Don S. Dizon , MD, FACP
This post was originally published on ASCOconnection.org, the American Society of Clinical Oncology’s professional networking site
“Great,” I thought, as I stood at my desk, looking at my patient list early in the morning. She was coming in today. “She” was a patient of mine in her forties, with newly diagnosed triple-negative breast cancer, without nodal involvement. Our first meeting had been several months ago, and it had not been a good one.
I had asked about her history, how she presented; she had been fairly surprised I did not have that information. “You mean, you don’t know?” she had asked. “I would’ve expected you to at least have read my chart or talked to my surgeon,” she said. Then, with a sigh, she had recounted how she got to this point—finding a mass, the normal mammogram, the ultrasound-guided biopsy, receiving her diagnosis. Then surgery, more results, culminating in a referral to me. Every question I asked was met with a furrowed brow, as if I were interrupting her.
“It must be really shocking to be here. No one our age expects something like this to happen,” I said.
She had gotten angry at this. “Just concentrate on the facts, please. I don’t need your pity. What I want is your expertise.”
We launched in to a discussion about her diagnosis, stage, and natural history of the disease. She questioned everything we discussed: “Are you sure your statistics are right? From what I read, it’s more like this . . .” I remember getting defensive, as if each question back to me was a personal attack on my competence as a physician, as an oncologist. I remember feeling flushed as we talked, trying to get my point across as clearly as possible, yet feeling that she did not (and was never) going to “believe” me.
We then discussed chemotherapy—both standard treatments and those available on clinical trials. She had even more questions:
“Why should I get doxorubicin? I heard I’ll be throwing up all day. Are you sure I need it?”
“How is a clinical trial better for me? There’s still a 50% chance I can get doxorubicin, so why is this even an option?”
We covered alternative approaches—ones that did not involve doxorubicin and were available off a clinical trial. I then rendered a recommendation taking into account her tumor, her priorities and beliefs, and what the evidence told me. We talked some more and I fielded additional questions; then I asked her if there was anything else she wanted to discuss.
“Not for you.” She said. I looked to the floor and left the room.
As time passed, I resented having to see her and take care of her because despite what I perceived as my best efforts, I felt we had no real doctor-patient relationship. Each subsequent meeting was tense because I felt more and more certain that (a) she didn’t trust me and (b) she did not like me. I had expected her to find a new doctor—within my practice or somewhere else—but she did not. Indeed, I remember being surprised (and anxious) each time she showed up.
On that day she showed up on my list, I confessed something to my partners: “I don’t like this woman,” I said. They looked at me, shocked. “You should not say that,” one had said. “It’s not her fault she has cancer, and people cope in very different ways.”
Although much time has passed, this patient stays with me because it was perhaps one of my most difficult patient relationships—not because she had questions, but because, as sometimes happens, I felt we did not “connect,” despite my trying really hard to make her like me, and to see that I was a good and decent doctor.
As I developed this blog, I decided to show it to a very dear friend, Dr. Barbara Rabinowitz, whose advice and guidance have been important to me on a number of occasions, particularly when we served on the board of a national organization together. I had wondered what she thought of my experience.
I do believe we hold high and sometimes unrealistic expectations of ourselves. In spite of your usual ease and rapport with patients, the experience you describe above is far from unknown. According to Haas et al., studies have shown that about 15% of the time physicians experience working with “difficult patients.”
In my experience, health care providers often feel trapped by the resultant negative feelings of these non-satisfying relationships. Though not in this case, difficulties may arise in the physician-patient relationship stimulated by pressures from the health care system itself (time allotted for visits, etc.), from undiscussed differences in expectations between the patient and physician, and the patient’s own previously held (and perhaps undiagnosed) conditions (e.g., personality disorders, etc.). Not uncommonly in cancer care, the free-floating anger at having been diagnosed with cancer may also be aimed at one or more members of the cancer care team.
I believe there is an even greater pressure to “like every patient” in cancer care than in general practice, as in this case, as exemplified by the reactions of your colleagues to your frustrated admission.
Ultimately, I clarified something with my partners: “I did not say anything about having cancer being ‘her fault’—I said I did not like her.”
With that, I realized that even with our white coats on, we possess our feelings, likes, dislikes, and personalities. Medicine requires us to do what is in the best interests of our patients, to “do no harm.” It does not compel us, however, to “like” everyone we treat. As a result, I experienced something interesting—almost liberating. I found that subsequent discussions and encounters with this patient became easier and that I was able to listen to her questions and answer them without getting defensive.
I realized that when I stopped trying to make her like me, I was able to take care of her. The pressure of wanting to be “liked” faded. It dawned on me that I was working so hard to make her like me (and vice versa), that it was affecting my ability to care for her. Once I admitted to myself that it was okay to not like a patient, I was able to do what she wanted me to do—to be her doctor.
At the end of the day, doctors are not a deity—omnipresent and omniscient. We are people—we are fallible, prone to our prejudices and our preferences, insecurities, and biases. I have learned that to become a good doctor, one must be honest with one’s self and exert introspection in order to become self aware; to admit that maybe the difficult patient is perceived as difficult not because of who or what she says, but rather the pressures we put on ourselves to “like” everyone we treat.