I Care About You, But I Hate What You're Doing: The Internal Struggles of a Primary Care Doctor

Gizabeth, a pathologist, just wrote about needing to maintain a "poker face" when she did a patient's biopsy, because she knew the diagnosis was metastatic cancer, and she knew it wasn't the right time or place to deliver that diagnosis.

This hit on something I've been struggling with for some time, now, and what I suspect many doctors struggle with (unless they've become completely detached):

Over these past five years as an internal medicine attending, there have been patients who have broken my heart, who have made choices I strongly disagreed with. Of course, as long as the choices are legal and not harming anyone but themselves, they can do that, and the point of my writing about these cases is not to debate these choices. It is to learn how to manage my emotions as both a physician and as a thinking, feeling human being.

How do other doctors deal in the immediate moment, and then in the long-term, when a patient follows a path you believe is wrong?

 I'm thinking of several cases (all details obscured or altered to protect true identities):

Several years ago, I took care of lovely, vibrant, fifty-ish year old woman, who in addition to living extremely healthfully, also saw a holistic provider. One appointment with me, we reviewed some test results that suggested she had cancer. I arranged for immediate referral to a wonderful specialist. The specialist confirmed cancer, and outlined a reasonable treatment plan that involved surgery and chemotherapy. About a week later, the specialist sent me a note that the patient declined all of it, and instead chose her holistic provider's plan of herbal remedies.

I was horrified. I called the patient and asked her if this was true. She said yes, that she thought of cutting and chemotherapy as worse than cancer, and would take her chances with the herbal tinctures, powders, teas, cleanses and energy healing offered by her holistic provider.


What would other doctors say to that?

I said, something along the lines that I respected her decision, but felt that I, as her primary care doctor, needed to inform her that she was choosing untested and unproven treatments, treatments that were not likely to help her at all. She said she would take her chances, and we hung up. That was the last I ever heard of her.

The above case is actually a combination of a few similar cases... It's not unusual for patients to turn down the 'Western medicine' treatment plan. Again, of course, the choice is the patient's, that is not debatable. What I struggle with is my own feelings. Because I know that when this situation comes up, when I KNOW the "Western Medicine' plan, though imperfect, is the patient's best shot at extending their life and quality of life, I know my heart beats like crazy, my palms sweat, and I have to work very hard to control myself, to NOT stand up and scream: "ARE YOU CRAZY?? You're planning on taking all kinds of potentially toxic and useless herbal crap when you have access to the best treatments in the world for this, and suffering people in every developing country would give anything to be here in YOUR place with the chance YOU have at a cure, and YOU are turning it down???"

Then, there's the opposite scenario.

I once took care of a lovely and also quite seriously ill man. He was extremely elderly and debilitated, with some dementia, enough dementia that all of his finances and logistics were managed by family members, though with enough insight and judgment to contribute to his own medical decisions. He had a terminal cancer diagnosis, on top of multiple medical problems, making his care quite complex. He was feisty at times. He had been asked to consider his palliative care and hospice care options on several occasions, and always became quite angry, usually ending up by shouting things like "I'm not going to let you kill me!".

He was admitted for serious, life-threatening complications related to his cancer. It was very likely that he would end up on life support without a chance of any meaningful recovery. He was asked again if he would consider hospice/ comfort care. He refused. His family, who had power of attorney, chose to abide by his wishes. He ended up near cardiac arrest and was sedated and intubated, and stayed in the intensive care unit on a ventilator for a very long time before he passed away, without ever having regained conciousness.

I don't need to tell many people in healthcare that this scenario is so common, I've seen in many many times. It plays out every day. It's just as heartbreaking to me, to see someone choose the cold, often prolonged ICU death, when they could have had the chance to go a homey hospice - or even home!- with the comfort of a morphine drip, holding hands with family members all around them, saying goodbyes or telling stories, until a naturally peaceful end.

Again, the choice is the patient's. But how do you deal with seeing this over and over again, trying to convince yet another human being that the choice they are making really, really sucks?

There are many other situations where my heart breaks. I hesitate to write about it, such a huge can of worms is the subject of abortion. It's with a heavy sigh that I even type this, as I know it stirs strong feelings and stronger words, pro- and anti-, either way. My point in writing is, again, not to debate the choice. In this country, thank God, the choice is up to the woman.

But I struggle, sometimes, to contain my own emotions when I am counseling a patient through her options.

I am pro-choice, and do believe that someone needs to provide safe pregnancy termination services to those who choose that. But at this stage of my life, I am personally, for my own self, pro-life. I did not choose to have any early risk assessment in my pregnancies, despite my own advanced maternal age. It wouldn't have changed mine nor my husband's decision; we agreed to carry on with any chromosomally imperfect fetus. We had even agreed to carry on with a pregnancy if it happened before we were married. We agreed that we have the financial resources and family support to care for a child, any child.

So, I struggle when I am counseling women who, like me, are financially stable, partnered, educated... who, in short, I perceive as having the resources available to care for a child, any child, special needs or not... and yet, they choose to terminate a pregnancy. In the room with them, I am professional; I smile kindly; I hand them the list of termination clinics; I counsel on birth control; I often see them after a procedure for followup.

But it is not uncommon that I tear up. I often need some space after one of these sessions to recover before I can go into the next patient's room. And I take it home with me. It makes me very, very sad.


How do other doctors deal with this? Especially, doctors who are mothers?

So many situations in medicine can affect us. We are all different in our beliefs and actions... But there must be situations that affect all of you, as healthcare providers. What are they? What touches you, and what do you do about it?