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After I declined to prescribe him stimulant medication, one of my favorite patients became angry and began to raise his voice.

It was the last appointment of the day, and the clinic was largely empty. I shifted back in my chair, leaning away from him, subtly trying to protect my pregnant belly and hide my fear and disbelief. 

“You’re just going to make me start using again,” he said, his face becoming red. “What’s the point if you’re not helping me!?” 

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I thought I was.

Despite being trapped in a vicious cycle of poverty, my patient was working hard for himself. He had been doing well in recovery from his opioid use disorder and we had been diligently working for several months to address his other mental health concerns.

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I brought my full self to each encounter — an open heart and an open mind. In the words of David Foster Wallace, my work was “morally passionate, passionately moral.” His progress made me feel as if my care mattered. 

But then he turned on me and our shared goals. All at once I felt betrayed, defensive, confused, and hurt. 

Was I caring too much? Was I in too deep? I made a mental note about the danger of growing fond of my patients: You risk having it thrown back in your face. 

My patient no-showed our next appointment and neglected to return any of my calls. And then I went on maternity leave.

I couldn’t help but worry about him the entire time I was away. Would I be responsible for his fatal turn back to heroin or fentanyl? Were his choices his or ours? 

I tried to remind myself that his life was not my life. But it was clear his life was impacting mine. As I cradled my newborn baby, I’d angrily rehearse what I’d say to him about my duty to do him no harm. I worked up the nerve to stand my ground and brace myself for the many difficult conversations that lay ahead. 

“I’m not doing too good,” he lamented, when we finally met again. He had lost a loved one to an opioid overdose just three days before. His pain had not yet dissipated. It was right in front of me. Inescapable, raw, and real. My silent resolve instantly shattered.

We spent most of that appointment sitting in silence. Holding back the tears that were desperately trying to escape my eyes, I just kept telling him how terrible this was and that I was so very sorry. “Thank you, Dr. O,” he said. 

I was equal parts sorry for his loss and that I’d steeled myself toward him. Our sorrow was not only an anticlimactic end to the fight I had spent months preparing for, but also a blindsiding knockout I didn’t see coming. How do we honor the call to medicine without becoming undone ourselves? 

Throughout my training I’ve watched mentors and fellow trainees turn away from complex clinical work because this balance is elusive. As I care for an increasing number of patients, I’ve learned that the work of medicine, the real work, is remaining emotionally within reach. When exhausted by the emotional ricochet of our patients’ triumphs and tragedies, it’s tempting to simply walk away. 

Moving away from paternalistic styles of practice, my profession preaches humility, a modest view of my own importance in the doctor-patient relationship. Perhaps humility frees us from the gravity of these intense feelings by giving us permission to stand back and look away when the embers of humanity burn too bright. After all, it hurts to look directly into the sun.

Should I be humble about my feelings and their impact on my ability to provide good, sustainable care? Perhaps, but I wonder if downplaying the emotional labor required to tend to human suffering is what makes burnout an inevitability.

Neither standing back nor denying my feelings satisfies. Nor do these two stances respect the emotional investment that separates doing a job from getting a job done. As I start my last year of residency training, I’m desperate to find a style of practice that will allow me to truly engage in my work.

There was something poignant between my patient and me. I am no longer full of the unjaded enthusiasm that made me feel like a good doctor to him, and there is stress in that loss. There is also an uneasiness as I look to answer the call that will come from the next patient. 

I have to believe by continuing to show up, I will be good enough.

  • I have always believed that much of our care is the transfer of healing “energies” from us to our patients. When we are fully empathetic, it drains us of our life force and it takes a while to recharge. Perhaps that is what lies at the bottom of the “epidemic” in physician burnout – we simply do not have the resources to recharge ourselves.

  • Congratulations on your courage to share such a personal, yet clinical story. As long as you allow yourself to experience others deeply, you will be effected by them and also effect them. I don’t think most psychiatrists allow for that, otherwise we could not have created the DSM. On the other hand, if you like talking to people, which you apparently do, you will be able to enjoy the work…and it is work. We psychiatrists are navigating for two.

    But what you describe, meaning knowing where you’re coming from, and sometimes not from the optimum place, gets less mysterious with time and practice. Then you can correct the latter. Peggy Finston MD

  • How sad to me that this young doctor has no spiritual well to draw from in times like this. She has no anchor, no compass, can only suffer her feelings, apparently. God and specifically the teachings of Jesus Christ would give her the context to be there for her patients, and for her new baby. But she’s going it alone, at least as indicated in this piece. All she can do is ‘show up.’ It won’t be enough.

  • You remind me so much of my internal medicine physician. She cared for my mother during her declining years and months, and continues to care for me. That care is always appreciated and valued. Please keep up the good work!

  • Like many other people, your patient was turned into an addict by the medical system. Addicts needing a fix isn’t personal.

    • “Would I be responsible for his fatal turn back to heroin or fentanyl? ”

      No, he or she is a heroin addict.

  • Like many other people, your patient was turned into an addict by the medical system. Addicts needed a fix isn’t personal.

  • I am sorry your medical training did not prepare you for the scope and breadth of professional care and did not process your role as a female and mother in that world.
    Anger is to be expected from clients. Actually a huge complement because the trust factor is there. No one gets angry at another human if Safety and or Trust is an issue. So kudos.
    You should get the big book off AA and go to some meetings. This request should or could have been expected.
    And also her Transference- it goes both ways my dear. Do some research on the area and thinking – why was this one your favorite?
    And oh the pregnancy !!! Mostly ignored but I think plays a major role and WE JUST DONT KNOW. Part of the Transference cycle but also something more.
    And what about the fetus? Is it affected by our human relationships.
    Keep writing and Keep thinking and get a really really good mentor- maybe Gabor Mate.

  • Post car crash I’ve been on both sides of delivering care and receiving. Thanks for sharing your experience. In the beginning especially, at times giving care didn’t feel like such a gift. As a patient, life often felt like a no win situation. The feelings of helplessness can lead to irritation, frustration and more. The process is complex and boundaries with kindness were, for me necessary. Like calluses on fingers that took time. Affection, like soaking hands makes them softer. That’s only human.

  • Outstanding article and a great answer to the why of practicing medicine and delivering care to patients! A great start to my day.

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