Time Stamps

  • 01:13 Introduction
  • 05:27 Question 1: What makes a patient difficult?
  • 13:22 Question 2: What is a “good outcome” when working with difficult patients?
  • 23:05 Question 3: What have you learned from your difficult patients?
  • 31:56 Conclusion

Show Notes

** These highlights are far from comprehensive – they just cover some of the themes that arose in the interviews.

  Thank you everyone we interviewed for their very honest responses to our questions

  • What makes a patient difficult for you?
    • Vocally argumentative
    • Non-adherent
    • Inability to remain objective when caring for a patient
    • Breakdown in communication
    • Problems in the therapeutic relationship that make the clinician feel insufficient
  • What is a “good outcome” when working with difficult patients?
    • Coming to understand why a patient is acting out/being “difficult”
    • Getting patients to engage with care
    • Re-defining “success”/managing expectations, both for clinicians and patients
    • Treating patients with respect as inherently dignifying
    • Helping patients come to terms with their illness
  • What have you learned from your difficult patients?’
    • Often, “being difficult” is how patients communicate that their needs aren’t being heard
    • The very use of the term “difficult” highlights how medicine can be controlling
    • Difficult patients have taught clinicians about their own countertransference, our assumptions, the goals we set, and our notions of a good outcome

Further Reading

Transcript

INTRO

MARGOT: In this episode, I want to come to a better understanding of the patients that we struggle to take care of, patients who are sometimes called “difficult”. “Difficult” means something different for everyone, but for me, this was a patient I took care of in July of my second year. He has decompensated cirrhosis, alcohol use disorder, and former opiate abuse currently on methadone, and he comes in every few weeks requiring a large volume paracentesis and a large dose of benzos to keep him from going into delirium tremens. Unfortunately, he lives on the streets, and has no access to a bathroom when he leaves the hospital – consequently when he is discharged, he doesn’t take the lactulose that would keep his mind clear, or diuretics that would prevent his ascites from re-accumulating. I was already feeling overwhelmed from the new set of responsibilities I had picked up in my transition from intern to resident, and found myself alternating between terror that he was getting sicker, and despair that I didn’t know how to make him meaningfully better. On top of that, we butted heads about his treatment plan. I reduced his dose of methadone because he became quite sick with SBP, and because every time we spoke he could barely keep his eyes open as we were talking. At the end of his hospital stay, we discharged him back to the street, knowing full well that it was only a matter of time before he came back.

I’m sure many of you listening have taken care of patients who evoke the feelings of helplessness, frustration, and frankly despair that I have experienced in taking care of my difficult patients. I wanted to know how providers found meaning in taking care of these “difficult” patients. I wanted to know how they worked through the obstacles inherent in taking care of patients who suffer from the sequelae of poverty, mental illness, addiction – how they found meaning when struggling against these forces that are so much larger than us, and very likely to overcome so much of what we try to do. I wanted to know how they could keep coming back to work day after day, taking care of these patients with the respect and dignity that all of our patients deserve. I wanted to know how people adjusted their expectations of success, how they worked towards what by necessity are sometimes a different set of goals for patients who may not get “better”, in a traditional sense. I wanted to explore what it means to be a good doctor, and how we often have to put aside our own intentions and our own ego when we take care of patients who we can’t heal.

So I reached out to medical students, co-residents, and attendings that I had worked with, people who I had come to look up to for being level-headed and compassionate clinicians. My plan was to summarize  all their answers, and see how those answers might change as people progress through their careers.

But the more interviews I did, the more I heard people telling me how they themselves had changed while caring of patients who they struggled with. They told me how their “difficult” patients had helped them understand flaws in our medical system, helped them understand what it was in themselves that brought out an emotional response when things didn’t go well. These interviews became really, really honest as people told me about their challenges and their triumphs, and in turn this episode became something more than I was expecting. 

