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an online version of the magazine Fall 2007
Learning Curve

Re-Defining “Difficult”



By Daniel Munoz, M.D. '04


Illustration of person with mask
Illustration by Sherrill Cooper

WE ALL FEEL IT. Anyone with medical training who claims otherwise is lying, in denial, or blessed with superhuman patience and perspective.
It is a sense of professional entitlement, a sense that, as physicians, we are inherently owed deference, respect, and gratitude from patients. From this entitlement is borne an interesting phenomenon: When a patient or a patient’s family member violates this unwritten covenant, there is a tendency to reflexively label them as “difficult.” 

Why does this occur?

As a first-year fellow in cardiology, I am now in the eighth year of my medical education, still trying to persuade some relatives and friends that yes, in fact, I am a real doctor. My friends from college are working—making laws, investing other peoples’ money (or what’s left of it), teaching, fighting for red or blue states, writing novels, suing each other, scuba-diving in Cabo San Lucas, making foreign policy. 

I went to college, then medical school—four years interrupted by a year in Boston for a master’s degree—then residency in internal medicine (three years), and now a cardiology fellowship (another four years).  More than a few of my friends have made hundreds of thousands of dollars in the time I’ve spent, or gone into debt, the same amount.

All of this translates into an expectation that, as physicians, part of our non-monetary remuneration should come in the form of instinctive appreciation from those whom we treat.

However, patients often see things a bit differently. And by labeling them “difficult” when they challenge our plans and recommendations, we can miss an opportunity.

Evelyn is 71 years old. She looks older. Years of smoking, high blood pressure and cholesterol, and kidney failure have conspired to weaken her heart. Her stiffened coronary arteries are clogged with cholesterol deposits and badly in need of replacement. I met her on a Friday. Her bypass surgery was scheduled for Monday morning. 

I had been warned by a few colleagues: “Avoid going in her room. Avoid long conversations. Avoid her demanding family.” I was, as a result, not surprised when I entered her room, began to introduce myself, and was immediately interrupted by the weathered-looking woman with graying shoulder-length hair who lay in the bed, a nasal oxygen canula in place. Despite her apparent frailty, her voice thundered off the walls of her room on Nelson 5. 

Evelyn’s questions, frankly, made little medical sense. But it was the tone, rather than the substance of her inquiries, that gave me pause. Her voice quivered with a blend of anger and frustration. This was clearly a smart woman (a retired scientist, in fact), struggling for some say in her eventual fate. She questioned the need for each of her medicines, for each of her blood draws, for each of her imaging studies. Our first conversation was not terribly productive. I politely excused myself after 15 minutes of unsuccessfully addressing her various concerns.

At 10 pm on the night before her operation, I was called to her room. Evelyn and her family were demanding to speak with the surgeon, threatening to cancel the plan for surgery. By this point in the night, the surgeon was home, resting for the next day’s cases. Thus, I was the one left to deal with Evelyn’s frustration.

My entrance was met with the skeptical glares of Evelyn and her two daughters, both of whom stood with their arms crossed. I pulled up a chair and sat by the foot of Evelyn’s bed. And then I listened. Seven minutes later, I got the chance to speak.

I revisited their concerns, one by one. They wanted assurances that all would go well. With her brow furrowed, Evelyn demanded a guarantee on the course they had chosen to pursue. I gave an honest appraisal. The surgery was risky, heightened by her chronic lung and kidney conditions. But there were also risks of not proceeding, risks of clogged arteries progressing to a heart attack from which she would not recover. After 30 minutes of intense conversation, I paused and then offered, “There is no perfect, risk-free option here. But, among imperfect paths, we think there is a better one for you to travel. That is why we’ve recommended surgery.”

Ten seconds of silence felt like 10 days. I braced for her frustrated, angry response. But instead, she softly offered, “Then I will do it. Thank you.”

Rather than automatically deferring to her doctors, Evelyn withheld her gratitude until she had been heard.  She did so, not because she wanted to be “difficult,” but because she was scared and felt increasingly powerless in the midst of her physical deterioration.

Relieving her of this angst, despite the medical challenges that remained, required time, patience, and sitting down to listen. And though her coronary arteries remained diseased with unclear prospects for successful repair, she shared something that night that provided all the gratitude I required: “Doctor Munoz, I feel a little bit better."*


Daniel Munoz, M.D., is a first-year fellow in the Division of Cardiology.

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