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Just before the holidays, I was treating a woman with severe pneumonia. As I examined her, day after day, she told me about her family, their plans for Thanksgiving, and how much she missed her children. I liked her. I cared about her. I even used the promise of free Wi-Fi to convince her teenage daughter to come see her.

The day before she went home, as I had done every day, we talked about her treatment plan. A couple of hours later, I got a page — this patient was angry because she said she hadn’t been seen by a doctor that day. In those days of caring for her, I introduced myself as her doctor, I mentioned being part of her team of doctors, and I was prescribing her different medicines. All of these indicators that I was a physician, and she had no idea who I was.

At that moment, I felt so defeated. I’m often mistaken for something other than a doctor because I am female, young, and black, but it was more than that. I was disappointed because I had committed a lot of time and energy to her care. I had assumed that this would lead to some interpersonal connection — that we’d stand together in her journey to get well. I wasn’t prepared for the hurt of being abandoned on that journey.

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I became a doctor because I saw something beautiful in helping patients overcome the agony and isolation of illness. I spent years training to build bridges with my patients, to listen, and to be empathetic. Medical schools are increasingly recognizing the importance of being “humanistic” practitioners. And patients tell us they want these healing relationships with us. They don’t want unfeeling caregivers.

It’s National Physicians Week, a time when doctors around the country reflect on the art of medicine. I’m wondering how to cope with these feelings and not get burned out. The more I open my heart only to be rejected, the less I want to risk opening it up again. How do you not become uncaring? I expect this rejection to happen many times over the course of my career, but if I become self-protective, am I setting myself up for failure?

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Doctors are supposed to be selfless. “Selfless acts lie at the center of the caregiver’s soul,” says Dr. Rajesh Panjabi, a Harvard Medical School instructor at Brigham and Women’s Hospital. But caregiving is emotionally complex and draining work. It’s becoming harder to ignore the entangled mix of anger, dismay, and purposelessness that takes me by surprise.

I asked a social work colleague how she dealt with this. “I do my best, but I always have to tell myself not to want it more than they want it,” she said about forming that bond with the patient. “When you want it more, you set yourself up for disappointment.”

But is fair for me to expect more from my patients when, in the doctor-patient dynamic, the balance of power usually tips in my favor? I know it’s not, because my patient comes first. That’s part of what Panjabi is talking about when he says we need to be selfless. So, I struggle with the idea of practicing humanistic, patient-centered medicine that requires me to stifle my humanity and to make myself small or even invisible.

While my patient with pneumonia was successfully treated, I couldn’t help but feel something between us had failed. I’m always looking to learn how to replicate the more positive, healing relationships I’ve had with patients, but its easier said than done. There’s no guidebook.

After his young wife, Laura, suddenly died, Peter DeMarco penned an open letter in the New York Times to the staff at my hospital who cared for her. I was on the neurological team that examined Peter’s wife in the ICU.

“Every single one of you treated Laura with such professionalism, and kindness, and dignity as she lay unconscious,” he said.

He described the heavy moments when we “deliver[ed] bad news with compassionate words, and sadness in [our] eyes.”

A resident recently told me that it was nice to be recognized, but Peter’s kind words just reminded her of all the other times patient’s families had screamed at her.

“I don’t really understand,” she said. “We always deliver the same care.”

I’m forming my identity as a physician, and I still have a lot to learn. Perhaps the art of medicine lies in this tortured ambiguity. And maybe with time and experience we stop struggling against it, and grow into its embrace. In the meantime, I’m still striving to be a humanistic doctor, and I’ll hope for the best — for both of us.

  • You are a wonderful doctor for thinking about these things. Emotional well-being is as important as physical. But as in any profession, they can be your friend, but you cannot be theirs. Because you are responsible for so much, only the rarest patient will not feel the severe imbalance. It happens in many professions, worse as a doctor perhaps. If you look to patients to give you validation you will indeed burn out. I have the reverse problem. I tend to minimize contact with clients because I am not good at putting people off when they want more than I am willing to give – a perpetual problem for people in the arts. We all must learn to protect our divine spark of love and curiosity, and the first place is in our own hearts. This is paradoxically the way that “no” can become yes. Learning where our boundaries are is as important as maintaining our skill levels and tools of our trade.