To quickly outline the episode – Tamar and Jafar will go into the answers people gave to the 3 questions I asked. Tamar will lead us through the first question, which explores what kind of patients we find “difficult”, and why. Jafar will take us through the second question, which explores how we adjust our expectations, and what to strive for; and Tamar will take us through the third question, exploring what we’ve learned from these patients. I don’t expect all listeners to come away from this with the same conclusions that I have, but I do hope to plant a seed: I hope to convince you to spend some time thinking about what you’ve learned from your difficult patients. I’m starting to think that my personal concept of “meaning” in medicine is inextricable from adversity, and I hope to show you why.

QUESTION 1: What makes a patient difficult?

TAMAR: We’re going to share just some of the many honest and really thoughtful responses we heard during our interviews. They provoked a lot of discussion and emotions for us. To our listeners: we really want to know what here resonates with you and your experiences?

So we started by asking our colleagues “What does the term ‘difficult’ mean to you? What makes a patient difficult?” And the first sort of theme that emerged — this one’s not really going to surprise anyone — was that a difficult patient was one who, for any variety of reasons, just doesn’t agree with the treatment plan or is vocally argumentative. 

Let’s start with Alison Perelman is a fourth year medical student heading to residency in OB/GYN.

Alison Perelman: One as a clerkship student on my medicine rotation who was very fearful of the medical establishment and also had a decent amount of psychiatric comorbidity. Um, that kind of I think obstructed his understanding of what was going on. Um, but I think that this patient, we as a team felt to be very difficult because he would refuse a recommended in her vengeance or agree and then change his mind or a split, um, between the different personalities of the team. And so I think that was different because we felt like the patient himself was a barrier to providing what we felt with the kind of optimal medical care that we could

And difficulties in communication were mentioned over and over again and another example was how tough it can be when cultural backgrounds come into play. So often the cultural differences with our patients can make encounters challenging. But we also interestingly heard from Dr. John Hwang, a hospitalist at Bellevue hospital, about what it’s like to relate to your patients’ cultural background. How seeing yourself in the patient or his family can also be a barrier of sorts, and maybe compromise the ability to be unbiased while providing clinical care. 

John Hwang: This was an, you know, an elderly, uh, Korean man, the very loving family who had just had undergone a, an elective surgery two years earlier and had suffered a terrible series of complications that had basically sent him into a terminal spiral of disability and deterioration and frequent bounce bounce backs between rehabs home and the hospital. I guess my answer to your question is it’s cases in which I feel myself, uh, exhibiting countertransference, um, because, so I’m Korean. Uh, there were a lot of parallels I think between my dad and the patient. I was taken care of between how his family members were reacting in this situation and how I think my family members would react. Um, just themes that resonate with me, you know, guilt, shame, missed opportunities, things like that.

And I was, it’s difficult, number one, because I don’t feel that way with everyone I take care of. And so maybe I just wasn’t prepared to take care of a patient that I guess was so reminiscent of my own family situation. And then I think, you know, your sense of professionalism and objectivity as a doctor it’s, it’s very important that you use it as a shield. 

Let’s change gears just a bit away from difficult communication. Many interviewees  also emphasized that difficult patients are those that lead you to feel somehow an inability or insufficiency or maybe a deficiency to form this ultimate positive therapeutic relationship that would have made everything so smooth. An important distinction we heard recurrently underscored was that difficult patients are rarely truly difficult themselves, but rather the encounters with these patients that we find so tough  — meaning part of what is difficult is that aspects of these encounters bring up hard emotions and force providers to reflect on themselves and their own performances. Dr. Darcy Banco, a PGY1 in internal medicine, described a poignant example of this, specifically in taking care of patients with chronic pain.

