A Clinical Conundrum

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Have you ever found yourself in a sticky situation with a patient? Of course you have; we all have. I recently found myself locked into an awkward moment with a patient during my FNP clinical rotation, unsure of how to proceed. I had to navigate around the issue of divulging personal information and I was unprepared. Do I share my own story with her? Do I hold back and hope that she can find commiseration someplace else? What do you do when you get shoved into these tenuous situations with patients? I don’t think there’s one right answer. It’s not black or white; it’s not a clear divide drawn in Sharpie, although we all wish it would be that easy. No, it’s simply a blurry, gray pencil line that leaves smudges all over you no matter which direction you go with it.

When I was young, unmarried, and working in the ICU I had my fair share of sticky situations, most of them surrounding requests for my phone number. A grandfather patient asking on behalf of his couch-potato grandson (yeah, that sounds promising) or creepy older guys who think it’s funny to make jokes about nurses giving bed baths (let me go find our two hundred pound male nurse and he’ll help you). People get delirious sometimes; they make statements or assumptions that are inappropriate because they’re on narcotics or recovering from head injuries. So, to some extent, you can easily forgive them their verbal fumbles.

Now that I’m a bit older and in the outpatient environment I don’t encounter those invitations as much anymore (probably thanks to that ring on my finger) but I still have awkward moments with patients, mostly around revealing information about my personal life. It’s a fine line that creeps up from time to time and I found I wasn’t trained for it.  Nobody tells you in school how you should act or react to personal questions, probably because it varies with each patient and situation. Sometimes you develop a relationship with a patient and voluntarily want to share more intimate aspects of your life. Stories about your kids, details of your recent vacation with your husband. In these cases, those topics come up naturally and since you both recognize the inherent formality to the relationship, you feel free to share personal tidbits and look forward to seeing that patient again in three months.

Other times patients press, wanting to feel like they know you, searching to get some need met from your relationship that falls outside the boundaries of professionalism. These needs can be obvious or complex. They want to be best friends or they want to manipulate or they’re desperate for attention. They have good intentions but it comes out wrong. They feel like they can’t talk to anyone else in their life so they completely unload on you. These conversations sometimes leave you feeling unnerved and you know that this patient isn’t capable of putting in appropriate stops in your relationship right now. But not every case is clear cut. It gets sticky. And if you actually talk to your patients when they’re on the exam table, you’ll surely encounter this problem at some point. You have to learn to straddle the amorphous line between being a healthcare provider and a friend, a listening ear and a professional.

To be fair, the inverse can be true. Sometimes healthcare providers are searching to get a need met from a patient- approval, attention, friendship- and it can make the patient uncomfortable. In short, the door can swing both ways.

I’ll share my recent example. One day we had a middle-aged woman with autoimmune complaints come into our clinic, so exhausted she could barely sit up in the chair. I had never met her before so I went into the room prior to my physician and talked with her about her chief complaint, did a focused history and performed a physical assessment. From the instant I saw her, my heart hurt for her. Between bouts of crying, with mascara staining her cheeks, she related the events of the past few months- how she had gotten sick out of nowhere, how she couldn’t get out of bed to go to work, how she felt useless to her family. She described a whole host of physical symptoms- fatigue, joint pain, and an inability to eat- and I knew how she felt. It was all too familiar. It was like listening to myself talk years ago when I went to the doctor’s office, desperate for help.

What this patient didn’t know is that I had been diagnosed with an autoimmune disease eight years prior and had struggled along the roller coaster of a relapsing-remitting condition ever since then. I knew what it felt like to be so tired that you can’t even get up and take a shower. I knew the physical symptoms that come from having an autoimmune disease. I knew how depressing it is to feel worthless, useless, permanently glued to your couch and addicted to prednisone.

She was understandably angry. Life had dealt her a harsh hand and she wasn’t coping with it well. She was bitter and hurt and experiencing all the emotions you would expect to feel if you were confronted with a life-long disease that you didn’t ask for and didn’t expect. As I gently asked more questions, she grew more and more hostile. She was taking out months of frustration on me and I couldn’t blame her for it. The conversation culminated when I said, “I know how you feel,” and she shot back sarcastically, “really? Do you know what it’s like to have an autoimmune disease?”