    Or, put another way, we as people can be awful and thoughtless to each other. To expect otherwise is to discount an important part of what goes into being good to people. We don’t do anyone any favors by holding our hearts out for target practice and then expecting it won’t hurt when it happens. The disappointment of not being appreciated (or worse) is part of the job and you can’t take it so seriously. Much has been written how to be loving in a healthy way, try Gangaji, the Dalai Lama, and Rumi. Open-hearted living is not for the faint of heart, but it is the most beautiful thing on earth, and you should be commended for wanting to include that in your practice. Opening your heart is only half of what you need to do, and that is why it feels off.

    Thank you for such a thought-provoking article.

  • Why don’t you take these scenarios to ask the patients involved why they have misperceptions about your role? You’re making many suppositions, but as this has come up more than once in your writing, patients may actually have some insights to share.

    One thing I can share having been on both sides of patient treatment is that I have prosopagnosia. If I see you in street clothes vs scrubs, different hair style, glasses on or off, etc., I won’t recognize you. I need to read ID tags – impossible due to backwards facing tags, small print and ID’s which don’t do so by full name and title.
    Providers speak FAST. If you say in one mumbled breath facing away from me that “HiI’m your doctorDrDoeHowAreYouDoingToday?” I won’t have any idea who you are other than someone I’m supposed to answer yet more questions asked.

    Try using business cards, write your name and title and role (I’m your breathing and lung doctor, for ex), or ask patients to read back your name and role.

    Finally, does this patient have sensory deficits? Does she have short or long term memory deficits? Is she sleep deprived? Low PO2? Look for reasons for memory/cognitive deficits.

    I hope that you’ll start to look at these issues with a broader lens. They may not be about you at all.

  • One other thought after reading the last comment. There may be another explanation for your patient’s anger about “not being seen by a doctor”.

    Healthcare, particularly in the inpatient setting has a very visible hierarchy. I’ve experienced this both being myself a patient and with my children. The difference between an intern, a resident, a chief resident, and an attending is glaringly obvious to the patient. I recognize all of these as being licensed physicians and clearly as doctors. I also am aware that the “chain of command” exists and who is at the top of that chain.

    While this hierarchy is visible, it is not as well understood by others who are not as familiar with healthcare. My mother for example can pick out the attending and knows who is “the top person” so to speak. She is less aware of the roles or credentials of those farther down the hierarchy – other than the fact that the are farther down the hierarchy. She would have residents, interns, etc tending to her and giving her good care – and still wonder why she hadn’t been seen by “the doctor”. This is regardless the race, sex, or age of those that had seen her.

    Actually let me correct that. She would be suspicious of anyone who looked like they just got out of high school. And when your in you 80’s anyone under 40 looks like they just got out of high school.

    Clearly I’m being a little facetious here, but there is a certain amount of truth in the fact that patient’s and not understand and misinterpret the very clear signals about the healthcare hierarchy.

  • In this case , you must face the obvious. Certain patients (and fellow doctors)refuse to recognize that females, or being of a colored race, could ever possess the intelligence to be a physician. I am asked at least once a week “what country are you from” and I reply Washington DC.
    Any patient that I see who doubts my ability, I ask them would they prefer a doctor of their own race. The patient/physician relationship is a partnership. The partnership should be terminated of either partner is dissatisfied

    • This lets me think of a traveler with typical Chinese features I met years ago. Another fellow traveler asked him: Where do you come from? to which he answered in Scottish accent: From Edinburgh. And the next question: But where to you come from ORIGINALLY?? To which he answered: Ach, from Glasgow. 😉

  • I think you are focused on a universal condition in this essay, felt by anyone who is working to provide a service to others. Some people can be completely blind to your desire to help and completely unappreciative of any effort you’ve made if it doesn’t meet their expectations. This seems to hold for all walks of life.

