A forlorn and needy patient of mine surfaced at the clinic today, after failing to show for bloodwork and an appointment with me last week. Based upon his unannounced arrival and my busy day, I directed him to be triaged as a "walk-in" in the clinic. Later on, the Physician's Assistant who saw and treated him called me into the clinical area for a chat. The patient's primary provider, a Nurse Practitioner with whom I share several other patients, was also present for the conversation.
As I bemoaned my patient's dysunctional patterns and innate ability to fall apart then come crashing into the clinic asking me to save him from himself, the NP looked at me and said, "Keith, every patient here has a story. Unfortunately for you, the ones with the toughest stories are referred to you. Without them, you wouldn't have a job." The PA added, "And that's why you have the hardest job of us all."
I realized that they were right. These stories all add up: AIDS, hepatitis, trauma, incest, abuse, neglect, generational cycles of poverty, diabetes, poor nutrition, class warfare, violence, disenfranshisement, racism, illness upon illness, learned helplessness, substance abuse, homelessness or risk thereof, splintered families, mental illness, lack of education----but how do we calculate their effects? How do we draw the line between individual responsibility and societal/cultural dysfunction? Of course, we wish to hold individuals responsible for their actions. Clearly, people can learn to be responsible, come to appointments, adhere to medical recommendations, choose to step up to the plate. As a white, middle-class American, these are basic expectations and assumptions that I can make of myself and impose on others. I can also judge others by their inability to adhere to my concepts of responsible action. Also, as a human being, I have the right to be annoyed with my patients who fail to plan and take appropriate action, only to look to me as a source of rescue in their time of need.
The secret here is balance. Can I recover from my annoyance, rise above my frustration, and deliver compassionate, high-quality care? Can I see my patients' dysfunction as what it is---symptomatic of so many other visible and invisible factors---and continue to educate, cajole, and empathize? Can I release my guilt over my own judgements and grievances, giving way to that heart-centered place of witnessing the pain of others and working to assuage it as best I can?
My work challenges my ability do just that, and more. Admittedly, some patients are individuals who I avoid at most every turn. I cringe when dialing their number, knowing that I could be opening a Pandora's Box by inviting myself into their painful and dysfunctional world. There are others for whom my tasks are a joy, their communicativeness and ability to be proactive in their own interest inviting me to gladly join them in a symbiotic partnership. For those who actively help themselves and meet me half way, joining them on that road is easy, intuitive, a pleasure to be of service.
This rumination is just that---a rumination. Each day is another opportunity, and my all-too- human failings can often shine through as I attempt to tackle the next challenge. I remind myself that my own judgements are not necessarily negative, as long as I can acknowledge them for what they are, and then move beyond them. Some days are easier than others, and empathy can wax and wane, as can any emotion. I do this work because I love it, because I have something to give, and the self-knowledge which is born of it is worth its weight in gold. Each day I offer what I can, and then move on, hoping that each day's learning will inform my subsequent life experiences. At the end of this challenging day, I close the proverbial book and welcome the forgiving embrace of sleep.