Ha, if she only knew. And I immediately started to feel conflicted. Do I share with her that I have a similar condition? Is it appropriate to commiserate that way? Would it make her feel better or make her feel like I was invalidating her feelings? I had no idea what to say and all the words stuck in my throat as I sat paralyzed in indecision.

Without knowing the right answer I blurted out, “actually I do. I have a similar autoimmune disease and I know how you feel. I’m so sorry you’re going through this.”

And the woman broke. Before I knew what was happening, she was bawling, telling me how hard things have been and expressing relief at being able to talk to someone who understood. I held her hand; she cried some more. We finished talking through the necessary components of the visit and then she actually smiled. I hadn’t done anything profound besides write a prescription for some prednisone (the best and worst drug in the world). Mostly I had helped her feel like she wasn’t completely alone. Someone else knows how you feel. Someone else can relate. It won’t always be this hard.

Was that the right thing to say? Should I have kept my big mouth shut? I don’t know. In this case, she responded well to my confession. I saw her several more times during my clinical semester and she remembered my name, asked if I was going to be there during her appointment. I gained her trust and while I still tried to keep the focus off of me and not reveal many specific details of my condition, we developed an appropriate, professional, beneficial relationship.

Afterwards, my preceptor and I discussed the situation. He laid out the pros and cons for me like I’m trying to explain it to you. Both extremes of the spectrum- sharing too much or not relating to your patients at all- can be detrimental. You’re a human being too and your patients should know that. You have a life, a family, your own issues. But you need to be self-aware enough to know when you’re searching to get a need met from a patient relationship. You need to be able to stay professional. In the end, he thought I had made the right call and I let out a huge sigh of relief.

There were other times during the semester when I had patients with similar complaints and I didn’t share my personal experience. Why not? I have no idea. I guess I just listened to that voice in my gut that whispered yes or no, and I went with it. Call it clinical intuition. Call it timidity. Call it whatever you want- you know what I’m talking about.

This topic of divulging personal information with patients is complicated and I make no claims to have it down. I’m not even suggesting approaching the issue from one side of the spectrum or the other- simply relating my own experience. I know I will have to continue to navigate these blurry lines for the rest of my career because I want my patients to know that I care. But I also want them to know that I’m competent and professional, someone they can trust with their life and sensitive information.

We all find ourselves in sticky situations every now and then because medicine is tricky business. Dealing with people is tricky business. We’ve all regretted saying or not saying something to a patient. And we all will have to find our own way of managing the tightrope of professionalism and friendship. It’s blurry; it’s difficult. We all walk around with smudges on our cheeks. But for the sake of our patients and ourselves, I believe it is a line worth walking.

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A Collector of Stories, a Reader of People.

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Everyone who sits in the chair or lies on the bed is there to tell a story.

Some stories start with a misadventure- a careless turn taken on an abandoned road or a flailing, drunken mouth at a local bar or a pop that came out of nowhere, annoyingly enough, and is now here to stay. Some are more memorable than others- breaking a bottle of Tequila on your foot for reasons that no one can quite figure out- and some are less romantic like a contagious illness acquired from a sick kid or a bland case of persistent indigestion. Despite the circumstances, the patient still ends up in the office, led to your chair by an element of surprise. Very few people come to the doctor’s office willingly, on a good day. Usually there are wrinkles in the story. Something has to change the direction of the plot and that is the reason for same-day appointments, plain and simple.

Other stories are more despondent, predictable, birthed from the same relentless situation of getting old. Cartilage does not rejuvenate itself; knees do not grow on trees (as much as the orthopedist might want you to believe otherwise) and people are not getting any younger. No, they are not, they are definitely not. No one can cure inevitable decay, just delay it as long as your insurance will allow, and many stories are repetitions. Slight deviations from the usual, symptom-riddled routine. Tentatively turning the page of a book that may snap shut any moment.

Regardless of the reason for the visit, there is always more to be discovered in the story. Always more details and more complications and other diseases waiting to emerge on a routine set of labs. There’s always more because people are vast and endless, full of the unexpected. People are the most complicated subjects in the world and I get the pleasure of trying to decipher them. To learn to read them.

There is always more to the story.

