Briana Buckner, MD, is a 2015-16 Chief Resident in Internal Medicine at the University of Pennsylvania in Philadelphia.
“Be careful. He’s violent.” That was the way sign out began for Mr. T. The intern continued, “He has been in the hospital forever because he was kicked out of his nursing home. Good luck. And, oh yeah… he’s blind.” Puzzled, I looked at my list of patients and, not sure whether I should write “violent” by this patient’s name, I decided instead to write “blind.” I paused. The intern said, “Don’t worry, he hit someone with his cane. When you enter his room, just keep your eye on the cane.”
The next morning, as I approached the room, I was nervous and unsure of what to expect. When I knocked on the door I was greeted sharply with a bit of a grunt and a quick “Is that my breakfast tray?” I quickly responded ‘no’ and that I was the new doctor on the team. Knowing that a hungry patient can be tricky to warm up, I decided to sit down first. I found a very tall African American man sitting near the window, listening to the radio. Mr. T appeared much older than his stated age, and he wore a spirit of fatigue that was heavy and ominous. I could also sense his strong feelings of distrust, which I often see in African American patients, but his inability to see his surroundings presented an even higher barrier for me to climb.
During my first two days of taking care of Mr. T, I didn’t examine him. I just sat there with him. Shamefully telling my attending on both days that the patient was on his way to dialysis when asked why I was unable to examine him. I knew he felt violated and distrustful, so I wanted to wait for him to trust me. First, I started with asking about the music he enjoyed, since he was always listening to the radio. Through his love of music, I begin to learn about his life. I found out that he grew up in the foster care system, that he had been homeless for a year, and that, at the young age of 40, he lost his vision due to diabetes.
While getting to know Mr. T, I also began to learn the dynamics of the unit. Mr. T had been labeled as violent and there was no turning back. The nurses didn’t take to Mr. T, and he didn’t like the nurses. The doctors stayed away from his room and only entered with a quick hello in the early morning during rounds. The most striking thing I observed was how people would talk about Mr. T very loudly near his room and as he walked the halls, as if he were both deaf and blind. The nursing assistants would say loudly, “I had Mr. T yesterday, I want a different patient today.” The phlebotomists would ask the nurse next to his open door, “Is this the blind man? Do you think he will let me get his blood today?” I often would get a frantic call to Mr. T’s room to find him in a yelling match with a team member about his food tray and why his breakfast never came before dialysis. At first, I didn’t understand: This was not the gentle Mr. T that I knew from our afternoon chats. But then, I realized that it was.
I realized that Mr. T’s greatest problem was that he didn’t feel in control. He could not see, he was in unfamiliar surroundings, and his housing security had disappeared abruptly. One day, after I was able to calm him down from yet another shouting match with food services, I finally asked him, “Mr. T, why are you so angry today?” He said to me, “I hear how y’all talk about me around here. These people come in my room with an attitude and an opinion of me before they even meet me. And y’all wonder why I’m so angry. I just want to be able to get my breakfast before I go to dialysis. I come back 4 hours later, hungry and tired. Don’t you get your food when you want it?”
I had no response to make. Although I did not know all of the background about what had caused his displacement, I knew we were failing him. Failing him as a team, as a unit, and as a healthcare system. I also questioned how we formed our opinion of him in the unit. Were most of our opinions and feelings toward him formed before we even met him? Did we let our professionalism level slip as a medical unit because of our biased opinions? Isn’t true professionalism defined by our insignificant daily activities? We were anchored into our opinion of him as violent, similar to how to a doctor can be anchored in a diagnosis of pneumonia. When presented with new information on Mr. T, were we able to reassess our position towards him?
With time, Mr. T begin to mellow out and became less angry about his breakfast. Less because he trusted the staff and more as a sign of defeat because the prospect of him finding a long-term home became dimmer. His fear, which initially was displayed as anger, transitioned more into withdrawal and quiet spirit. Despite this change in spirit, the unit continued to label him as “angry” and, each shift, the nurses and doctors would sign out, “He’s violent. Watch his cane.” Without any mention of his distrust, loss of control, and the effects that his vision impairment had on his interactions with the staff.
Finally, a nurse came up to me and said, “I don’t know how you deal with Mr. T. He seems to only like you.” Frustrated with the stigma surrounding my patient, I wanted to ask everyone on the unit, “Why have we let our professionalism suffer when faced with the demands of a difficult patient?” But I was too exhausted and weathered from the dynamics of the situation. I simply answered, “I’m not sure either.”
Want to comment on Briana’s post? Visit the NEJM Journal Watch Insights in Residency Training blog