    My son works in a hardware store. He has dealt with his share of unappreciative, angry and abusive customers. The anger is often due to the customer’s stress and frustration at not being able to accomplish things according to their expectations. They often don’t see that the person trying to help them is really, really trying to help and they lash out. It can be demoralizing.

    I can only expect that when you are dealing with really serious issues – with a family of a patient in an ICU, or someone dealing with issues of life and death – that the frustration, fear, and anger can get in the way very very quickly. Much more so than the frustration of a leaky faucet or being unable to find the right color of paint.

    Keep open and know that this is not being directed at you, but probably more just lashing out at the world. Even with an unappreciative patient, your approach goes a long way toward helping them through the process. Don’t lose your compassion. It is probably the greatest gift you can give to your patients.

  • As a criminal defense lawyer, I understand your frustrations. Assisting individuals under great stress is not easy. I do what I can, and try to be empathetic, but I won’t be small or invisible. Some clients are unappreciative, some unreachable, and some hostile or demanding. That’s on them. I am not going to let them drag me under. Life is simply too short. Keep your chin up.

  • Having spent 80% of my working career in hospitals, I am now spending 80% of my time visiting physicians as aging tightens it grip. First, I appreciate your column and the critically important question(s) it poses.

    The variables are myriad. For example and as general questions not directed to you:
    Do you practice at a teaching hospital/medical center with patients requiring more complex care?

    What is your specialty, or sub-specialty, and what outcomes are more typical of the disease spectrum you encounter?

    What is your patient load and, sad to say, (as is the new mantra in corporate-managed medicine these days) what “throughput” is expected of you?

    I could go on, as you well know. These are all part of the continuum of possible answers for any given doc.

    I always assume that the entire staff, not just the docs, want the best outcome possible, but believe that patients and families are owed the unvarnished truth, as early as is it clear and, certainly, when its inevitable. When it’s unclear is when I’ve seen the proverbial fan hit hardest with patient/family upset.

    I believe that most “yelling” at physicians is an expression of grief, whether at actual loss of life, or when it’s impending. Some people don’t appreciate the very real limits of modern medicine, especially as the pharma companies relentlessly advertise a reality to the contrary. And some are righteously angry at staff whose bedside manner is brusque, or non-empathetic or just downright ornery and unprofessional.

    Young physicians, in particular, need more training about this subject and about death and dying, to augment their own abilities to heal themselves and and about to best help patients and their families cope with hard realities. The emotional hits are so significant to physicians, as you point out, but the answers seems to reside within the toughest balance to achieve – real compassion without falling into the abyss.

    Wish you luck and know you’re on a good road by what you wrote. Keep questioning.

  • You sound like a wonderful Dr. My heart goes out to you. Time constraints and paperwork make for weaker bonds and burnoutall around. Know that many of us are truly grateful for your caring self. Respect and hugs to you for your spirit and devotion.

  • Please, please, don’t give up! Yes, there are enough unappreciative people out there but you find them everywhere, not only in your office. I feel sorry for these people that they unable to see the love and passion they could experience. There are enough doctors out who are lacking of that. I saw some of them and was able to walk away most of the time to find another doctor like you! You will be so appreciated by people like me!

  • The world needs more compassionate doctors like you! Don’t “give up” on one of the greatest “treatments” you can offer patients. I worry the art of bedside manner is gone, except for the older generation of doctors who were mentored in bedside manner, and here you are, a young doctor already rocking it! I do think doctors need more support than they are given, however, and that is why depression and even suicide are serious risks to address. Whether or not the patient realizes you are a doctor could have to do with what you describe in your thoughtful article, and that’s the horrible truth that in our society, racism, sexism and stereotypes still exist. But always remember what you have given of yourself to sick patients, even mean or grumpy patients. In addition to your great knowledge and medical care, you have given your heart, your compassion and understanding which often helps patients more than the prescribed treatment. Keep up your wonderful work and don’t burn out, get support, you have a wonderful career ahead of you! I’m impressed. And also an extremely well written article!

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