Darcy Banco: Something I’ve recognized about myself as a lot of patients who have chronic pain or have pain that is not well managed are really difficult for me to deal with. Like I have like a very visceral reaction sometimes to patients who, who are in pain. I think that’s kind of twofold. One is that we don’t have a lot of good ways to treat pain and medicine. I mean, we can give medications and to a certain extent, but you know, there’s, there’s always tolerance that develops and giving pain medication is never enough. Um, and I think that we don’t have a great way to treat like the suffering that goes along with pain and I don’t feel as equipped to do that in an inpatient setting, um, as I would do maybe in an outpatient setting…

And they’re also very, I don’t want to use demanding because I think that has a derogatory connotation but have a lot of needs, um, and require a lot of attention because they’re in a significant amount of distress. And I don’t always know how to fix that and that’s very draining for me and leaves me very unsatisfied and it leaves them unsatisfied. 

It’s hard to know a patient is frustrated, and it’s just really a bad feeling to feel like the cause of that frustration. In this way, maybe part of what is challenging in difficult encounters is how they threaten our self-conceptions as physicians. They question the strengths we identify in ourselves, such as successfully fostering rapport, or creating a caring atmosphere. As Dr. Milna Rufin, a PGY3 in internal medicine, said:

Milna Rufin: I have always really felt that I can slow people down and get on their level and when I can’t do that, um, it, it can be really hurtful to my sense of myself. Um, and my sense of my ego as a physician and my sense of like who I, who I am and who, what I can bring to the table. Because I always thought of myself as a really good communicator.

A final really meaningful and big takeaway from hearing responses to this question was that these insecurities or the worry about being ineffective, it importantly really spans all levels of  training and practice. Dr. Barbara Porter, an experienced attending in primary care and hospital medicine, described a patient that stuck out to her as especially difficult. This patient, she told us, has multiple medical problems including untreated bipolar disorder, and has presented with physical symptoms of her medical problems, as well as somatization. 

Barbara Porter: She also has some real, real medical problems, serious medical problems. And so, um, so I’m in this constant inner dialogue, uh, as I’m listening to her about is this real, is this not real? And then what is even real mean? … I, there’s a, there’s a loud inner voice critiquing, criticizing the way that I feel about her criticizing the way that I am taking care of her, criticizing, um, yeah. Just thinking that I should, at this point in my career, I should be able to rise above the way I feel when I take care of her. And I, I, I, I haven’t been able to do that.

 

QUESTION 2: We then went on to talk about what it means to find a “good” outcome when working with difficult patients?   

JAFAR: When I was thinking about patients who I struggled with, many times it feels like it boils down to the patient wanting something I can’t give them, or me wanting them to do something they have no interest in doing.  We get to this logistical impasse, where none of our goals are lining up, and the resentments and the frustrations start to pile up–on both sides. I still want the same outcomes for these patients, but surviving these encounters has meant adjusting  my expectations about the aspects of care that usually give me pride or joy in my work.  

So we asked the question:  what do we actually work for when our normal markers of success can’t be attained? How do we reconcile and transform this disappointment into opportunity?  

We spoke with Dr. Dave Ellenberg, a critical care fellow, and he explains how he finds fulfillment even in just the process of working of patients and uncovering the roots of their struggles

Dave Ellenberg: 

Almost everyone we spoke with felt disappointed by the limits they faced trying to develop a therapeutic relationship.  But many of them felt that by adjusting their expectations, they found manageable goals that made these encounters satisfying, whether it was just getting that patient to show up for a clinic appointment, or stay engaged with care, even when they didn’t accept most of what was being offered.  I gotta bring it back to that person in front of me, and think about them in terms of where they’re at in the stages of changes, and that reminds me of where to keep my aims. It’s just about getting them grounded in the basics. Dr. Matt Kladney, a primary care attending, reflected on his time working with the homeless in San Francisco: 

Matt Kladney: I worked in the, uh, for the Department of Public Health in San Francisco doing homeless outreach, um, and advocacy worked. And one of the docs were actually one of the nurses there. Um, her whole lesson to me was that your goals completely changed when you’re working with, with different populations and her whole goal, she did primarily HIV care for homeless individuals in, in San Francisco. And her whole thing was you just got to get them to come back. That was for her, that was a win, not prescribing the medicine, not getting lab work. Her whole thing was you just got to come back and creating a space that is a place where these people whose lives are incredibly complex and incredibly chaotic can come back. And her whole thing was if we do that, eventually we can get what is considered a traditional wind, which is eventually getting them to a, eventually getting them to engage in care and then eventually get into this, start taking HAART and then eventually getting them to have a low viral load.

