It’s not your ulcer
“I am not a diabetic. Look, this morning my blood sugar was 193 and I hadn’t even eaten anything. That’s not diabetes.”
“Ma’am, that 100% is diabetes.” This conversation quickly became a stalemate between ignorance and my inability to explain her diagnosis in a way she would accept. In fact, every conversation I had with her went this way. She was perhaps the most obstinate and oblivious patient I had ever met. And she was my patient.
She had come in with the worst foot ulcer I have ever seen. It tracked all the way down to the bone, meaning an amputation was likely in her future. According to her, the ulcer had started a couple days before and she had never had an ulcer before in her life. I used my years of medical training to quickly deduce that a) there was no way that ulcer happened in a few days and b) she most definitely had two very bad looking ulcers on the other foot. When I pointed that out she became upset, telling me they were just split calluses, not ulceration. Every attempt to diagnose and explain the diagnosis was refuted by her “intimate knowledge of her own body.”
The next several days were some of my most frustrating. I was called to her room for numerous reasons, including refusing insulin (because she wasn’t diabetic), refusing dressing changes (because she was allergic to the dressing), complaining that the hospital food was inedible and rotted, and yelling at nurses about their inadequate care. Each time I walked to the room and took my verbal lashings. I listened. I empathized. I did everything I could to put myself in her place and see the fear she likely felt about losing her foot.
None of that was enough.
I am not sure if I have ever truly hated a patient. But with her, I came close. Despite my ill-feelings I spent hours coordinating her care between multiple surgical specialties, all of which wanted to pass on taking a non-compliant diabetic, vasculopath to the OR. Podiatry, vascular, and orthopedics all subtly yelled, “not it.”
Several days into her hospital stay I expressed my frustration to my attending. “They are not your ulcers,” he replied. I looked back, confused, as he continued. “They are not your ulcers. If you care for every patient’s problem as if it were your own, it will destroy you. She got herself into this and she has to bear some responsibility for getting herself out. If she refuses to take our recommendations as to her care, there is nothing we can do. There are times you have to step back and separate yourself from the patient.”
I have thought about his words a lot since then. In some ways if feels antithetical to my nature to see medicine as a job. But I have also experienced the severe mental fatigue and frustration that comes with trying to help a patient unwilling to help themselves. At the end of the day, how far should we go? How much time should I spend on one uncooperative patient knowing it takes time away from other patients who also need my services? In the end I did step back from the case and allow myself to see my care for her as something closer to a job. I switched off service a few days later and the last I knew she was getting an amputation, though she spent time fighting with surgeons about where they could cut.
At some point we have to protect ourselves as physicians, despite how mentally strong we believe ourselves to be. This year has taught me a lot of medicine, but it has also challenged me mentally. I am still searching for the coping skills necessary to survive life as a resident and eventually as an independent doctor. Despite the frustration this patient provided, she did allow me some excellent learning in this area. In the end, I have to appreciate her for that.
