A reflection essay for Patient-Doctor III about the same patient:

I have observed often during my clerkships that the hardest patients to deal with–for myself, and for my team–are the ones who are not easily categorized. I have heard comments about so many variations on “those people,” perpetuating stereotypes about people with back pain, diabetes, obesity, or high blood pressure. Regardless of their veracity, they sometimes seem to help residents redirect their frustrations and the stresses of their job towards a depersonalized amorphousness based on diagnosis, rather than towards a given individual. And I am well aware that over the course of the year I have absorbed many medical prejudices about what “those people” are like and how they will behave while under our care and after they leave the hospital. It is unfortunately cynical, but also a defense mechanism counterbalancing some of my naivete. Still, it is hard to only be a little cynical, or only lose a little optimism.

A patient on my service challenged my developing familiarity with these stereotypes and prejudices, not because he contradicted them in any way but because he was simultaneously so frustrating and so inspiring of sympathy. He was a middle-aged man who came in with a chief complaint of “seizures,” describing two episodes of falling to the floor and shaking his limbs. No one else had witnessed the events, but he was insistent that they were seizures. Red flags started to go up when, after hearing that a seizure meant he would be unable to drive, he began to change his story and said that “maybe it was just vasovagal.” The team got more suspicious as he told different versions of his history to different people at different times and deflected any of our attempts to redirect his circuitous and occasionally self-contradictory tale, as if he wanted to stick to a script he had in his head. He perseverated on certain topics, repeating them in response to unrelated questions, particularly his chronic pain after a neck injury in an accident; another red flag, another “those people” category. He was obese. He included extraneous information about his job, his dog, and his experiences at other hospitals. All of this already meant he was labeled as a “difficult patient”–difficult to round on because he took so much time to talk to, and automatically raising the ire of the members of the  team, who felt they were being manipulated. The last and most overwhelming piece of evidence came when we got him out of bed to watch him walk. Unsuspecting, I questioned to myself whether the two petite physicians on either side of this very large man would be able to do anything at all if he started to fall. He did sway and lose his balance, numerous times in the short walk around the room, and each time I jumped forward to help them catch him. But he never actually fell. The attending remarked to the resident “Hm, astasia-abasia,” and we left the room soon after. I learned in the hall that astasia-abasia is a “nonphysiologic” gait disturbance; in other words, a psychogenic problem, with no true neurological cause.

Now, in all our minds, this patient had become one of the worst of “those people”: a malingerer. It was revealed that he had been trying unsuccessfully to get disability benefits. From the tone of the conversation, it was obvious that we were all feeling used, exasperated, and also bored: now that we had him categorized and we had “diagnosed” his problem, he was no longer neurologically interesting, and we couldn’t wait to sign off.

Still, I left the room shaken, not by his obvious creation and magnification of invented problems, but by the depth of his true problems and the suffering they caused. Even without knowing where exactly truth stopped and fabrication began, it was obvious that what he told us had some basis in his reality. He had been healthy, a lean and muscular gym-goer, until a fall on the job damaged his neck. Unable to exercise, he went from a husky man to what the stereotypes told us was just one more morbidly obese patient compounding his own medical problems. His work as a contractor had fallen on rough times already because of the economy, and now he could seldom take whatever jobs he was offered. He was homeless and lived in a shelter. He had at some point developed atrial fibrillation. He felt weak, and had two of these seizures or whatever they were, so he wouldn’t be able to drive even if he had a car. He was depressed, he told us, and had thought about suicide. He seemed still in shock about how different his life had become, and how with each new problem it seemed harder and harder to get out of his hole.

In an in-class exercise for a writing course that night, I wrote about him as I imagined he saw himself, rather than as we saw him: not as a schemer or a whiner, but as a man somehow suddenly fallen from grace, coming to us because he had no one else to turn to. Looking back to our encounter and tapping into a wellspring of sympathy for him was effortless. Yet it had also been effortless to join in the categorization and subsequent dehumanization, and even disgust, the team collectively experienced when we met him. There was no way to reconcile the conflict of this juxtaposition, because both realities were true.

In the hall outside his room, as we began to exchange knowing looks and tear apart the inconsistent story and impossible exam, my senior resident spoke up. “It sucks for him that he’s a malingerer. It means we’ll automatically give him worse care.”  The  words stuck with me because they were neither the cynicism I had come to expect from some residents, nor were they credulous sermonizing about being open-minded and treating everyone with love. What was said acknowledged the tension between resentment and sympathy this man inspired, and let it continue to exist, only pointing out our duty to give him good care regardless. The comment captured the unresolvable conflicts that I have learned over the course of this year are confronted in every field of medicine, especially between unguarded caring and get-it-done practicality, and reminded us of our role as medical professionals. Then we all got back to work.