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I was a 3rd year integrated plastic and reconstructive surgery resident rotating for the final time on the general surgery trauma service. It was that special time in surgical residency when you act as senior half the time and junior the other half, forcing you into a disorienting purgatory of occasional near-autonomy interspersed with bouts of inscrutable micromanagement. This day I was a junior, and exhaustion and frustration were peaking.

Upon entering the room and introducing myself, I was lambasted by the most abrasive patient I’d met in my first three years of residency. Now in my sixth year, she remains top 5.

“Dr. WHAT?!” she spat.

“Goldman. Gold…Man. Gold like the precious metal, and you know…a Man.” This was a carefully crafted response to nursing phone calls when probed for verbal orders. It had been curated and vetted by years of countless returned pages and it rarely failed to produce a chuckle. She was not amused.

It remained unclear why the patient asked me to repeat myself since she never called me Dr. Goldman, and thereafter referred to me with a disdainful and contemptuous, “Rosenberg.” I get “Goldstein” and “Goldberg” regularly, but this was unique. I introduced myself to her every single day and every day she called me “Rosenberg,” and, though I’m not a stickler for it, the absent prefix added insult to injury.

I reviewed my list of 30-something patients before entering her room. Next to her HPI, read “AutoPed,” our shorthand for automobile versus pedestrian. The patient was a 36-year-old female admitted for road rash and multiple rib and pelvic fractures. She had incurred her injuries after robbing a convenience store. On the counter of this particular store stood a nearly two-foot, white plastic, barrel-shaped receptacle with slotted duct tape over the round top. The word ‘TIPS’ sloppily adorned its side in faded black permanent marker. I knew the jar well because it, and $37.23, were at her bedside wrapped in a plastic bag along with her other personal effects. I found it odd. The money and jar would later be repossessed by the police.

She had walked into the shop, grabbed the tip jar, and booked it out of the store. She made her escape, hugging the loot, wind in her hair, and adrenaline undoubtedly coursing through her veins. In her hurry, she neglected to assess her surroundings. My parents had always cautioned me as a child, “When fleeing the scene of a crime, ALWAYS look both ways.” As she leapt off the sidewalk, she was promptly hit by a sedan traveling the speed limit (35 mph). The ambulance picked her up ten feet from the convenient store doors. On the trauma service, we called that CARma.

By the time I saw the patient, orthopedic surgery had signed off in standard fashion: “TTWB RLE, pain control, FU outpatient, ortho s/o”. My assigned job as today’s junior would be “pulm toilet and pain control for discharge.” The patient, a chronic pain patient and IV drug abuser, would make the next 7 days miserable. Pain, the fifth vital sign, would tether her to the hospital. She had weaponized it and would expertly wield it against everyone standing between her and a push of Dilaudid, Ativan, and Benadryl. On her hospital day 5 (my hospital day 928), the floor pager received 27 calls. She represented approximately 3% of our patient list and accounted for >50% of pages. I saw her for every call. When it wasn’t pain, it was the poor quality of the food, the unavailability of a certain cola brand (per her, the generic was “disgusting”), and the lack of attention by nurses I knew to be competent and compassionate.

Each complaint began with the same condescending, nasty-toned, “Look, Rosenberg…”. I could feel my patience waning along with the last bastions of my sanity.

After 14 hours on in-house call, I triumphantly walked out the hospital doors toward freedom, microwaved food, a gym, and maybe even a bathroom break. As I looked both ways to cross the street to my car, my personal pager alarmed. I visited her one last time. The patient was unabashedly screaming threats of calling “the cops” (who, mind you, would be arresting her shortly), an “ambulance for transport to another hospital” (a private hospital that would not be accepting an uninsured, county patient), and “the channel 3 news” (to, of course, alert other citizens that she was being imprisoned against her will without even the decency to provide her name-brand Sprite).

