This article was published in Scientific American’s former blog network and reflects the views of the author, not necessarily those of Scientific American
"You wanna talk? Let's talk."
The 42-year-old man sits up straighter in the hospital bed and grins a toothless grin. "Those other doctors, they don’t understand. They don't get what I'm going through, you know?"
I know only what they told me.
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A few minutes earlier, our team had gathered outside the door, where the senior resident had instructed the intern on how to handle it. “You have to lay down the law,” he said, emphasizing that she could not budge and give Mr. H the painkillers he wanted. He reminded her what the medical records showed: that Mr. H visits different hospitals and clinics around the city every two weeks or so, asking for stronger and stronger doses of narcotics, and then leaves abruptly if he does not receive them.
"I know what works for me. And these pills, they work, dontcha see?"
Yes, I can see. Your pain is real, and your body is addicted to very powerful drugs, and it’s not your fault. These drugs are designed to do that to you.
But sometimes, seeing and acting don’t necessarily go hand in hand. Sometimes, it’s a transaction that is desired – not a negotiation. A person desires a very specific course of action, and if we do not provide it, there are no empathetic words or gestures that would make it acceptable in your eyes.
When that occurs, conflict seems inevitable. In our case, the sentence that launched us into enemy status was simple.
“You haven’t been taking your regular medications at home.”
“I have a home. Don’t you talk to me like that! I have a home. How dare you!”
Wrong word choice. Wrong wrong wrong. Or maybe not. Maybe it’s intentional anger over a benign word choice in an attempt to trigger a guilt complex and get the desired outcome. Either way, this is not a comfortable situation. Either way, it escalates quickly. Either way, we are now at odds when the goal is to be on the same team.
He’s not grinning anymore, but now yelling, now waving his cane furiously, but also sadly because he is legally blind and even his attempts at violence seem to represent a shadow of what he once was. I step back as the worn wooden stick swipes the air.
“I know you must be smart, cause you’re doctors and all. But let me tell you, you doctors, you have a God complex.”
*
In hospital medicine, there is a thin curtain separating the patients sharing a room. A caregiver can cross this curtain and fulfill a completely different persona depending on whether she is standing on its left or its right.
Somehow, our intern can be a callous bully with a God complex, standing between a vulnerable person and the medications that would help him – and then she can Purell her hands, traverse a curtain, and morph into a trusted, compassionate healer.
*
Ten feet over, separated from the clash by the thin curtain, Mr. M lay quietly at first. Blankets pulled up to his neck, he curls himself, his hospital gown offering little protection from the cold sensations that are not stemming from the outside, but from his own hurt body. Even under all the layers, he shivers violently.
Just two days earlier we had sent him home in his regular clothes and told him we’d call back if any of the pending lab results returned out of the ordinary. We didn’t expect them to; that was, after all, why we felt comfortable sending him home. He smiled; we smiled; how nice to see someone leave this place better.
Forty-eight hours into his excursion home, he received an urgent call to come to the emergency room immediately – your blood cultures are showing bacteria growing in your bloodstream. There were a few possibilities; it could be a false positive from contamination; it could be a Staph infection susceptible to standard antibiotics; or it could be the MRSA, a more dangerous drug-resistant option that is harder to treat.
The hospital room where he had previously stayed had been filled with posters and pictures from his kids urging him to get better soon. These walls, however, are bare. The news is too fresh for decorations.
“If it is MRSA,” he whispers, teeth chattering. “Is there anything you can do?”
We will treat you.
That is the simple answer. But it was a more complicated question, even if its complexities were not explicitly voiced. Couched in it was the question of “what is my prognosis?” This patient, with a complex medical history, now immunosuppressed from chemotherapy, was aware that his hospital course might run differently from that of the 40-year-old with no past medical history. The intern explains the treatment regimen and then, noticing his still fearful expression, shifts her chair closer to the bedside, squeezes his hand, and promises: “we will do everything we can.”
But he doesn’t look reassured, and I understand that too.
*
It’s a bizarre idea for two individuals, going through perhaps the worst days of their lives for completely unrelated reasons, to be thrust side by side as roommates. Enter the world of inpatient medicine, where this is the everyday.
