Daily Briefing

The patient was 'difficult.' His lessons were unforgettable.


Editor's note: This popular story from the Daily Briefing's archives was republished on Apr. 27, 2023.

Writing for the New York Times, Gina Siddiqui, an emergency medicine physician, explains how a "difficult" patient showed her how to be compassionate and not just see patients as "machines in a body shop."

Toolkit: 7 tools to improve the patient experience

A 'difficult' patient

While in her first year of medical school, Siddiqui met Sal, a 58-year-old man with cystic fibrosis. He was considered an "old survivor" of the disease and had outlived many of his friends who had been diagnosed at the same time. At the hospital clinic, the doctors referred to Sal as a "difficult" patient, one that they preferred to avoid.

"I watched him quiz new doctors to see if they had read his chart carefully," Siddiqui writes. "… He rewarded correct answers with even harder questions about local antibiotic resistance patterns. If the doctor said he or she didn't know, Sal glared quietly; if they made up an answer, he was merciless."

Sal also diligently kept detailed records of his lung function, muscle strength, and respiratory symptoms. He had thick binders filled with information on clinical trials and review articles for cystic fibrosis.

However, "[t]he doctors made fun of Sal's tomes and took bets on who would catch the hot potato next month and be expected to wade through his thousands of pages in 30 minutes," Siddiqui writes.

According to Siddiqui, this experience was her "first lesson in recognizing patient qualities that benefited their health but not the doctor's workflow." Instead of commending patients who took the time to understand their illness or pushed back on certain treatments that weren't supported by strong evidence, many doctors often complained about them.

The mechanization of medicine

As Siddiqui progressed through medical school and began to see her own patients, she "learned a 21-point inspection of sorts to troubleshoot each malfunctioning part [of every organ system], as if my patients were machines in a body shop."

"Hormones, fluids, wires, tubes, sedatives, paralytics; the bone's ability to remodel, the heart's strength to contract—I was responsible for all of these things and had limited time to make all these plans," Siddiqui writes.

Unlike Sal, many of Siddiqui's patients had less to say about their own conditions or care and "didn't cloud the picture with any personal thoughts of their own." Over time, she became more effective at distilling "patients' histories into a single sentence" or "medical one-liner[s]."

Siddiqui also practiced "therapeutic distancing" so that she could make decisions about her patients "coolly and unemotionally." She didn't share much about herself personally and avoided showing uncertainty or vulnerability.

"I now had a command of anatomy, pathophysiology and pharmacology," Siddiqui writes. "I had impressed my supervisors and diligently maintained therapeutic distance. I was finally starting to become confident as a doctor. Why, then, did I feel so empty?"

A speech when 'patients are at the end of their rope'

Years later, Siddiqui remembered a conversation she had had with Sal after one of his appointments. At the appointment, Sal had complained about not being able to lift as much as he had the year prior.

The doctor attending to him explained that it was likely due to "advancing age, nothing to be done about it." Although Siddiqui had expected Sal to push back on the doctor's response, he did not and "seemed to shrink into himself on the examining table" during the rest of the appointment.

Later, Sal wrote Siddiqui an email, saying, "Prepare a speech for those moments, like the one that week, when patients come to you at the end of their rope, and you have no more solutions to offer."

Although Siddiqui brushed off the email in the moment, she returned it to years after she had become more established as a doctor. Although her responsibilities often prevented her from having intimate conversations with her patients, she still wanted to be understanding and considerate of their problems.

"Now the speech that Sal inspired is directed inward," Siddiqui writes. "I tell myself that patients reach the end of their ropes for medical reasons, personal reasons and often a mix of the two. Sometimes just managing the medical reasons is challenge enough for me, and that's OK."

"But when I'm the 'patient' at a bank or courtroom or post office, I'm reminded of what competency feels like without humanity," Siddiqui writes. "That helps me summon that timid young woman on the buffed lobby floor, who knew nothing about medicine but earned her first patient's trust by being kind and sincere. She has started seeing patients again." (Siddiqui, New York Times, 10/21)


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