14 April 2010


Intueri has it.

Go read.  Really.  I'll wait.  Go read that and come back here, because I have something to say too.

She writes beautifully, and it's a hard read.  I almost stopped before I finished it, and I did flinch more than once.

This man was in my ER today, or at least someone very like him.  He was rolled onto a hallway gurney, given a cursory inspection, and left to sleep it off before being given the bum's rush out when he became more sober and obnoxious. 

He was viewed by the staff as an irritation, a burden, an annoyance.  Smelly, dirty and creepy.  Scaring the children as they walked by to their rooms. Nurses were short-tempered and brusque to him, and the doctors avoided him as much as possible.  They were probably angry at him for showing up, and for doing this to himself.  He was as thoroughly dehumanized as he is when he lay in the gutter.

It's easy to view these folks though the judging filter.  It's their own damn fault.  We've sobered them up and put them through detox so many times and they just come back again and again.  Why should I have compassion for someone who is trying so hard to destroy himself?  Indeed, it's hard to bring yourself to have compassion for them, and systematically we fail to provide that caring element to our patients.

But it's not just the bums, though they're the most obvious victims of compassion failure on the part of the ER caregivers.  There are patients for whom it's easy to feel compassion -- the children, the dying, the innocent victims of some terrible disease, the ones in acute pain from some accident or sudden illness.  They're suffering and since it's not their fault we don't judge them, but simply feel for them.

But the guy with COPD who refuses to stop smoking?  The unemployed mom whose teeth are rotten and can't afford a dentist (though she does have a cell phone and cigarettes)?  The fat guy with diabetes, hypertension and a stroke as a result?  The chronic migraneur who everybody suspects is just addicted to narcotics?  How much compassion do they get?  How much do we judge them and find them wanting?  It's hard to muster the emotional energy to get past the self-inflicted elements of their illnesses, and it's so easy to slip into contempt for their weakness and frailties.

I see it in my co-workers, and I am as guilty as any of them.  And I see it in the writings of my Emergency Department colleagues in the medical blogs and comments.  On the net, behind the veil of anonymity, people are more willing to express their darker sides, and the intensity of the contempt and the venom directed towards our patients can be disturbing.   (If I delve too far into my own archives, I might find some expressions of which I am not entirely proud.)

So how do we avoid falling into the trap of judgment and contempt?  I think Maria nails it: "What if you remembered how much he laughed when you cycled with him through the park?"  By which she means, what if you could identify with him?  What if you were him, or someone you loved were?  I see these poor souls and I remember that once they were seven years old, like my older son, and their whole lives were ahead of them, full of promise.  And I try to see them as they were when they were seven.  That works for me.  Your mileage may vary.  I also try to remember that my children's lives could easily go wrong and if any of them are someday in the ER, broken and suffering, someone will remember that I loved them and treat them with compassion.

More humbling, I try to remember that physicians are prone to substance abuse, and that I have seen former professionals in the ER, victims of their own self-destruction, and I think, "There but for the grace of god go I." 

There are exceptions to the epidemic of compassion failure.  On the net there are people like Intueri, Dr Charles, and StorytellER Doc (to name a few) who strive to capture the human beings behind the cases.  In my ER there are nurses who will often go above and beyond the call of duty to help someone.  And there are even some docs who manage to approach each patient with respect and a smile.  I may not be one of them, but it's good to have role models who can remind me to refill the old compassion well every once in a while.


  1. In order for you or I to stay fit and healthy, one must dislike gluttony , alcoholism drugs/excess etc.
    Initial anger at seeing a wasted life is not unfounded. A potentially good life gone to waste.
    Anger means you care, if you didn't care you wouldn't feel one way or the other.

    Forgiveness for the (example of) alcoholic that returns is important because they have no other way of life. They don't know any other way to live. How would they escape that way of life?
    They would have to be open to teaching from another, willing to listen to a teacher, and have the strength and endurance to change their wrong habits.
    Like alcoholism as a way of life, once morbidly overweight, it is NOT easy to change that way of life that got them in that position.

    The easy solution to lifes troubles is drugs and alcohol.

  2. I think you nailed it - "think of them when they were 7.

    In my years of training (here, at UW, particularly formative at Harborview and the VA) I certainly wrestled with this and came to the view that everybody was once someone's baby - an innocent child deserving of unconditional love. (Not to say we're not all deserving of this - it's just so much easier and unambiguous with a child.)

    Somehow this disheveled/malodorous/abusive/demanding/manipulative/malingering (take your pick, you may use more than one) person, keeping me up late, away from my family, was once a vulnerable child, the love of someone's life, or should have been. (Not getting this, in fact, may very well have contributed to where we are now).

    This made it WAY easier to muster the compassion and patience and perseverance to care for them the way that they, and anyone, entrusted to my care deserved.

  3. Well said, Shadowfax.They are broken individuals.

    If you could see the scars within them, they might look something like a burn victim to you. Some of the scars formed through no fault of their own. Some of them made while they were the young and innocent.

  4. thanks for the compassionate bloglinks. i had to stop reading a few blogs that had these negative attitudes you talked about - especially when i found myself nodding in agreement. it wasn't until my sister came home from college to get treatment for alcoholism when i realized just how judgemental i am/have been.

  5. I think that a part of why bloggers write about them negatively, is that they do not behave that way with them in person. They do provide appropriate care for them, in person.

    They save the venting for later. At home. At a bar. On a blog. It may be better for family for it to go into a blog post, than to interfere with home life.

    I have seen plenty of people say all sorts of horrible things about certain patients. Then, the very same people will go out of their way to make sure that the same patient is comfortable. I have seen very few people who follow up on horrible comments with horrible treatment.

    I don't write about these patients because I tend to vent about problems with the system. Just a different kind of ranting.

  6. I agree with Rouge Medic. I very rarely express my disgust with patients when I am seeing them. I save my anger and annoyance for my blog. Unless you are some sort of Saint or OD'ing on happy pills, there is no way to avoid feeling contempt for people that yell at you, refuse to listen to your suggestions, make unreasonable demands, or otherwise behave in a reprehensible manner. Thing is, we have to swallow that pill for the time being and take care of the patient. That does not mean we don't vomit it back up later when we get home - either to our spouses, our blogs, or our dogs.

  7. Nietzsche once wrote, "If you gaze for long into the abyss, the abyss gazes into you." This is what I try to remember in regards to maintaining my compassion while practicing nursing. It's difficult to remember the humanness of the people we treat on a daily basis. There are several factors that contribute to this. The most important being that we see human suffering constantly. There comes a point when one must detach themselves from the reality of what they see. I don't know if this is for good or for ill but it's what I've observed in my own life and practice. It really hit home for me today when I was provided post-mortum care for a woman and I felt almost no emotion. What happened to me? Who is this person that's not moved by the passing of human life? I'm not cold and heartless, I'm actually teased at work for being kind and compassionate. But I don't feel this way at all. I feel jaded and judgemental. This isn't what led me to the profession. How do you maintain compassion? And even if you're looking at each patient as a 7 year old child, how do you motivate them to make positive health decisions in their lives?

    Contrary to a previous post, living the life of an alcoholic or drug addict is no easy solution. It is a life of guilt, misery, and self-loathing. Not to mention cirrhois, hep c, HIV, and endocarditis.

  8. As a CPS social worker with 23 years of working with drug using and mentally ill parents and the damage they’ve some to their children, I can say getting mad shows you’re still human. Spilling your anger and venom on your client/patient just means you’re unprofessional or need a vacation.


Note: Only a member of this blog may post a comment.