“Listening is talking for him; there’s an eloquence to this kind of attentiveness; it’s rare.”
― Abraham Verghese, The Covenant of Water
All clinicians experience from time to time what we call the “difficult patient.” For just a moment, as you read those words, reflect on what arises within you. It may be that you want to stop reading. Interesting. It may be that a restlessness arises that speaks to wanting to experience something other than this, an uneasiness occurs in the stomach that has you just about to reach for water or food to settle that uneasiness, a tension begins in the muscles that is preparing you to run away, or thoughts form that judge others or equally possible judge yourself. That is also interesting. Of course, these thoughts, feelings, and sensations that combine into the experience of this moment now, or during the patient encounter, or in anticipation or reflection thereof, are not problems by themselves. They are valid and normal parts of human experience. As normal and valid as the multitude of experiences we have from moment to moment that become our lived experience, our real lives.
Yet, if we are honest with ourselves, we often wish these away, deny them, doubt and criticize ourselves for having them, and criticize our patients for evoking them. And, upon reflection, one of our strongest impulses may be to investigate the “why” this occurs. Why are they so difficult? Why am I not able to handle this? Why now with all the work I am facing? Why me? Why didn’t others address this with this patient? Yet, this line of inquiry can be fraught and full of implicit and explicit biases, as well as rife with the seduction of justification, especially given the complex, uncertain, and overwhelming distress that exists within the healthcare ecosystem, within the delivery of patient care, and within the distress so acutely experienced by clinicians.
A different more fruitful direction of inquiry occurs when we trust in our mindfulness practice. It asks us to start close in and first inquire into the what rather than the why of these experiences. The qualities of curiosity and kindness when engaging in this investigation, and attentive observation of the foundational experiences of the sensory, emotional, and cognitive, with a desire to deeply understand through these foundations can help us better understand what is actually unfolding for us. We could say that this requires a deep listening, literally and figuratively, to the thoughts, feelings, and sensations that arise, held with an awareness of the intention to understand.
And that leads me to an idea that may seem like a non-sequitur, the word crisis. Originally derived from the Greek word krisis, meaning discrimination and decision, with the noun form derived from the verb krinō, meaning distinguish, choose, and decide. We do face crises in our work, sometimes daily, but certainly over time, and with the challenges facing healthcare, most agree we are indeed currently in a crisis. When faced with difficult patients, difficult encounters, and difficult situations, and when our mindfulness practice allows us to recognize the what that is actually going on, we can then choose, discern, and decide what kind of action or actions would be most skillful.
Will we always choose, discern, and decide the best course of action? Of course we won’t. Remember, we are not perfect. (That is easy to forget). But whatever the results of our actions, we can continue to rely on the foundations of our mindfulness practice to help us understand the what and then respond to each subsequent crisis with choosing, discerning, and deciding. And so on. There really is no end to this practice and no end to the many ways in which it can impact not only how we choose to be present and impact the quality of our work and ultimately the quality of the patient’s care and wellbeing, but also our own wellbeing.
But don’t take my word for it. Try it out! Be your own investigator- as both the scientist and the subject of investigation. And what have you to lose? You are already experiencing the difficult patient anyway. You and I and the entire human race face difficulties from moment to moment and from day to day which will never end. The good news is that we can enter the ongoing crisis choosing, discerning, and deciding to enter with awareness the adventure anyway, to explore the what, which is to explore the experience of living, beginning with listening in the broadest and most skillful ways possible.
Mick Krasner MD is a Professor Emeritus of Medicine and Co-Director of the Mindful Practice in Medicine program at the University of Rochester School of Medicine and Dentistry and Chief Medical Officer and VP of Education at EmPRO Insurance Company.
As the fifth of six children to a father who was himself the seventh of seven children, Mick draws from his chaotic upbringing the motivation for making sense of human flourishing, especially for his fellow health professionals. For enjoyment, he derives great meaning and satisfaction from walking, to nowhere in particular.
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