She again complained about the food and the lack of promptness the nurses showed when she requested her bedpan. My mind raced with thoughts so loud I worried she’d hear them, “Ya?!, Well I haven’t eaten today! In fact, I’ve only ‘eaten’ stale, beef-jerky flavored coffee and I’m grateful for that. And though it ran through me, I haven’t had a single second to urinate. What I’d do for a bedpan.” She threatened to leave AMA, threats I assumed were empty since physical therapy’s note stated that the patient could not walk on her own. I calmly let the patient know that I would call the ODA and the Patient Advocate to address her concerns. As I left the room, she hysterically let me know that she would be telling the news about me as well, and once more, she demanded my name…

It happened. At that moment, I hated her. For the first time in my life, I hated a patient. And I wondered if I would hate every patient for the rest of my short, hate-filled career. I turned and started toward the door and, as I walked away, cool as Walter White I replied…

“My name?…(I paused for dramatic effect) It’s Rosenberg.” I walked to the nurses’ desk, wrote some orders, made some phone calls, and went home.

It didn’t matter that she was an addict. I hated her. It didn’t matter that she was in pain. I hated her. It didn’t matter that she had a very pleasant teenage son who constantly apologized for her behavior. I felt bad for him, I did. But I hated her. It didn’t matter that maybe her parents never taught her to look both ways, or maybe she didn’t even know her parents. I hated her.

Recovering from the patient, once discharged, took a few days. The previous, not-so-long-forgotten me, the empathetic medical student who went into healthcare because he “loved science and wanted to help people” felt distant. The clear and ongoing abatement of my own compassion troubled me. I reminded myself what I had learned from reading House of God, “Law #4: The patient is the one with the disease.” But she had made her pain, physical and psychological, mine against my will, and it forced the point that, “Law #8: They can always hurt you more.”

Eventually hate gave way to lesser forms of anger and resentment, which, after significant self-reflection, led to quiescence and eventual epiphany. Samuel Shem wrote new laws 34 years after House of God that included, “Law #15: Learn Empathy.” Most people enter medicine with or as a result of empathy, and the decline throughout medical training is multi-factorial and well-described. It seems that learned knowledge conspires with imposed stoic principles to slowly swap logos for ethos and pathos until little room is left for all three and parts must be sacrificed. For me, the task of re-learning empathy meant shaping it within a new, unexpected paradigm; one based in reality where patients may not be good, or kind, or deserving, or appreciative. I found the work of remaining empathetic is not just in putting myself in another person’s shoes, but also decentralizing my values within the situation.

In This is Water, Dave Foster Wallace characterizes this type of thinking as “not a matter of virtue — it’s a matter of my choosing to do the work of somehow altering or getting free of my natural, hard-wired default-setting, which is to be deeply and literally self-centered, and to see and interpret everything through this lens of self.” He later notes that the “only thing that’s capital-T True is that you get to decide how you’re going to try to see it. You get to consciously decide what has meaning and what doesn’t.” I could or should have chosen to ascribe meaning to the patient’s suffering rather than demeaning it because it negatively affected my day, chosen to see the beauty in her son’s struggle to finish high school while selflessly attempting to take care of his mother, chosen to take pride in doing my best to treat a patient in the face of adversity.

Had I been more in tune with this concept, I could have not just avoided the foreign, uncomfortable feeling of hate and the self-disappointment that accompanied it, but found the entire situation “not only meaningful but sacred.” Per Wallace, “the really important kind of freedom involves attention, and awareness, and discipline, and effort, and being able truly to care about other people and to sacrifice for them, over and over, in myriad petty little unsexy ways, every day.”

True empathy, perhaps especially in the current healthcare environment, is a tool that requires constant sharpening. It requires reflection, consciousness, and plainly put, work. Three years later, I would like to believe that no matter how many pages, ignored introductions, or complaints later, I would exercise the freedom to redirect exhaustion and frustration and reframe their meaning. When she threatened and once again demanded my name, I would turn back around, look her in the eyes, and remind her, cool as Walter White, that my name is Dr. Goldman, and I’m going to continue to do my best to help her.

Joshua J. Goldman, MD is a PGY-6 Plastic and Reconstructive Surgery Resident at the University of Nevada, Las Vegas School of Medicine and is Microsurgery Fellowship-bound. His professional interests outside PRS include healthcare advocacy, device innovation, digital marketing, ethics, medical education, and physician wellness. You can follow him on instagram at @GoldStandardPlasticSurgery. Thanks for reading!

The above represent my experience and viewpoints alone. They are not representative of my institution, program, or hospital. I have no conflicts of interest to disclose. Disclaimer: Details of this article have been altered to maintain patient privacy.