One of the challenges of medical training is that you sometimes have to learn from docs who you don’t actually consider to be good role models. Not most of the time, but occasionally. Yesterday I was working with a new preceptor who falls into that category. His general “fuck-you” attitude towards evidence that he doesn’t agree with (eg. screening recommendations) was easy for me to just ignore, and I definitely learned things from him. But trying to work with him and one patient in particular was crazy-making.
Unlike my main preceptor, he wasn’t letting me go and start H&Ps without supervision. So he followed me in on a woman who is your classic obese, hypertensive type-II diabetic. The way in which she is not classic is that she has maintained a 22% weight loss for years. Loyal readers, repeat after me” “95% of people who attempt to maintain a weight loss of >10% for more than a year will fail.” So, to me, she’s already exceptional. He told me that he had “demanded” that she lose another 5lb in the past three months, and we could see on the sheet from the nurse that she was the same weight as previous. I knew at that point that he and I were not on the same page with this woman, and that I had no intention of going in and browbeating her about 5lb. I put on my Arrogant MS3 hat and went in fully planning to ignore my doc, practice my motivational interviewing, and give this woman a rare humane encounter with a healthcare professional.
As soon as I started talking with her, I could hear her anxiety about being here and discussing her health yet again. She sounded like she was near tears. She started describing the stresses in her life, and how she knew the things she should do but just didn’t have time for any sort of self-care. She said, point blank, “I can’t make more changes right now”. She came in with a record of her BP and BG readings for the past month (awesome), and I could see from her BG numbers that she had made some kind of abrupt positive change during that time. I pointed it out, and she explained that she had cut out certain foods. I asked her if she could sustain that change, and she said yes. I basically just stopped and told her how well she was doing on multiple fronts, and to keep it up, and then started talking with her about her mental health. I got her to articulate, in full motivational-interviewing-magic glory, the reasons why SHE wanted to take better care of herself, and some of the things that would need to happen to make space for that. I then started a depression screening that seemed really, totally necessary.
At which point my doc, who had been sitting in the corner making grumpy faces, lost his patience and interrupted me. He launched into his full paternalistic, condescending, tone-deaf spiel about her excuses, and what she needed to do differently, and how she knew better, etc. I wanted to throw my iPad at his head. He did a quick exam while continuing to lecture her, and that was basically the end of it.
I did my best for her. But I woke up still feeling bad the whole thing. I’ve gotta figure out how to let go of this stuff.
When I woke up there was this intense dawn light coming through my open bedroom window, and I heard the rain. Been missing the rain. I went outside and looked up and there was a full double-rainbow across the bright pink sky. I stood there in the rain and looked at it for a while, and decided that today gets to be new.
Maybe, if I’m super lucky, there will even be time for lunch!