Difficult patients

I am often told that I have a lot of 'difficult patients', which is code for other doctors hate them. Sometimes, I agree with this assessment. Not all of my patients are the nicest people. However, it's also disappointing to know that a lot of folks I see are labeled as difficult because they want to be involved in their own care. And I think it's shameful that we discourage that.

I had a patient say to me last week something very nice: 'You're my favorite doctor because you always tell me things honestly and straightforward. I can trust you.'

It is a nice compliment to me, but such a sour turn on the profession. The default used to be that physicians deserved to be trusted, whether we deserved it or not. Now, a doctor is viewed as special because of such a basic piece of human interaction.

Privileged #4 - Thankful

On ICU call, sometimes it can get pretty awful, and this night was terrible. It was 3 AM, and I had just finished admitting a patient to the ICU who has gone into respiratory failure, when a code was called overhead. It was a bad scene. The patient was roughly 300 lbs, lying face down on the floor. He had apparently tried to go to the bathroom and never made it. Usually the nurses would be in the midst of CPR by the time I arrived, but they couldn't even roll him over because of his size.

It took 4 guys to muscle the patient onto his back so we could finally check for a rhythm. Of course: pulseless electrical activity. PEA is a really painful code, not because it is difficult or complicated, but because it is so frustrating. Everything on the monitor looks right, except that your patient is dead.

We ran the code on the floor, since we didn't have the strength to get him to a bed. After 20 minutes of futility, I called the code and paged the patient's attending. As I waited for the call back, one of the floor nurses grabbed me. The patient's wife was here.

At the nurses station sat a willowy, elderly lady. She was wearing an overcoat, a light blue lace nightgown, and pink house slippers. The nurses gave her a cup of that terrible coffee ubiquitous to every hospital unit, but she could barely hold onto it. It was singularly the most pathetic sight I had ever seen in the hospital to that point in my life.

I took her to the conference room and sat her with a couple nurses. They held her hand while I explained what happened. Her husband got up in the middle of the night and had a sudden heart attack, likely (hopefully) dying instantly. We made every effort to bring him back, using shocks and chemicals and CPR, but nothing worked, and we declared him dead (As an aside, when you tell someone that their loved one is dead, you must be tragically blunt sometimes. Denial is a powerful thing).

Tears were already pouring down her face. I told her the nurses were getting her husband cleaned up, and she could visit with him shortly. She had no questions, no accusations, just tears. I sat with her for a few minutes, and then excused myself to leave. The nurses had her well in hand, offering tissues and hugs. Before I could leave, she stopped me to say one thing: "Dr. Ifinding, I know that you didn't know my husband at all, but I just wanted to thank you for doing all that you could to save him. He's a good man and would've appreciated it."

I stopped by later that night to finish some charting. She was still there, weeping at her husband's bedside, holding his cold hand, whispering softly to him.

This code hurt for so long. It hurt because I had failed this patient and failed his wife, and then to have her thank me, it was salt on a wound. As a resident, the sight of her sitting next to his body was painfully seared into my mind. But when I think back on this now, I am so touched by this whole event. It must've taken so much courage for her to thank me, when she had so little to be thankful for. And it was such a beautiful thing to see, a wife crying over her dead husband. It was a display of love that far outshone the most joyous wedding. Words cannot convey how utterly heartbreaking a sight this was, but at the same time, how grateful I am to have seen it.

Privileged #3 - kindness

In my resident clinic, I had a patient who was an asshole. 100% asshole. He was mean and rude to doctors and staff. He had a hard life, harder than most, and suffered severe disabilities from his medical condition. He had bounced around the medical system, and found his way to my clinic.

I picked him up because one of the other residents unceremoniously dumped him on me. The other resident knew him and had him in the hospital, but feigned total ignorance when he bounced back to the hospital, and so I took his case. I realized a week later that this was a dump, and was I ever pissed off. But I took the patient into my resident clinic, because I will never turn down honest work.

In clinic, he was instantly trouble. He was rude and mean to the staff and other physicians. He complained bitterly about everyone. My attending advocated dismissing him from the clinic. I picked an alternate plan: I would be nice.

And so he would come in every 8 weeks or so and I was nice. He was rude and abrasive to me, and I returned kindness. He cursed and scowled, and I reassured. He was hateful and self-loathing, and I was empathetic. He railed and complained, and I listened.

And for three years this dance continued until my resident clinic ended. At his last appointment, he was quiet and thoughtful. He shook my hand and thanked me for helping him. He left, saying good bye to the staff by name, and thanking them for helping him recently with a prescription issue. One of the staff came up to me afterward and said, 'I can't believe that's the same Mr M! When he started here, he was such an asshole!'

For me, it was such a special moment to see the power of kindness, and that it is possible to do good in this world. I did nothing special for him except show him kindness and compassion, and that was all it took. You can do good in this world too, if only you can remember that in order to do good, you must be good.

"Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that." -Martin Luther King, Jr.

