By LEAH EBURNE
It takes me a while to know when I’m angry.
The attending warned me Lynn rarely showed up for her appointments and “was hard to get through to” before I entered the room. She yawned frequently and apologized. She was sharp, hard-working, and exhausted from her night shift. A clinic visit meant getting off work as soon as possible and delaying sleep to make it on time. Excited to meet another person who spent years working nights, we struck up conversation on the struggles to get chores done when our bodies begged for bed, when friends and family were asleep while we were wide awake at 2 AM, how dawn painted the sky on the drive home, and the curse of Fall daylight savings shifts. This patient had a lot of struggles and she knew very few people in the area. She had no family. Her blood glucose and A1c absolutely stank.
She was well-aware of the need to improve and mindful to watch her weight. Her vitals reflected as much. Lynn dropped enough pounds over the last few visits to fall under a 30 BMI but recently stagnated. It frustrated her. With money being so tight, she knew her metformin was probably not enough but had no way to afford insulin or much of anything else. She was a month behind on rent and her phone was shut down. Glucose testing strips did not factor into her life so much as keeping a roof over her head. Having few other alternatives, she chose to focus on what she could control by cutting out fast food, juice, soda, and sweets. She was walking daily and reaching out to other diabetics at work for tips on how to maximize her medications and balance her sugars. The details in her day-to-day life gave me a clear picture. There was no sob story. No excuses. She asked for nothing but guidance as long as I kept in mind the reality of living paycheck to paycheck.
My attending walked in. She shut down.
Whatever history lie between the two only revealed itself through her politely wooden responses to his ice-breaker jokes and review of her 3-month labs. I watched a full-grown woman tighten, and withdraw, and shrink until her presence disappeared. My attending gestured o her as if she were a case report - to demonstrate to me, the student, a classic example of a noncompliant diabetic. Lynn, the exhibit – the main character of a cautionary tale on the verge of her final poor life choice – Once, she and I exchanged glances. This was not The House of God and I was not Dr. Roy Basch. The patient was not a gomer. Nor was she deaf. She turned her eyes to the floor as she repeated, stiffly now, her financial situation and her lifestyle changes. She braced herself after each reply then fell silent when it came time to discuss her missing home blood glucose logs, need to lose more weight, and adding another medication. The small achievements from the last few months were minimized. I watched the light inside her dim. I stood there, nodding in my short whitecoat, limply consulting Epocrates, powerless.
When does one physician’s tough love become another patient’s browbeating?
Our visit together was her last. I reached out shortly after but the number was no longer in service.
We cannot, in our wildest fancy, believe we are capable of making friends with every patient we meet. And, hell. We are not here to make friends with our patients. I’m not. But I knew I didn’t want to misread them so poorly as to mirror the missteps of my predecessors. All clinicians are different and, naturally, employ different practice styles; medical paternalism is alive and well. Maintaining a paucity of choice, with a vast array of obtuse and confusing treatment modalities at hand, still suits many people just fine. Some patients want all the options and then advice on what the best choice for them would be. Some want a little in between. It’s tough work knowing what the right approach can be especially since it evolves with a patient’s understanding.
I know what my own preferences as a future psychiatrist are. It smacked me in the face that day. I want to honor the therapeutic alliance. I want to be a steward.
The concept of a therapeutic alliance is odd to explain due to it being thoroughly common sense. It means listening to what they say as well as paying attention to what is left unsaid. It means, at your core, being empathetic to their experience and taking that into consideration when you make plans for their care. It means, regardless of how different your patient is from you, that you have developed the art and integrity to cognitively empathize and remain an objective steward of their medical care. It means being present. It is not about rapport for the sake of rapport. We cannot ignore the value in how the adaptation of interpersonal dynamics colors the way a patient chooses to interpret your intentions and treatment recommendations. It most certainly not about the emotional contagion type of empathy where a patient’s pain feels like your own. It is not about sympathy, which can be infantilizing, minimizing, and insulting. It is about self-awareness, good sense, and attention to the person in front of you.
Lynn’s visit was almost a year ago. It took me half a day to realize why it incensed me. I have no idea what happened to this individual or her reasons for not returning but, as a result, I paid more attention to how other mentors and their patients interacted. Who talked? Who listened? How did both sides do that? Who pushed? Who pulled? When a patient withdrew, did the physician respond? And what did that look like?
It was evident when the alliance was strong. The trust built between a perceptive physician and their patient built a foundation sturdy enough to weather differences of opinion, differences of personality, and everything in between. They used their strength for others, not for themselves.
“I can always tell you care what’s going on and I come to you because you make things happen,” one woman said to my preceptor. My review of prior records revealed they didn’t always agree but communicated openly.
That’s it, I thought. That’s the alliance. That’s stewardship.