It isn’t always bad. I’ve witnessed the inspiring stories, complete with the unexpected advocates and surprising sources of support from the strangers on the other side of the curtain. There was the pediatric room, where at first glance the fourteen-year-old with a new diabetes diagnosis and the hyperactive two-year-old was not the best pairing, but where the latter’s continuous demands for the young man to “play! now!” offered a humor and cheer that helped him get through his hospitalization. There was the blossoming mentor-mentee relationship between the two individuals on the psychiatric ward, both struggling with severe depression, but one of them a week into the future: one week into electroconvulsive therapy and showing massive improvement. Seeing her success instilled a sense of hope in the struggling patient more than any doctor could.
You can lose a lot in the hospital. Your independence, your familiar surroundings, your 9-5 schedule. Your sleep. Your sense of safety. Home cooked meals. A comfortable bed. Immunity to hospital-acquired infections.
Amidst all of this, so often goes privacy.
Two strangers, perhaps going through the worst days of their lives, overhear it all: the unimaginably personal questions about social and sexual histories, the soothing words during painful bedside procedures, the phone conversations where you inform your family how it is really going.
Hearing it all, distracted by the misery of another, while lying quietly under the covers, worrying mostly about yourself.
*
"And I know what works for me. You only want to do what’s good for you!”
"No, when I was home, I was actually feeling OK. Nope, no fevers. No night sweats. No, no."
"I come in and I know myself, and you doctors, you think you know better."
"I even had energy to play with my little one, she's four."
"Fine, say no morphine. Is there anything you can give me?"
"Is there anything you can do?"
*
The next morning, I go to see Mr. M. There is only one binder stacked against the door, recording one set of vital signs. The bed next to him is neatly made.
I learn from the nurse that Mr. H stormed out around midnight, after finally accepting that no narcotics were headed his way.
No one goes into medicine to play the role of the bad cop. Rather, it’s just a part that develops over time, as patients ask for things we cannot provide, often unintentionally or sometimes purposefully confusing the options we have to offer in medicine. Unfortunately, I’m seeing, it’s a role we fall into far more frequently than any of us would like. I’m so sorry; I can’t help you. No, I cannot write you that prescription. I’m sorry you were evicted from your apartment, but no, this is not a place for you to stay. The role can be endlessly frustrating: we may empathize with the struggles of addiction and feel sorry for the pain of homelessness, while feeling forced to act in ways that suggest otherwise – because we simply don’t have the tools to help.
At the same time, we function as primary providers; trusted confidantes; beloved caregivers. We wear masks, transitioning between the roles of good cop and bad cop multiple times a day. The switch can even happen within the same room.
That we display different personas with different audiences is not exactly a new insight, or one specific to medicine. But it presents with an intensity in the medical world that is partly caused by the unique roommate setup. I can step past a curtain – and transform from a Jekyll to a Hyde. I can walk ten feet over – and evolve from an empathetic ally providing comfort and treatment, to a power-hungry white coat who doesn’t understand what you’re going through.
Why are we so different, or perceived so differently? When are certain personas appropriate, and when are they clouded by our own biases?
The curtain may divide, but it also makes me more aware. I am conscious of how I am overheard. I am mindful of how a conversation with one patient can influence how I am perceived by the other. The curtain's existence forces me to evaluate my interactions with different patients critically and honestly. There are so many undesirable traps we can fall into: of playing favorites, of being dismissive, of selective empathy. It takes vigilance – and an enormous amount of honest self-reflection – to avoid this.
The curtain reminds me to check myself.
*
“It must be nice to have your own room,” I say to Mr. M, feeling sorry for a man who, on top of having to deal with a frightening hospital re-admission and significant physical discomfort, was also subjected to a commotion that must have been the last thing he needed.
There were many things he could have said. He could have complained about the “difficult roommate.” He could have opined about the “difficult patient.”
Instead he said: “That poor man. Had nowhere else to go.”
Thank you, roommates, for the reminders. Thank you for the unexpected sources of support, for holding a mirror to our own behavior – and for the reminder to remain empathetic, always.
Instead he said: “Bless his heart.”
(Certain details of this story were modified slightly to protect the privacy of the patients.)