Courtesy and Destiny

“Straightforwardness, without the
rules of propriety, becomes rudeness.”
-Confucius

She was my first patient with rheumatoid arthritis. She had severe disease; by the time that she arrived at my office she had numerous deformities of her hands and she could not walk without help. She had been to every other specialist in town. I was literally the last doctor standing.

As our interview progressed, I realized that I would have my hands full. Every doctor loves a challenge: there is this incredibly energizing rush that I feel when a poor soul who has been in pain for months is transformed into a fully functional and satisfied human being. When the patient in question has seen other doctors who failed to help them, then success places me on top of the world. I do not know how a professional baseball player feels when he is the one responsible for the winning hit, but it cannot be any better than I feel when my patients improve.

So yes, doctors do have a prominent competitive streak not far from the surface. When she told me the names of all of her former doctors, I was eager to take on this challenge. I knew all of these people. When she elaborated on the reasons that she had dismissed them, it became clear that she was the problem, not her disease. She had used every possible excuse to justify being angry with her doctors’ offices. Soon it became clear that she hated everything about her existence. If one could bottle up anger and sell it on the open market, she would have been a millionaire.

Her parents did not love her. Her two former husbands were bums. Her only daughter was self-possessed and never bothered to call. During her working days, all of her bosses were inconsiderate slave drivers. She had no hobbies; she enjoyed nothing. She had developed side effects to every medicine that had been tried to control her illness, and they were too expensive anyway. And the clincher: the government had a cure for arthritis, but they did not want to release it because they were making too much money keeping people sick.

How does the government make money from sick people? You are on disability. You cost them.

The second I said that I realized what a stupid mistake I had made. She gave me an angry look; a sneer of contempt and pity: how could I be so stupid as to not see her point?

“They do.  All those drug companies and the government are in cahoots.”

Now I had this urge to ask her to leave and never come back. But she was obviously in pain, and deformed, and she had nobody else. I swallowed hard.

OK. There is a new medicine. There may be side effects. But I can see that you are smart: you will be able to figure them out before they can harm you.

I noticed that she was listening, something she had not done throughout the interview. I continued.

You are supposed to take eight pills. Every week. But your body is different from anyone else’s, so it may take only six pills to help you. Or it may take nine. You decide.

I looked straight in her eyes. With some satisfaction I could see that I had her hooked. I proceeded to outline the monitoring schedule, of course hastening to add that she could have the blood tests every three weeks instead of two or get them a week early if she felt that her body was doing something unusual. I gave her control; she, in turn, handed it back to me. 

“I will take them for a while,” she added. She went on to say that she would be watching me, and that all deals were off in the blink of an eye if I slipped.

After this visit we got along well. There were a few tiffs with my staff, but as soon as I made it clear that she could be rude to me but not to them she got the point. Her joints improved. Her pain, for the most part, disappeared. Her mood was no longer accusatory. Her long-estranged daughter began to visit her, and to help around the house.

I began to look forward to her visits. My staff could not understand what I saw in her, because she had a stare that could turn mountains into molehills. But I was not intimidated, and she knew it. She began to trust me with her vulnerable points. There were a few times when she admitted to feeling proud about a granddaughter’s achievements. I found out that there were some crafts that she enjoyed.

All good things must come to an end. There was a fall, and a nasty fracture. There was no way that she would be able to care for herself. She could have moved in with her daughter for six weeks; her daughter was willing to try. As we were talking to the social worker to plan for visiting nurses and therapists, she had a meltdown. In an angry, uncompromising tone she set down a set of rules that her daughter’s household would have to comply with if they were to have her as a guest.  None of her demands were reasonable. Her daughter stormed out of the meeting.

Now you’ve done it.

“I don’t care.”

But you do. She is all you have. It is her house or a nursing home.

“Then it will be a nursing home.”

You have no idea what you are saying. You are on pain medicine. You will not get it on time. If you think that your daughter’s rules are stifling, the nursing home will feel like a prison. You will hate it.

“It is only six weeks. I am going to the nursing home.”

Please call your daughter.  I beg you. Tell her that you have changed your mind.

I got the angry look. Within five minutes she signed the nursing home papers. I walked away, almost in tears. I knew what was going to happen.

She left the hospital for the nursing home the next day. I was out of town for a few days. The office was inordinately busy when I got back. She had been in the nursing home for ten days before I had a chance to visit.

I found a wrinkled, sedated, unkempt shell of a woman. Her knees were curled up. So that they seemed to be attached to her chest wall. I could not force them down. She had and early bedsore. She smelled of sweat, urine, and feces.

I looked for the head nurse, to ask for an explanation that I already had figured out. She was a young woman; smart; accomplished; someone who could have had an easier job and made more money elsewhere. She liked old people and she had a ton of patience.

What happened?

She refused to get out of bed from the moment they wheeled her in. She would not participate in therapy. She hated the food and would not eat it. She called for the aides every five minutes. She was rude, mean, and demanding. Within two days the staff learned to avoid coming in the room when she was awake. She frequently complained of pain. The staff was more than willing to sedate her as much as possible.

I called her daughter. She had been mean to her daughter, and her husband, and her two grandchildren. She asked them never to come back. They avoided her.

I walked away from the nursing home, a defeated man.

The bedsores spread. The elbows locked up. By my third visit she did not recognize me. She died within two months.

Courtesy. We have powerful medicine and dedicated staff willing to help. But all of us are human beings; we need that teaspoon of sugar to help us tolerate the enormous demands that sick people place on us.  In every endeavor you are so much more likely to get what you need if you are kind and gentle.

And yet there are so many people like my unfortunate patient! There was one day when she was being so difficult that I could not help myself. In a stern tone of voice, I spoke to her.

You know, I think in your case it was anger that gave you the arthritis. I think that if you could have learned to accept life’s imperfections you would still be healthy.  

To my surprise, she smiled.  

“But then I would not be me.”

I felt like slapping her, real hard. This is what happens when you do your best to treat your patients like family. You have these lapses where you really want to treat them like family. I took a few minutes to calm down. Then I answered her.

I wish you could learn how to get along. There is so much of you that you have missed…