{"id":1975,"date":"2016-05-13T16:33:26","date_gmt":"2016-05-13T20:33:26","guid":{"rendered":"http:\/\/blogs.nejm.org\/general-medicine\/?p=1975"},"modified":"2016-05-13T16:33:26","modified_gmt":"2016-05-13T20:33:26","slug":"daily-challenge-professionalism","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2016\/05\/daily-challenge-professionalism\/","title":{"rendered":"“Be Careful. He’s Violent.”"},"content":{"rendered":"
\"Briana<\/a>

Briana Buckner, MD, is a 2015-16 Chief Resident in Internal Medicine at the University of Pennsylvania in Philadelphia.<\/p><\/div>\n

\u201cBe careful. He\u2019s violent.\u201d That was the way sign out began for Mr. T. The intern continued, \u201cHe has been in the hospital forever because he was kicked out of his nursing home. Good luck. And, oh yeah… he\u2019s blind.\u201d Puzzled, I looked at my list of patients and, not sure whether I should write “violent” by this patient\u2019s name, I decided instead to write “blind.” I paused. The intern said, \u201cDon\u2019t worry, he hit someone with his cane. When you enter his room, just keep your eye on the cane.\u201d<\/p>\n

The next morning, as I approached the room, I was nervous and unsure of what to expect. When I knocked on the door I was greeted sharply\u00a0with a bit of a grunt and a quick \u201cIs that my breakfast tray?\u201d I quickly responded ‘no’ and that I was the new doctor on the team. Knowing that a hungry patient can be tricky to warm up, I decided to sit down first. I found a very tall African American man sitting near the window, listening to the radio. Mr. T appeared much older than his stated age, and he wore a spirit of fatigue that was heavy and ominous. I could also sense his strong feelings of distrust, which I often\u00a0see in\u00a0African American patients, but his inability to see his surroundings presented an even higher barrier for me to climb.<\/p>\n

During my first two days of taking care of Mr. T, I didn\u2019t examine him. I just sat there with him. Shamefully telling my attending on both days that the patient was on his way to dialysis when\u00a0asked why I was unable to examine him. I knew he felt violated and distrustful, so I wanted to wait for him to trust me.\u00a0 First, I started with asking about the music he enjoyed, since he was always listening to the radio. Through his love of music, I begin to learn about his life. I found out that he grew up in the foster care system, that he had been homeless for a year, and that, at the young age of 40, he lost his vision due to diabetes.<\/p>\n

\"hospital<\/a>While getting to know Mr. T, I also began to learn the dynamics of the unit. Mr. T had been labeled as violent and there was no turning back. The nurses didn\u2019t take to Mr. T, and he didn\u2019t like the nurses. The doctors stayed away from his room and only entered with a quick hello in the early morning during rounds. The most striking thing I observed was how people would talk about Mr. T very loudly near his room and as he walked the halls, as if he were both deaf and blind. The nursing assistants would say loudly, \u201cI had Mr. T yesterday, I want a different patient today.\u201d The phlebotomists would ask the nurse next to his open door, \u201cIs this the blind man? Do you think he will let me get his blood today?\u201d I often would get a frantic call to Mr. T\u2019s room to find him in a yelling match with a team member about his food tray and why his breakfast never came before dialysis. At first, I didn’t understand:\u00a0This was not the gentle Mr. T that I knew from our afternoon chats. But then,\u00a0I realized that it was.<\/p>\n

I realized that Mr. T’s greatest problem\u00a0was that he didn\u2019t feel in control. He could not see, he was in unfamiliar surroundings, and his housing security had disappeared abruptly. One day, after I was able to calm him down from yet another shouting match with food services, I finally asked him, \u201cMr. T, why are you so angry today?\u201d He said to me, \u201cI hear how y’all talk about me around here. These people come in my room with an attitude and an opinion of me before they even meet me. And y’all wonder why I\u2019m so angry. I just want to be able to get my breakfast before I go to dialysis. I come back 4 hours later, hungry and tired. Don\u2019t you get your food when you want it?\u201d<\/p>\n

I had no response to make. Although I did not know all of the background about what had caused his displacement, I\u00a0knew we were failing him. Failing him as a team, as a unit, and as a healthcare system. I also questioned how we formed our opinion of him in\u00a0the unit. Were most of our opinions and feelings toward him formed before we even met him? Did we let our professionalism level slip as a medical unit because of our biased opinions? Isn\u2019t true professionalism defined by our insignificant daily activities? We were\u00a0anchored into our opinion of him as violent, similar to how\u00a0to a doctor can be anchored in a diagnosis of pneumonia. When presented with new information on Mr. T, were we able to reassess our position towards him?<\/p>\n

\"walking<\/a>With time, Mr. T begin to mellow out and became less angry about his breakfast. Less because he trusted the staff and more\u00a0as a sign of defeat because the\u00a0prospect of him finding a long-term home became dimmer. His fear, which initially was displayed as anger, transitioned more into withdrawal and quiet spirit. Despite this change in spirit, the unit continued to label him as “angry” and, each shift, the nurses and doctors would sign out, \u201cHe\u2019s violent. Watch his cane.\u201d Without any mention of his distrust, loss of control, and\u00a0the effects\u00a0that his vision impairment had on his interactions with the staff.<\/p>\n

Finally, a nurse came up to me and said, \u201cI don\u2019t know how you deal with Mr. T. He seems to only like you.\u201d\u00a0 Frustrated with the stigma surrounding my patient, I wanted to ask everyone on the unit, \u201cWhy have we let our professionalism suffer when faced with the demands of a difficult patient?\u201d But I was too\u00a0exhausted and weathered from the dynamics of the situation. I simply answered, \u201cI\u2019m not sure either.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"

\u201cBe careful. He\u2019s violent.\u201d That was the way sign out began for Mr. T. The intern continued, \u201cHe has been in the hospital forever because he was kicked out of his nursing home. Good luck. And, oh yeah… he\u2019s blind.\u201d Puzzled, I looked at my list of patients and, not sure whether I should write […]<\/p>\n","protected":false},"author":1272,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2,3],"tags":[17,24,31,37],"class_list":["post-1975","post","type-post","status-publish","format-standard","hentry","category-about-residency","category-cases-and-rounds","tag-chief-resident","tag-diabetes","tag-patient-care","tag-resident-experience"],"yoast_head":"\n"Be Careful. 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