This idea of managing our expectations as providers is an important one, and one that should have probably been more obvious to me, since I’m frequently trying to manage the expectations that patients have when they’re dealing with serious illnesses.  Patients get frustrated with being sick, and they reflect this anger back on me as their doctor, and then I hit them back with the label of the “difficult patient” almost as some kind of retaliation. Look, it’s unrealistic for me to believe that people will be happy with everything I’m telling them, and sometimes being in the line of fire as a doctor, I should actually expect to feel some collateral damage from patients struggling to come to terms with their illness.  A lot of what we tell people is sad, and some people just react to sadness with anger or by becoming combative with the treatment plan, which I see as their attempt at controlling the uncontrollable.   When things start breaking down, it’s helpful to take a full stop and try to reorient the conversation on the things that matter to that person in front of you, not only to diffuse things, but to understand that person better.

In this quote, Dr. Darcy Banco comes back to explain her process of seeking out her patient’s definition of a “good outcome”:

Darcy Banco:  I think, um, like in an ideal world, like what I always liked to talk to my patients about, particularly in the outpatient setting and like what I’m getting someone ready for discharge is, you know, what, what are the things you like to do before you either came into this officer came into the hospital or had this medical problem, what were you able to do? And like how is this illness affected you? And like, what’s my role in getting them back to where there used to be? Can they get back to where they used to be? If so, how? And if they can’t, how do I manage those expectations?

Ultimately, this idea of coming down from OUR strict definitions of health, to what health means for this particular person, reminds me what it means to have respect for their dignity as individuals.  It takes flexibility on our part, and a willingness to take on another perspective when that person can’t see ours as their healthcare provider. I had one attending who talked about this as “sitting down in the dirt” next to the patient.  Maybe just listening to them is all we can do for that moment, and maybe that’s all we have to do. In any case, it’s been helpful to me to be reminded that even when things don’t turn out the way I would have hoped, there’s always something meaningful to be found in just the act of offering ourselves to others.

Dr. Collen Farrell, a second-year internal medicine resident at NYU, shared her story of the “Homeless Jesus”, and it really resonated with me when I was reflecting on what it means to live a life of service to others — especially to those like our difficult patients that most people would simply write off: 

Colleen Farrell: To be totally honest, being able to care for patients that are so-called difficult. Um, for me as a really spiritual question, um, if I was raised Catholic, I don’t particularly identify with Catholicism, but they’re like, the stories of Christianity are very much part of my formation as a person. And in college, I read this article about this statue outside of church that was called homeless Jesus…..

This church had basically this statue outside of it, of a park bench with somebody sleeping on it who looked like a homeless person. And I don’t know if there’s something about the statue that identified it as Jesus or it was just named homeless Jesus. But it was for me really provocative, this idea that like Jesus would be someone who was an undocumented immigrant and migrant and asylum seeker. 

And so when I see our homeless patients, I see people who are using substances and struggling with addiction. I see people that society has neglected in so many ways and I remember that statue and like I have a very strong sense of that everyone is a child of God and that it’s my job to serve them and that like Jesus would clean people’s feet and like that’s a really beautiful thing to do and you don’t do it for gratitude but you do it because it’s compassionate and dignifying. And I think it dignifies even myself as a human being to say that like nobody, there’s nobody who’s not worthy of love.