So what is my job? To find out the particulars of the story. How do I do this? By asking questions. By gaining facts, collecting them in my mind like a child gathering polished stones. At first glance it seems formulaic and in many ways, it is. These formulas are exactly what is taught to all the students who have degrees that enable them to ask such questions. What brings you in today? When did that start? How long has that been going on? Occasionally, you’re allowed to ask a question like How do you feel? but even that is too esoteric for everyday use, a special indulgence reserved for an open afternoon on a boring day. Most of the time it’s a fact-finding mission. Does it hurt a little or a lot? Is it acute or chronic? Can you walk on it? Has this ever happened before? The questions are the title page, the introduction, the scattered highlighted portions that catch your attention as you skim through the chapters. These are the facts.

Some people only tell the bare minimum while others, let’s be honest, tell far too much. Sometimes you’ve already done a full assessment, ordered all the appropriate labs and medications, written the discharge summary and the patient is still telling you unnecessary details, much to your chagrin. That’s where practice comes in- being able to to navigate to the right details, ask the right questions, make people feel like their story has been heard, and still get them out then door feeling satisfied with the plan. You become a narrator, guiding them towards a path you think is the best course of action or leading them away from a more deleterious one, from those singed, cigarette-smelling pages at the end. Sometimes your efforts work and everyone leaves happy and on time. Sometimes you spend the rest of the afternoon frantically trying to catch up. And in almost every circumstance, the extra time is worth it because certain people need a little extra listening, to know that their story is weighty and unique and significant. They need to know that their story matters, even to you.

The real down-in-the-dirt interesting part comes when people won’t tell you some vital detail of the story, something that you know may change the crux of the plot and the direction of your diagnosis. These questions are trickier and consist of types like: How many beers do you drink per night? Would you like to be tested for sexually transmitted infections? Have you ever thought of harming yourself? I try to be an unobtrusive as possible by explaining that I ask everyone these questions and I don’t judge; I just need to know the truth. It’s even more fascinating to watch someone unweave a tale they just told you, realizing that they’ve gotten themselves in too deep. The wiggling in the chair, the lame excuses, the backtracking that has no end. Don’t get me wrong- I’m not trying to catch anyone in a lie- but those things have a way of rising to the surface when the patient is lying naked with a hospital gown on, even without my questioning. A nakedness of the soul, if you want to think of it that way.

Some people think they’re lying successfully but it’s almost always painfully obvious that you drink more than one beer a night or that you haven’t been checking your blood sugars, especially because I’ve become accustomed to patients lying to me from years of being in healthcare. (And even if I miss the deception, labs are always unsympathetically honest). People will try almost anything to get away from shame and sometimes you have to leave the visit in the discomfort that there are pages that the patient simply will not allow you to see and you must do your best despite that reality. It’s unfortunate but I cannot force my way into a story that I’m not invited to read.

It’s even more invigorating to watch someone divulge those details to you willing after you’ve established some trust. They recognize that you have to see all the pages, like an editor who must know every upcoming plot twist, and that they will ultimately suffer if they hide sections from you. They tell you their story; they let you in. They admit things that even their spouse doesn’t know, emotions that they’ve locked away, memories that made them who they are today. It’s a humbling experience, reverent almost, and you don’t forget those visits easily. Those are the lines that you memorize and hold close to your heart, the pages you reread on the days when you wonder if you’ve gotten into the right profession.

And then it doesn’t just stay their story- you enter in. You become a character and establish yourself in a scene, as a life-altering influence who informs them of a cancer diagnosis or a reoccurring character who resurfaces every so often to fix a smudge or wipe some tears and then recedes into the background until needed further. My story blends with theirs, just for a twenty minute appointment, and suddenly we have shared memories, communal pages. That is the true magic of medicine, the part that I fell in love with a long time ago. It’s the part that keeps it all so darn interesting and keeps me wanting to go back and read more. I am a collector of stories. I am a reader of people.

People never get tired of telling their stories and I hope I never get tired of hearing them, of turning pages that always end up surprising me. I am in love with the narratives of the people who wander in to see me. I am infatuated with being a part of a bigger story than my own. I am a nurse practitioner (or at least well on my way to being there) and a storyteller at heart.

And, strangely enough, I have figured out that those are really the same thing.