“I remember you,” said Gracie with the look of having found a long-lost friend. “You gave my husband the option to be treated aggressively in the hospital or return home with palliative care. He chose to go home.” I hesitated to ask, “How did he do?” Gracie went on to say that her husband had passed in the last month, yet lived nine months following our brief encounter in the emergency room. She sang the praises of the hospice organization that guided his end-of-life journey.

Gracie was referred by her cardiologist to the ER after telling him about an episode of numbness on her left side. He determined that her heartbeat was irregular (atrial fibrillation) and expressed his concern about a potential TIA. There was no option in my mind that Gracie would be admitted to the hospital for further evaluation and treatment. But Gracie challenged our “friendship” by asking, “Can this be treated as an outpatient?” She seemed to be suggesting I give her the same choice as her husband. However, Gracie was not near death. She was a lively 78-year-old grandmother at risk for a stroke.

In each situation, I didn’t live up to Gracie’s expectation of me as a physician. I often hear patients and caregivers state, “No physician has ever talked to me this way.” Is my practice of medicine out of the norm?

In July of 1988, I crossed over from being an internal medicine intern to a resident allowed to moonlight in the ER. I never completed an emergency medicine residency and have no formal training in palliative care, but I’ve improvised and created my own practice along the way. Medical problems and decisions are rarely textbook. Therefore, I fail patients during most of my shifts. I often ask myself, “How did I ever manage to cope with the bullpucky of trying to please all the patients all the time?”

These are my best tips for coping while failing patients:

1. Get real without using “scripts.”

Health care administrators are implementing the business model of talking to every patron with the same verbiage. Most audiences prefer speakers not to read from scripts. Patients deserve the same respect. Rolling with my train of thought makes me appear authentic and allows me to speak with patients like I mean it. While listening carefully, I look for the opportunity to add a punchline.

On rare occasion, I can evaluate a patient and not write a prescription. One out of 10 patients force my hand to write for their drugs of choice. The middle ground is in reminding patients that medication is often a temporary fix, not a permanent solution. Hoarding medication can sabotage a patient’s well-being.

2. Acknowledge your commitment and let go of others’ expectations.

Believe it or not, some patients are miserable and simply not likeable. When an uproar occurs, I de-escalate the situation by stating, “I’m here to take care of you — not upset you.” This friendly reminder reassures the patient of my fervent commitment to help others while communicating the subliminal message, “I’m not an asshole — I’m your doctor.”

The best pearl I learned in medical school was: “It takes a good patient to make a good doctor.” Patients often want me to live up to their own expectations, yet I can only be as good as they allow me to be. I can’t help but take insults personally, but try to practice the art of forgiving rude patients.

3. Practice being vulnerable.

I vividly remember a picture hanging in the office of my first EM director that read, “Sitting Duck.” It was the perfect personification of an ER doc being attacked by administrators, medical specialists, hospitalists, nursing supervisors, patients, their family members and the next ambulance with incoming wounded. I can only hope to practice EM with the hope of two steps forward, one step back — while not getting plucked off.

I’m reminded by my yoga instructors that if I’m not falling, I’m not maximizing my potential. If I fail to satisfy a patient, am I doing a good job? Did I fail Gracie when I allowed her husband the choice to go home and leave well enough alone? He and I were both vulnerable in that moment, yet I probably had more practice at it.

4. Be a better version of yourself.

I set an example for patients by practicing what I preach about diet and exercise. Nevertheless, I may fail them while not personally relating to their being overweight, stressed out and in chronic pain. We’re all challenged to wear our emotions on our sleeves and not hoard them in our bodies.

We fail others by lacking the ability to express our emotions and heal spiritually. A spiritual being uses the heart in making no comparisons, having no judgments and deleting the need to understand. This receptivity and acceptance allows me to be “good enough” and a better physician.

5. Build confidence in others.

In full disclosure, I often must apologize to patients for being an optimist. I believe the glass is half full and try to reimagine patients as being well. When I fail by not treating them like they’re ill, there are both pushbacks and breakthroughs. Patients begin to appreciate the limitations of their own thinking.

To be a good physician, I need to build the confidence of my patients through making their situations more manageable. Sometimes this means giving them permission to laugh at themselves or me. We’re only human to the extent we accept this. Yet, I happen to believe there’s a higher power within each of us that’s yet to be revealed. Gracie’s husband proved my point.

Gracie may remember me not for being the greatest doctor in the world, but for failing her in an hour of need. Yet I made a difference in her quality of life and her husband’s quality of death. After practicing emergency medicine for 30 years, this is might be my greatest accomplishment and legacy.

Kevin Haselhorst is an emergency physician and author of Wishes To Die For: Expanding Upon Doing Less in Advance Care Directives.  He can be reached at his self-titled site, Kevin Haselhorst. 

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