For me, the spiritual aspects of medicine have come out most in my time working with dying patients and their families.  These are also the times, unfortunately, when I’ve seen the worst breakdowns of communication and relationship between doctors and patients or their families, and we all have probably been around the “difficult family member” or struggled with a patient who just doesn’t get how sick they are — and their lack of acceptance comes out as distrust for their providers and breeds all kinds of friction.  In most of these cases, we as doctors know we don’t have any real control of what’s happening to the patient  Dr. Barbara Porter comes back to describe how we can find satisfaction just in helping people come to terms with all kinds of illnesses.  People may not accept our treatments, they may be angry at us, at themselves, with the universe or fate, but maybe over time we can help them get to a new and more peaceful understanding of their disease:

Barbara Porter: I think I’m at the point in my career where I know that it’s funny, like I have a secret and that’s that every one of my patients is going to die, you know, and I’m, and I’m very accepting of that. That’s going to be her outcome. And my hope for her, the good outcome for her would be that her level of, uh, distress decreases before she dies. She’s clearly got 10 or 15 years left in her life and whether I’ll be with her during those times, I don’t really know. But I, you know, the good outcome would be for her level of distress to decrease before she, before she leaves. So,it’s funny, like when I think of good outcomes, it’s really about the patient’s relationship to their pathology more than anything else. It’s less their pathology then their relationship to their pathology, if that makes sense.

The bottom line with finding good outcomes for difficult patients is that it’s all a matter of compromise.  It can be really, really frustrating. Sometimes it just plain sucks. It sucks being yelled at, being underappreciated, or made to feel like a bad doctor.  But it’s not about who’s right or who’s being difficult in a situation, but how to move forward. It’s about staying curious and open to different perspectives on success, trying to meet and accept patients where they’re at, to find compassion with the fact that they’re struggling to find control when they’re sick, and finding gratitude in the simple act of being there for another person.   And when you’re stuck with a bad outcome, it’s about how to attend to the relationships in the patient’s life–even with themselves.

QUESTION 3: What have you learned from your difficult patients?

TAMAR: For our last question, we asked what our interviewees felt they learned from patients or patient encounters that were “difficult”.

Some spoke about developing a slightly better understanding for the reason conflicts or tense situations come up. Let’s go back to Dr. Milna Rufin:

Milna Rufin: Had this very difficult situation where it was actually not even a difficult patient so much as it was a difficult family encounter. Um, and we had this amazing woman who was an amazing advocate for her husband who is, um, who is a patient who couldn’t really speak on his own. He had a lot of deficits from having had a stroke and she, um, she just really was worried about him at some point being transferred his care to another facility where, um, she was just worried about having enough suctioning for him, having the right kind of care that’s going to keep him outside of the hospital and keep them healthy. Um, and she kind of came in guns blazing when she found out that he was going to be moved to another facility and I had to find a way to kind of diffuse the situation, but also like not just, not just so that we could just discharge them. So that we could be happy with a discharge, but also so that I could get a sense of why she was so scared for him to leave. Like, so, you know, the first thing I did when I sat down and I was like, I just want to know what your perspective is and what do you know, what’s going on with him so far and like what makes you concerned about the next steps? Like what do you think the next steps are and what makes you concerned about them? And we talked for like an hour and at the end we were able to hug and all the nurses were actually very surprised because all of the interactions previous to that with other providers she’d been very gruff about. But I don’t think that anybody just let her express her goals for him, you know, um, and what she thought his goals were. And I think it just takes, for some people it just takes time

I love Dr. Rufin’s story, how listening diffused the situation. But in thinking about “difficult” encounters, it’s also important to say that unfortunately things don’t always resolve quite this way, you know, with a happy ending. And it’s frustrating to admit, but also true, we want to be real about this, that even when we try our hardest, with great listening and open communication, it just doesn’t always end with coming to a common ground, and there’s still often frustration on both sides.

