't anticipate any of them for her; she can't predict them for herself. As they say, "life happens," and her life happens as calamitously as any I know.
The handwritten sliding scale I prepared for her, I would suggest, is placebo. It is a physical connection to me that resides in a place of honor on her refrigerator [the same spot, perhaps, where she used to proudly display the artwork of a 3rd grade daughter who is now grown up and crazy and a potential cat-killer and her only accessible relative]. I do not carry the delusion that my primitive insulin adjustment protocol is making her diabetes control better; to do that would require that I make her life better. Instead, my written sliding scale in the kitchen lets her know I am out there, somewhere, and I am "with her." And that, I know, was the reason for her anger at my illness. Because of it, I deserted her for a while, just as so many others have done in the past.
Even though I have no fantasies that the sliding scale I designed for her is helping her diabetes management, it does play a therapeutic role, and I think the "handwritten" aspect is important.
We can print sliding scales and other patient instructions from the computer, and it is efficient for us.
A doctoring fact: It takes just a little longer to write it out in our own hand.
A doctoring secret: There is therapeutic "magic" in sitting in front of a patient with a blank piece of paper and writing out instructions in our own writing. The patients see our furrowed forehead as we struggle internally with guessing a dose that might be helpful without being too aggressive. It lets them know we are thinking about them as unique beings. And that we are struggling on their behalf. And we are agonizing, often, for them.
Note the emotion in her statement that Dr. Ober wrote the scale "for ME!"
We all want some recognition of our individuality.
And the sliding scale's significance is not only that I wrote it for her, but I HANDwrote it for her [she, who is in constant doubt that there is a single creature in the world, other than her cat, who really cares about her...but she saw that I paused my busy world long enough to HANDwrite – to personalize – a sliding scale for HER...].
And, in full disclosure, there is fulfillment for me in this, too. As clinicians, we have chances for getting positive feedback daily. For me [thanks for telling me THIS part, Xanthia!], the honorary thing is that my note is on her refrigerator, the place of household distinction where the things of great value [and of great symbolism] tend to get posted. I had forgotten about her sliding scale, it is so ancient, but Polly sees it every day.
Diabetes confession: I have no delusions of improving her hemoglobin A1c. Ever.
Functionally, I am not her endocrinologist; I am her doctor [which is a lot bigger and harder job....].
She is a fighter, and even though many would describe her with pejorative terms, she refuses to be one of life's "losers," and that is one of the things that endears her to me. She has an almost inspirational "kick-butt" approach to the world, and her statement that she was "going to call Mrs. Ober and come over to [my] house to help make [me] better faster" is SO typical of her! [I was obviously a slacker for being sick, Mrs O was obviously negligent by allowing me to be sick, and SHE could have set us both straight if she had the chance.] False bravado is better than no bravado at all...how can you not love the woman?
She can cuss like a sailor too, and she does.
She acts brave when she is frightened.
She is a human.
She is a lovely person.
But she doesn't really want anyone to find THAT part out, lest they take advantage of her.
[She is you and me and everyone else…just in a slightly exaggerated version...she is the one who never had access to resources and opportunities and love and support the rest of us have taken for granted...]
She is why it is such a privilege to be a doctor…
A privilege to be HER doctor…
As physicians, we get to meet all of the well-drawn characters there are in this world.
[And, in so doing – if we stop to pay attention – we get to meet ourselves.]