I will be leaving my current practice in a couple months and starting work at a different clinic in a different city. This type of transition really brings to light how much I had really gotten to know patients on a personal level. This became surprisingly clear not too long ago.

One day, I saw a patient on my schedule that had historically required more of my emotional energy. We often have patients like this. It is the nature of our job (unless we are anesthesiologists or radiologists). Let me tell you about this particular patient.

Our relationship started simply enough a few years ago. He was middle-aged, healthy, and on just one medication for a relatively simple medical issue. He would come in yearly and get this refilled for a whole year. He was happy-go-lucky, it seemed. Unfortunately for him, he inherited me as his doctor when his prior PCP relocated. I ordered some overdue screening labs that led to a cascade of other events. Now, thanks, to me, he is on multiple medications. He told me this outright, by the way – that things were essentially better before I took over his care.

At every appointment I would find something else wrong, something else that needed tweaking. The condition that he has is relatively “silent” so, to him, I was just pumping him with drugs for no reason. I had turned his world upside down.  At every visit I dreaded having to tell him that he should be on another medication or that a lab was abnormal. I began to feel that I was perhaps overwhelming him, so I started to pick just one thing at a time to reveal to him.  Every time he saw me, I felt he disliked being in that exam room with me, listening me telling him to do this or that. That translated into hesitancy on my part.

Through all this, though, I tried to listen to him and to engage him in decision-making. I tried my best to educate him on why every step was being taken. I would always ask how he felt about this or that particular approach, but he seemed to just begrudgingly go on with treatments.

There was one particular day I was sure he was going to be done with me as his physician. I had sent him via ambulance to the ER when his labs came back showing an elevated potassium level (I checked it twice to be sure) and an abnormal EKG. He didn’t have any symptoms, but I feared a cardiac event could occur. The ER doctor, having had the opportunity to see that the potassium level returned to normal on the 3^rd check in his lab, suggested to the patient that I had overreacted. This set the patient off. He came back and basically laid into me. He vented and vented. I could only listen in silence. At the end, I addressed all his questions. I know with my knowledge of medicine AND with my gut that I had done the right thing for the patient. Any good physician would have done the same. But I empathized with him and gave him the option of seeing another doctor within our group. I was sure I wouldn’t see him again.

A few months later, he was in my schedule.  And he kept coming back. I didn’t understand why. But I continued with business as usual, trying my best to manage his illnesses without getting to the point of overwhelming or frustrating him, the discontent from that prior incident still very clearly in my memory.

It was business as usual, that is, until the last time I saw him. Two of his major medical conditions were now well-managed. We were getting close on the third. But it was the day I was going to let him know of my relocation. I was certain he would be elated. I had come to believe that he felt he was “stuck” with me.

On the contrary, he admitted that the news was going to make him cry. To be honest, I did not realize he was serious – he tends to like to joke around – but there was a period of silence before the visit ended. “Thanks for putting up with me,” I joked. The nurse that was tending to him after I left the room said that she had “lost him” after I gave him the news. She said that he felt that I was his only doctor, the only one he would listen to.

Sometimes appreciation can feel sparse in a field that is built on trying to fix problems. Sometimes a kind word from a patient can lift us up during a challenging day. I have had many patients who have done just that. But on this particular day, this patient’s silence was the most touching and heartfelt expression of gratitude. I completely misjudged the nature of our relationship. The mere fact that he kept coming back to follow-up with me should perhaps have been a clue, but the confidence I now realize he had in me reminds me why I chose to do primary care. It also taught me that doctors and patients alike should not “give up” on each other hastily. It taught me that fixing every single problem in one visit is not always the answer. The best medicine sometimes involves a careful consideration of a patient’s own “pace” or ability to digest complex information that seems simple and straightforward to us. It taught me that sometimes patients are listening to us, even though it may seem to be the contrary. He taught me a lot that day.

A doctor-patient relationship truly is like no other when it works well.

Linda Pourmassina is an internal medicine physician who blogs at Pulsus.

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