On that very positive note, let’s turn to the whole use of the label “difficult”. I’m sure many of you listening have thought about this, as did many of our interviewees, they questioned using this label, realizing that it can sometimes say more about us as the medical establishment, than about a patient or his behavior. As put by Dr. Colleen Farrell:

Colleen Farrell: I think I’ve learned that medicine is really controlling. Like we expect sort of bizarre behavior from our patients like in both the inpatient and outpatient world, like the kinds of stuff that can get somebody labeled as a difficult patient. It doesn’t really take much like it can take like raising one’s voice, asking about side effects of a medication. Wanting to see additional specialists, not taking a med for whatever reason. I mean usually it takes more than that, but I’ve just heard in our medical culture that were tossed around or that vibe tossed around so loosely. I think it’s the fact that we use that term and talk about patients and then that way is more revealing of medical culture. Then the patients themselves.

And this doesn’t take away from the fact that many interactions are in fact strained, that difficulty, that frustration, it’s there and is real, but it does maybe show how concrete these labels can sometimes wrongly be, a thought that Dr. Rufin also discussed:

Milna Rufin: One thing I learned about difficult patients to is that somebody can be labeled as one and then you walk into the room and they’re actually like quite lovely and you have to really remove that from your mind that this person is difficult. Like has, because everyday is different and your moods are able to shift and um, and patients are allowed to be angry one day and be totally nice the next day and it’s kind of, it’s kind of sad when like this person is labeled as a difficult patient, you know, because then it kind of clouds where other providers are going to do when they walk in that room.

Difficult patients or interactions teach us about ourselves as individual providers, what triggers us, upsets us, why countertransferance so naturally arises, and how to develop more realistic expectations. As Dr. Darcy Banco says: 

Darcy Banco: They’ve certainly taught me a lot of patients too and like just knowing when I need to maybe take a step back or take a deep breath and like check my own emotions before responding. Um, because they, patients can bring up some real, like visceral emotions sometimes. And I think just being cognizant of those and being aware and yet either taking a moment to yourself or  redirecting or just figuring out strategies for how to manage that so you can kind of get closer like the doctor that we all aspire to be, but you know, every encounter isn’t perfect. And just learning how to ebb and flow with those, um, encounters I think is something that I’ve, I’ve learned from them is like patience with them and also like patience with myself.

And finally, we’ll turn back to Dr. Colleen Farrell on how quote-unquote difficult patients force us to re-examine our assumptions, the goals we set, and our notions of a good outcome:

Colleen Farrell: I think I’ve had to learn to recognize what I’m trying to get out of patient encounters for myself and kind of check that I think in med school. So in medical school and my internal medicine rotation, I took care of a patient who had endocarditis. Um, she used IV drugs and I was like so excited to take care of this patient because it’s like, oh my gosh, like this is my chance to care for somebody from this vulnerable in society and I can really help her. And then like our interactions did not go well and she like screamed at me and then I was like so hurt by this. And the whole team was like, oh, she should never have treated you that way. And like, I was wounded by this. And I think like I get why it hurt, but it, it’s taken me a long time to realize like it was never about me. And like I was going into this interaction with probably a bit of a savior complex that like, I was going to be this like profoundly compassionate and empathic medical student who sat with her and understood why she use drugs and we would form this deep bond and the whole team would see how much I cared about her. But like looking back, like I went about it all wrong…

….And I think the more I’ve realized, like you really just need to listen to patients and belief them a bit more. Like, I think, I think if I had recognized that this patient in a medical school was yelling at me, not, not maybe because of me per se, but because of all the other stuff she was dealing with and I had just made space for those emotions and given her space to express them, like something else could have happened. But instead I was in this place where I took it really personally, and I get why I did. But I also see now that like I had a lot to sort through and I think I was in a, a mindset of I want to help her even I want to fix her rather than I’m here to listen to her and serve her, not serve her as in like the sense of like be her servant, but to be present and compassionate towards her, um, and not make it about me.

