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Journal of General Internal Medicine

, Volume 32, Issue 1, pp 136–137 | Cite as

Stained

Healing Arts: Materia Medica

My favorite preceptor makes mistakes. She’s an ob-gyn in a rural area, where a lot of her patients have made mistakes too. There’s the woman on methadone maintenance who keeps miscarrying, who worries that the pain pills she abused through her adolescence have made her body too beleaguered to bear a child. And the woman who came to the hospital after a meth binge made her bleed so much she thought she’d lost the pregnancy. My preceptor’s mistakes aren’t on the same plane as those of her patients, but she owns them just as ardently as they own theirs. “I don’t know,” she says frequently, “I’ll need to look that up. I misspoke, I was wrong, I’m sorry.”

I have a different preceptor who is flawless. When a patient’s A1C is 7.1, she intensifies their medications to get them to 7. A calcium slightly above normal will get a full parathyroid workup. I don’t think she has ever struggled with the problems her patients experience—alcoholism, smoking, excess weight—and if she has, she would never tell.

I’ve seen professionalism done many different ways, and I’ve been trying to figure out who I want to be when I walk into a patient’s room. On one hand, you have the physician in the billowing white coat, whose healing power rests in part in the confidence patients have in him. On the other, you have a human being who just happens to know more about the human body than you do. Infallibility versus empathy. Perfection versus vulnerability. Sometimes you need to wear the white coat; people need answers, and they want to hear them from someone who knows what they’re talking about. Knock on the door. Shake their hand. Nod empathetically. Don’t tell them that you share their problems—it won’t engender confidence, it’s not the right time, it’s not about you.

But sometimes patients come in and make themselves so vulnerable that it seems unfair not to give anything of your own back to them. In the past week, I’ve had two patients who have made me wonder who I’m supposed to be.

One man came in because he was trying to stop drinking. When I asked why he couldn’t quit, I was blown away by the degree to which he shared. “I drink to help me be around other people. I drink because I can’t handle the anxiety. I’m sorry I can’t quit, I’m sorry I never come in for follow-up. I’m sorry to be taking so much of your time.” When I tried to normalize his feelings, he said no, not everyone is like this, and he told me that I seemed well-adjusted. I didn’t say that I’ve thought those thoughts too, or that I cover my cheeks when I feel the heat rising from them, or that I have to keep myself from overanalyzing every conversation. All I gave him for pouring out 40 years of psychological suffering was the reassurance that he’d be shocked by the burdens people carry, and that I seemed well-adjusted was because I was the one wearing the white coat.

But there was another patient where I had to take the white coat off. I’d met her a few times in other clinical settings, where she always looked so put-together, laughing and joking with us. I was surprised to see her in the psychiatrist’s office one afternoon. When she opened up about the eating disorder she’s battled since she was 17, listed all the medications that have failed to quell her self-immolation, described a family that’s too perfect to acknowledge the streak of suicides and anorexia, and admitted that she stops seeing therapists as soon as they delve into the psychological underpinnings of her eating disorder, I didn’t know what to say. So there she sat, holding the pen and intake clipboard tight through our hour-long conversation like some kind of shield against the secrets she shared with self-deprecating laughter and tears. Was it appropriate to let some of my own secrets show? When she wasn’t sure about her antidepressant dosage, was I hogging the limelight by asking what the pill looked like, then acknowledging that I knew the dose because that’s the one I take too?

Both patients left the office looking shaken, as though they hadn’t meant to share their secrets and were trying to figure out how they ended up on the table. I was kicking myself for delving too deep, and expected both to cancel their follow-up appointments. But the woman with eating disorder hugged me when she walked into the office and our conversation started where it had left off—only this time, she didn’t hide behind her clipboard. The man with anxiety had managed to hold off on drinking, but was still too fraught to attend the AA meetings that had helped him in the past. He shook his head when I asked whether he would be open to therapy or medication for anxiety—“I can get through this on my own,” he said. “I can be strong.”

My biggest struggle with my white coat is that it’s supposed to stay unblemished. My coffee stains are scrubbed off, the ink stains doused in bleach. But the stains are still there—so when should I let them show?

Notes

Compliance with Ethical Standards

Disclaimer

Some details have been changed to protect individuals’ identities, and one character represents a composite of several individuals.

Copyright information

© Society of General Internal Medicine 2016

Authors and Affiliations

  1. 1.UNC School of MedicineChapel HillUSA
  2. 2.AshevilleUSA

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