Privileged #2 - Happy birthday

In the ICU, it is sometimes easy to forget that we are dealing with people. There are tubes and machines and alarms, and somewhere in all of this is a human who can't talk, can't move, and can't proclaim to us their humanity.

I had a patient during my residency who was in such a predicament. She was without any family or friends. She had no visitors. She was in severe septic shock from pneumonia, unconscious and barely clinging to life. Her legal guardian told us, "If there is any chance of recovery, you should proceed. If it is futile, then stop."

Futile? Who's to say what is futile? Is futile a 5% chance of survival? Is it 1%? Is it 10% but with permanent, neurologic damage? We settled on some criteria and proceeded. If she showed any improvement, we would continue aggressive measures.

She only worsened. Each day I came to the hospital hoping for some sign, but every day was worse than before. Finally, the day came where we all agreed her care was futile. That day happened to be her birthday.

There was no one there to celebrate or wish her well, no cards or decorations. The nurses got some cake from the cafeteria, and we sang happy birthday. Then I wrote the orders, the nurses turned off the vent and pressors, and I closed her eyes and declared her dead.

That afternoon spent with the nurses was such a special moment. Without friends of family or anyone to mourn, we took a minute to celebrate her life, even as it ended. Because being a doctor means never forgetting that life is beautiful, and although no one else treasured this life, we did.

Privileged #1 - How are you?

One of my most memorable patients was a wonderful lady with floridly metastatic, unresponsive to treatment, triple negative breast cancer who developed subsequent cardiomyopathy from chemotherapy. She had an EF of <10% and during the course of her hospitalization underwent multi-organ system failure from end organ ischemia. To translate this into normal speak: she had the worst possible breast cancer, with the worst possible response to treatment, and the worst possible side effects.

I was only an intern but I had to give 'the talk.' I sat her family in a conference room, went through the facts of her case slowly, and gave my assessment: she had two terminal conditions, both of which we could not fix. The family cried, and the oncologist piped up about radiation, or another round of chemo if we could get her heart back, or something ridiculous. I ignored him completely. I sat there for five painful minutes while they cried and asked me "Why?!" Once you have done this a few times, you realize that as much as a family wants the answer, you do not have it. Bad luck? Fate? God's will? There is no right answer to this question, only tissues and holding a hand.

The family consented to weaning off vasopressors (medications to elevate blood pressure), and with her loved ones at her bedside, we turned off all the supportive measures. I declared her dead about 30 minutes later. As memorable a moment as this was, it was not the most memorable.

The privileged moment came one day earlier. The oncology attending had just met with the family and discussed keeping their hopes up as well as future chemo options. It was a pep rally, to be sure. I was eating lunch at the time. My senior resident asked me to check on the labs, so I headed back to the ICU, and ran into the patient's sister in the hallway. I said, "Hi! How are you?" with a little wave.

She looked at me, and managed say, "I'm fine, tha-" before bursting into tears. She collapsed to her knees in the hallway, and I had to help her into a chair. I got her some tissues and sat with her for 15 minutes. We joked a little about some funny things her sister had said. After regaining her composure, she looked at me directly, and asked, "Dr ifinding, is she going to die?" I told her that we should get her family together and talk about this, leading to the family meeting the next day.

I am still amazed that this small, chance event of saying hello could be so profound. It was the opening she sought, the chance to ask the question everyone had avoided. She just needed a chance to ask. And it made me realize that even the smallest interactions can have big impacts.

I also felt very honored by the trust placed in me by this family. I was the wet-behind-the-ears intern, but they saw me every morning doing my job, and that was enough for them, because being a good doctor means that you are someone worthy of trust.


In today's world of medicine, I think that people forget that being a physician is a privilege. There are plenty of things in life that you earn with hard work and skill, and medicine requires those things too, but it is a unique privilege to be a physician. We are asked to do things to people that are painful, we are told things in confidence, we are asked to make life or death decisions. We are the ones who have to tell the family that their loved one is now dead.

I have had a lot of fun writing the "Don't be a doctor" series, but I think it might be nice to write something a little more inspirational, and so I am going to embark on another series of posts, about moments I was privileged to witness in my medical career.

You'll have to excuse me for repeating some post content. I have undoubtedly blogged about some of these events before.

(1) How are you?
Even the smallest interactions can have big impacts.

(2) Happy birthday
We took a minute to celebrate her life, even as it ended.

(3) Kindness
It is possible to do good in this world.

(4) Thankful
She had so little to be thankful for.

(5) Reconciliation
Love will always be more powerful than hate.

(6) Enough
Sometimes a person has to say enough is enough.

(7) Comfort
I was not a stranger in his life. I had been a part.

How do you know?

Perhaps the most common question I receive on this blog is a simple one: how did you know you should be a doctor? Well, I have written no less than 4 times on that subject, and posted a litany of reasons why to avoid medicine.

But the truth of the matter is that there is no way to know for sure. Is there any way to know for sure about any career decision until you've already made it? What I can tell you is this: all the reasons YOU think you would be a good doctor are bullshit. Total 100% crap. Because I had the same thoughts, and it just wasn't true.