CONCLUSION

MARGOT: I wanted to round out by revisiting the story of the patient I mentioned at the beginning. I was rotating through the emergency department, and was working at 4 am one night when my patient came back – again, with a distended abdomen; again, with tremors from alcohol withdrawal, again with somnolence and subjective fevers. I was surprised not that he was back but that he recognized me. He’s seen so many providers, and honestly I never thought his eyes were open enough for him to actually see me. As I eased the paracentesis needle into his abdomen, he thanked me for the care that I’d provided him last time. He told me – “You doctors work so hard. I really appreciate everything you’ve done for me.”

I was struck by his story, and I wanted to share his story, not because it ends so neatly, not because he thanked me. I think the reason he taught me so much as a patient because it kind of highlighted a few things that have really hit home for me. I was trying to figure out what it was that we were doing for this patient – because he didn’t want to go to a shelter, he didn’t want to go to a shelter, and like I mentioned before that was effectively making all of our medical care temporary – and some would say, ineffective. So I kept asking myself, what are we doing for this patient, what are we doing for this patient. And when he came back, I realized that what we were doing was treating him with respect. I realized when he came back through the emergency room that there’s a reason that he keeps coming back. There are so many hospitals in the city – he could go to any of them – but he keeps coming back to us, he keeps coming back here. He keeps coming back here despite the fact that we keep messing with his methadone dose, and we’re titrating down off the benzos, which he really doesn’t like, but he keeps coming back. Patients living on the streets are up against so much, and one of the things they’re up against is the threat to their humanity. You know, people walk by, no one is paying attention to them. And I’m just glad that this patient had somewhere he could come to where he felt respected. Where he feels human.

I wanted to wrap up with a few thoughts. I want to start off by thanking everyone I interviewed for talking with me so honestly about a challenging topic. People shared evocative stories and discussed thoughts and emotions that they weren’t always proud to have, and I think that this vulnerability is an important step towards letting us all come to a better understanding of these challenging issues. These conversations have stuck with me in a very enduring way, and my hope is you as listeners feel empowered to have these conversations too.

I also want to tell you what I’ve learned. I have a sense, from my short time thus far in residency, that when I talk about what gives me meaning in my work, it would be disingenuous to ignore the parts of my work that I find really difficult. My kneejerk reaction when I think about what gives me meaning is the positive stuff – the good relationships I have with my patients, or the instances of diagnostic decision making I’ve been proud of, or attention to detail that makes a patient’s hospital stay better, and addressing the psychosomatic aspects of their care. And those are all really positive things, things that bring me a lot of pride in my work.

But I’ve also found that what has changed me the most as a person, and what I’ve learned the most from, has been conflict, and the parts of my work that I find emotionally or intellectually difficult. I’ve learned how to be more empathetic from some of my patients who were initially really antagonistic, or rude – then all of the sudden they’ll have this break and they’ll open up about the problems they’re going through that make them act out against me and their other providers. I’ve learned so much about the social problems that plague our patients and society by, for example, trying to discharge a patient who is homeless and has nowhere to go and no way of taking the medicines they need to take to take care of their chronic health conditions. And I’ve learned so much about myself also, from the way that I respond to, and react to, these conflicts. And I personally feel as though it’s made me a better person with others in my life. It’s made me a lot more understanding of the adversity that my friends go through, and it’s given me a much better sense of how to be a good listener to them, how to support them, and how to just be there for them because sometimes I don’t know how to solve their problems, and some problems just aren’t solvable. I hope you enjoyed listening, and I hope you’ll come away with this maybe – maybe with the sense that your “difficult” patients are just as much a part of the journey as the easy ones.

Thank you to:

Audio Editor: Julia Skubisz

Illustration: Dr. Michael Shen

Endless Technical Support: Harit Shah

Music composer: Peter Mark Kendall and Gabriel Stern of Hickory Collective from Hickory Collective 

Mentorship of Dr. Margot Hedlin: The Rudin Fellowship in Medical Ethics and Humanities at New York University School of Medicine

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