Be nice or leave.

Turn your lights down low
And pull your window curtain
Oh let the moon come shining in
Into our life again

~ Bob Marley and Lauryn Hill

______________________________

When I came into the room it was dark. The shades taut without even the tiniest glimmer of sunlight escaping inside and the kind of stillness that instinctively made you think twice before flicking on a light switch.

"Good morning, sir," I spoke softly. "I'm one of the senior doctors on the team taking care of you. Would you be okay with me turning on one of the lights so that I can better take care of you?"

No answer. In fact, he didn't even move in response. And on this day, I was alone. Even though my entire team was standing just outside of the door, I'd entered alone because I'd been forewarned.

"He's tough."

"He wasn't so cooperative with us."

And those were nice ways of saying that this patient was one that would require some advanced communication skills. Or at least some very, very careful thought before I spoke with him. Even the nurse, who I've known and trusted forever because of his amazing interpersonal skills and knowledge, looked at me and raised his eyebrows.

"Don't go in there with that whole group. He even gave me a run for my money."

That alarmed me the most. Because this senior nurse was a master at navigating around and through even the most difficult patients. And knowing that even he had been challenged greatly by this patient on the other side of the door made me nervous.

And so. I took his advice. I left my team standing in their same semicircle as I peeled away to see the patient on my own.

"How are you feeling now compared to when you first got here, sir?"

"What the fuck do you want?"

That was the first words I heard him speak. I swallowed hard and coached myself to not counter his antagonistic words with the same.

"I'm so sorry you don't feel good. I actually want to see what I can do to help you feel better."

And when I said that, I gently rested one hand on his back between his shoulder blades. He was lying face down in the bed with his head away from me. And the moment I touched him, I knew it was a bad idea.

"Move your hand. Take it off of me."

And so I did.

"I've been reviewing your medical chart and talking to the overnight doctors. They told me that you'd been feeling really awful. I know of your past medical history and I just want you to know that we are working hard to make sure that in addition to managing your pain we try to look for any other things that might be going on at the same time. Like. . .you've been breathing pretty fast so we wouldn't want to miss a pneumonia or something like that."

Silence.

"Sir? Would it be okay if I listened to your lungs? Just to be sure that I don't hear sounds that make me think of pneumonia?"

"Didn't y'all do a fucking xray? Look at that."

"I saw your xray, sir. I did. It actually looks really good. But sometimes your exam can tell us things before the xray can. Would you be okay with me taking a listen?"

Silence again.

"Sir?"

"Just fucking listen and don't do anything else."

And so I listened. I asked him to take deep breaths which he promptly did not and I awkwardly maneuvered around his chest from his face down position. None of it was ideal.

I didn't hear any crackles or wheezes but it was such a limited exam that that meant nothing.

"Who are you?" he finally said.

"My name is Dr. Manning. I'm the attending doctor taking care of you."

"The what?"

"The senior doctor. Leading the team. And we are really concerned about you. I'm hoping we can work together to get you feeling better."

"That shit is so cliche."

"Pardon?"

"You just want what you want and don't give a shit about me. I wasn't born yesterday. I know the drill."

"Hmmm. I'm sorry you feel that way."

"I guess you think talking in that soft voice is going to trick me? Man, please. You don't give a damn no more than any of these other folks."

And the worst part is that he didn't even look at me when he said all this. Like, he hadn't even looked at my face in that dark room or didn't even remotely try to factor anything else into that accusation.

"I can't speak for every other person. But as for me, I know for sure that that isn't true. I know for sure that I do care and that I do very much give a damn. About you and about all of our patients."

Silence.

"Sir? I've been here for almost thirteen years. And I assure you. .  ."

He interrupted me. "Are you through preaching? About you and why you're so great?"

I stopped talking and just stood there. My cheeks felt like someone had taken a torch to them. I'm pretty sure I was more embarrassed than anything else. In that instant I couldn't have been gladder for the dark room or the absence of my team.

"Ummm. . . . listen. . . I think. . .uhhh. . . .yeah.  So now doesn't seem like a good time. I will come back and try to examine you a little later, okay?"

"Close my door behind you."

And that was it. That was his response and that was what happened.

I came out and told my team exactly what he said. I even shared the awkward parts and told them that I wished I hadn't said that part about myself and how long I'd been at Grady because it seemed a little defensive. The senior resident looked at me and twisted his mouth in concern.

"Should we take Jacob off of this patient then?"

Jacob, the medical student caring for him, looked over at me to see what I'd say next.

"No," I said. "I think Jacob has to learn how to manage difficult patients sooner or later. Unless you're very uncomfortable, Jacob, I say you keep seeing him."

And Jacob nodded hard to let me know he was cool with that plan.

I spoke to my team about how I'd try navigate this. I told them I would reflect on this patient and our interaction and think about ways to break through. Because the only things that were completely clear to me was that this patient was sick and also that whatever was making him so nasty to his caregivers was about him and none of us. That part I knew for sure.

"So what is the strategy?"  Jacob asked.

"To come back. And not take it personally. But more than anything, to come back. Again and again and again. We are all works in progress. There's no magic."

And you know what? I did. I came back. And so did Jacob. I watched that senior nurse interact with the patient and learned from his years of experience, too. I asked for his insight and got some suggestions. I also listened to Jacob when he told me of the things he said to our patient and learned from those words, too.

That patient was unkind to me a few more times. He was. But I kept coming back and thinking and trying and remembering that it wasn't about me. And eventually, the walls started coming down. First he started looking at me. And eventually, he allowed me to turn on the lights. Well, he let me turn on one indirect light because he preferred that the lights be kept low. And that was something I could do and so I did. Which was a step in the right direction in terms of our therapeutic alliance.

Eventually things got more normal. The patient never apologized for being mean but that was okay. I signed up to be the nice one. And him? He didn't sign up for anything.

Yeah.

***
Happy Thursday.

Note:  People have mixed views on dealing with not-so-nice patients. I'm not a fan of allowing someone to abuse me. But it takes a lot for me to see it that way in the hospital setting. I'm not really sure why.

Now playing on my mental iPod. . . . .