Anger in the clinical encounter

 

Mrs. K walked into the clinic with a broad smile. Today she had cropped hair that was oiled and parted in the middle held by a series of clips. Usually, she has long hair that is braided. She must have gone to a temple to fulfil a prayer to the God and had her head tonsured. The hair must have slowly grown back. Women in this part of the world, especially women Mrs. K’s age (mid 50s), do not cut their hair short for style. It is usually to honor a prayer. Also, the fact that the hair had grown this much told me that I hadn’t seen Mrs. K in more than 3-4 months. I smiled back at her and offered her a seat. As soon as she sat down, she handed her case record notebook to me. When I flipped the pages, I noticed that I had seen her 4 months ago. Along with the notebook she also slid an envelope. When I opened the envelope and pulled out the slip of paper in it, I noticed that it was a lab report from yesterday. Her fasting blood glucose level was more than 200 and post meal blood glucose was more than 350, both of which indicated very high and uncontrolled diabetes. 

 

“I have been coming to see you regularly for many years now. Why is my sugar still not under control?” asked Mrs. K. 

 

“Amma, you last came to see me 4 months ago. I gave you a month’s supply of medications. And you haven’t come back to get a medication refill after that. Have you been taking your tablets?” 

 

“I have been taking my tablets regularly” said Mrs. K and smiled. 

 

Here I will pause the narrative to give some context of my interactions with Mrs. K. I have been treating her for her diabetes for more than 6 years, but our physician-patient relationship has not been a very smooth one. Mrs. K comes very irregularly to visit me. I would discuss the importance of taking tablets regularly. She would argue with me that she is feeling well and would ask me why she should take medicines if she is well. I would try to explain that diabetes is a silent condition that can cause problems. She would keep saying different things without even listening to me. Over the years I realized that she would come only when she had some symptoms like burning sensation over the feet, dizziness, or blurred vision. She would take tablets for a month or two and then stop them. After the first few years of patient explanation and intense efforts to convert her to a believer in taking medicines to prevent complications, I understood that I was not making any headway. So, I would just refill her prescription and give her generic advice on taking tablets regularly. She would give me an all-knowing smile that would mean something like, “you say what you have to say, and I will do what I have to do” and she would leave. Now coming back to the present.

 

“How can that be possible? It is impossible for you to be taking tablets regularly. We gave you a refill for just one month. How many months is it since you came here?”

 

“No doctor. I came in the middle when you were not there and got the medicines from the nurse.”

 

“That is impossible, no medicines are given here without documenting in the case record note book. There is no entry here”

 

She did not respond to this and started laughing. 

 

“If you do not take the medicines regularly, the sugars will remain high. If the sugars are high, it will affect your health. It can have serious effects on various parts of your body including your kidneys.” I said. 

 

“I know doctor. You tell this every time.”

 

This statement irked me badly. She said this with such a casual and dismissive attitude. It was afternoon 2 PM. I had sat through several hours of clinic and was exhausted. There was still a big crowd waiting outside to be seen. I was irritable. And at this time this nonchalance hit me hard. 

 

“Exactly! How many times have I told you the importance of taking medicines. Why can’t you take them regularly? You don’t have any regard for what I am saying. You think I am just playing some games sitting here all day long. I have patiently explained so many times to you the importance of taking tablets. All you have done is disregarded whatever I have said and ignored everything. You take tablets as and when you please and turn up here as and when you please.” By the time I was saying this the decibel levels of my voice had increased several notches. I had lost control over my emotions and was outright yelling at her at this point. Our nurse who was in the adjacent room walked in hearing me yell. 

 

“Look at this woman. She doesn’t take tablets regularly. She disregards everything I say and is asking me why her sugar levels are so high. I don’t think she has the right to ask that.” I told the nurse. 

 

“Sister, today doctor is very angry.” said Mrs. K and laughed. I was so agitated and tensed and Mrs. K was cool, calm, composed and laughing. It felt like she was laughing at me. 

 

I fell quiet immediately and finished writing her prescription and handed over the case record notebook to her. I did not say anything after that. She got up and walked away. As she walked away, I heard her say, “Poor doctor, he must be upset about something. He took it out on me and is yelling at me. Usually, he never shouts like this.” That statement hit me hard. 

 

After seeing all the patients, I got up and left for home. On my way in the bus, there was a lot of time for reflection. In my 25 years as a doctor, there are a handful of situations where I have lost my calm and composure and shouted at people. I remember once I had shouted at a colleague, a nurse in the labor room where I was working, and once I had shouted at an intern working with me. But I don’t remember any instance in the past where I have lost my temper with a patient and have yelled at them. This is the first in the past so many years if my memory serves me right. I feel very bad about yelling at her. Hunger, irritability, tiredness, all these are not new. These are routine phenomena that I have experienced daily, and they are not excuses that made me lose my temper. Although, their background role in this whole episode cannot be completely ruled out. 

 

When our conversation started, the focus was Mrs. K. I was talking initially about Mrs.K’s health and how it is important for her to take tablets. But at some point, the focus of the conversation shifted from Mrs. K to me. It started being about how ‘I was disregarded’, ‘I was disrespected’, ‘My instructions were ignored’, ‘My efforts and my time was wasted’ etc. When the focus shifted from Mrs. K to me, Mrs. K also became defensive and started telling lies to diffuse the situation. Thinking back, I have been able to maintain an even keel during all my patient encounters only because the encounters have always been about the patient and all our conversations have focused on them. It has mostly been about “your health”, “your wellness”, “your happiness”, “your comfort” and less about “my instructions”, “my advice”, “my efforts”, “my intelligence”, “my knowledge”. But in this conversation when the focus shifted, it started going south and deteriorated rapidly. This was a very important realization for me. It was just a moment’s indiscretion when I lost control of the focus of the conversation. This could happen to any of us at any random moment. I realized the importance of being mindful during every patient interaction. It takes many years to train ourselves to be a physician who is calm and composed, but just a moment’s indiscretion to be laughed at and pitied for losing our calm. Having said that, medicine is a human enterprise and maybe I should just pardon myself for today’s episode and reflect and learn from it.