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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