My friend, a newly minted PhD, and I taught a behavioral medicine seminar this morning for a group of internal medicine residents. Our (over-) attention to semantic detail led us to title the seminar as “The Role of the Provider in Challenging Interactions with Patients”. Usually, these types of interactions are referred to as “difficult patient interactions”, which are then further abbreviated to “those difficult patients”. Approaching patients—or people, for that matter—as “difficult” doesn’t help anyone; it merely girds the physician to enter a battle that may not actually exist. Last I checked, medicine is a collaborative endeavor, not a blood-drawing sport.

My friend and I had given this seminar to a different group of internal medicine residents earlier this year, when the interns had about eight months of experience under their white coats and the more senior residents were slogging through a drab winter of discontent. When we solicited the group for challenging interactions, they easily rattled off many, many specific instances of professional frustration. When we prompted them for obstacles that interfere with their goals in patient care, they provided a litany of complaints. Most of them involved “environmental” issues (the endless paperwork, the incessant pages, the unending requests and clarifications from ancillary and other medical services, etc.), but many of them focused on issues that they attributed to patients:

• “Sometimes they are so demanding and they’re asking for things that aren’t reasonable.”
• “When they’re homeless, they often can’t make their appointments or get their meds filled.”
• “They want to talk about things that aren’t directly related to their health.”

When we asked them how they themselves might be obstructing their goals, they paused—

—and soon were able to realize that their own behaviors could adversely affect the interactions. (Hence “the role of the provider”.) After further discussion, the group, as a whole, conceded that one of the main points it learned from the exercise was that physicians themselves do play an active role in the interaction and that their own behaviors can shape the eventual outcome. Many residents do not have opportunities to reflect upon what they do and why they do it.

This is why my friend and I wanted to hold this seminar.

Today, the group consisted primarily of interns, who have been doctors for about one month. Four weeks. When we prompted them for their experiences and thoughts, we often heard silence.

There were two clocks in the room, both with loud and unsynchronized second hands. The passing time was noisy.

I was particularly struck with vast experience we all obtain during our intern years. It’s not that these interns had romanticized patient interactions—they hadn’t. They were merely extraordinarily anxious about their own performance and potential incompetence—which is completely developmentally appropriate. In fact, that itself caught my attention: These interns were so focused on themselves and their perceived inabilities that they could not focus outwards. Thus, when asked what patient characteristics may obstruct health objectives, they merely stared back at us. Maybe shame prevented them from sharing what was on their minds. I’m not sure.

The senior resident and the attending in the room, however, easily piped up with responses for patients and for physicians. In fact, it was the more experienced physicians (no doubt by seniority) who engaged in the discussion and, at least overtly, reflected on their awareness.

To say that this “saddens” me is inaccurate. I’m pleased that, when given the opportunity to do so, physicians are able to step back and reflect upon how they interact with patients. I’m “sad” that physicians do not regularly engage in this self-awareness. This is not to suggest that physicians should routinely sit around a campfire, hold hands, and sing “Kumbaya” while mulling over suboptimal interactions with patients. I just wonder if physicians and patients would share more useful experiences and effective communication if people were more mindful of what and how they contribute to an interaction.

I’ve been invited to give the talk again—solo, as my friend is going to New York City for his post-doctoral work—after the new year. I already wonder how that will go.

I also taught medical students today. This is the first time I’ve had a formal opportunity to teach a group of medical students in a more “lecture” style; I’m more accustomed to teaching individual medical students. There was the “Futon of Knowledge”, where I taught three medical students at one time, but that experience was limited to the room with the futon in it. (There are many ways to distort the idea of the “Futon of Knowledge”—it wasn’t like that.)

The medical students are also four weeks into their medical careers, so, for the most part, they are bright-eyed and eager. Teaching, for me, is tons of fun as it is, but teaching medical students is especially rewarding. It’s neat to see the lightbulbs over their heads flicker with curiosity before illuminating with understanding. And—shall we be honest?—it’s neat to think that I may (positively) influence the way they think about and interact with patients in the future. Truthfully, I can’t take credit for this stuff, though; medical students will incorporate what they like into their repertoires and toss the rest.

I saw one of my former medical students today. He is one of those double doctors—you know, he’s got an MD and a PhD. When we met, he had already earned his PhD. He arguably knows all there is to know about vitamin K. And he was my medical student—a good one at that, too. Curious, thoughtful, kind, and intelligent. Gentle with patients.

Except, now, he’s an intern. He was wearing the requisite long white coat. It was still starchy and thus, didn’t sit quite right on his tall, lanky frame. His hair was unkempt and his posture was slouchy.

“Hey, look at you!” I enthusiastically greeted, tugging on his coat to emphasize it’s “real doctor” length.

He smiled at me—he looked tired and much older than I remembered. “Hi,” he greeted, rubbing his head. “I’m post-call—I was falling asleep on the shuttle—”

I patted him on the shoulder. “Go,” I directed, hustling him into the hospital. The more time he spent talking with me, the more time he’d be in the hospital, and the less time he would have to sleep.

In his fatigue, he tried to continue our conversation, though I made it difficult for him. In retrospect, I probably should have allowed him to ask me how I was doing.