I want to help people. I'm compassionate. I care. I had a grandfather who was really sick. Blah blah blah. This is all trite garbage, and doesn't cut to the heart of the matter.

In high school, I decided that I would consider being a doctor. Instantly, my teachers were enthusiastic. They thought I'd be an excellent doctor, as did a few college professors and a boss or two. What did they know? They didn't see my transcript. They didn't read my admissions essay. They knew nothing about my motivations.

In truth, being a good doctor is not one quality, but a myriad. It is compassion, but it's also conviction, empathy, faith, indignation, professionalism, perseverance, reverence, charity, dedication, hope, intelligence, skepticism, forgiveness, anger, and so much more. It is a whole subset of skills and traits that you don't know you have at the tender age of 18.

I realize now that all those encouraging words from my teachers and superiors, it was because they could see in me things that I could not see in myself. I wanted to become a doctor because I thought it would change me, make me different. They saw that the other than some coursework and a stethoscope, I didn't need to change a thing.

I needed that

I saw a patient today, and had some bad news. We talked about what we can do and how to approach it, but ultimately, things are getting worse, and we'll have to see if we can turn things around or not.

As I finished up, he said to me, "Dr ifinding, you gave me all kinds of news today that I didn't want to hear, but I'm glad you were the one telling me."

Thanks, dude. You have no idea how much I needed that.

Quality improvement

Our length of stay is too long. That means on average, we are keeping people in the hospital longer than we should, given their diagnosis. But we will be penalized for bounce backs, which is where a patient is readmitted within a month. So, we need to get people out earlier and ensure they don't come back. Our A1c's are too high. We are not keeping diabetes well enough in check. Our blood pressures are not well enough controlled. We are not getting enough yearly mammograms.

Quality improvement can be frustrating at times, because there are so many places where a quality standard is being imposed, either now or in the future, and many of these standards have no evidence whatsoever that they actually improve patient outcomes.

So let's be honest here. These goals are not to improve quality. They are to save cost. There's nothing wrong with that. We waste a lot of money in health care and trimming our expenditures is reasonable for any business. But I resent the idea that I am not delivering quality care because I don't hit some arbitrary target, or document something so some quality maven can review it.

A few years ago, I had a patient with HTN and diabetes who was passing out frequently. So I changed his meds so SBP was >140 and A1c was >8.0, and he hasn't passed out since. I think he would say that he's getting quality care.


I have a patient who is a liar. He is telling me a story to get pain medications. I don't have any proof he is a liar. He has no incriminating evidence that I can find. There is no labwork that I can do to prove his pain one way or the other. Without evidence, I am inclined to give him the pain meds. I am willing to play this game. All he must do is play the game with me.

Instead, the staff catch him with secret pain meds not prescribed by me, and eating meals from the cafeteria when he swears that he can't keep anything down. All he has to do is play along, and even that, he can't do.

And that is the sad fact about addicts. He has me beat, and still, he cannot stop himself from ruining it.

Leukemia is an asshole

I am currently reading 'The Emperor of All Maladies' by S. Mukherjee, MD. It is a biography of cancer. I got 20 pages into the book before I had to put it down and walk away for a while. It is tough to read. Only last week I had a patient die from acute leukemia, so it hit close to home, but this book struck a nerve with leukemia. I hate leukemia.

I do not hate diabetes or hypertension. In fact, I love them. If you remember the movie 'Backdraft' there's a nice quote: "the only way to truly kill it is to love it a little." There is a certain love of the pathologic. When I see something going wrong, I know what it is. I know why it does the things it does. I do love it a little.

But acute leukemia I hate with a burning passion. If leukemia was a man, I would kick him in the crotch several times, and then let him get up, and kick him again in the crotch, and then pee on him. THAT is how much I hate leukemia. I hate leukemia because it is totally unfair. It picks on little kids. It strikes hard. It is relentlessly fast. It is cruel. It doesn't care if you've been a good person. It wants you to suffer, and it makes you suffer in all sorts of horrible ways. It is an asshole.

You would be right to say that this is not unique to leukemia. Certainly, sepsis is similar in its tenacity. But with sepsis, it only asks for a cure. If you can treat with the appropriate antibiotic, then the cure is delivered. All I must do is keep the patient alive long enough for the foreign pathogen to be removed.

Acute leukemia is entirely different. In order to kill it, you must also try to kill your patient. You must play a game of chicken: if you swerve, leukemia wins and your patient dies, but if you stay straight, you may kill leukemia but also kill your patient in the process. All the odds are already stacked against you, but instead of other cancers where you think and plan, you must act now. So you destroy what remains of the bone marrow. You pour toxic substances throughout the patient's system. You push the patient to the very edge of death, and sometimes over. And in the end, all that buys you is a 20% shot at being alive after 5 years?

Fuck you, leukemia.

(Of course, prognosis for acute leukemias vary by many, many factors)