I miss Alba. I don’t know why, but I do. She was the most challenging patient I’ve ever had. I dreaded seeing her in the office–and yet, somehow, she won me over.
Alba was fifty-nine, with short, silver hair, a deep, gravelly voice from decades of smoking, and an attitude. She had lung disease, heart disease, depression, arthritis and HIV. She also had a complicated social situation. She’d used cocaine and heroin until her husband had died of HIV. She’d then moved in with her elderly mother and cared for her until her mother died of a stroke. Now Alba lived in a shelter right around the corner from where her father had been shot years before.
The biggest joy in Alba’s life was her granddaughter; but her estranged daughter wasn’t letting Alba see her.
Alba frequently missed appointments or, just as often, walked in without notice, demanding to be seen. She was always in crisis–and she generally took out her frustrations on me.
But when she wasn’t crying or yelling, Alba was charming and funny. She would tell me amusing stories about her family. She described how she helped care for a disabled neighbor. No matter how sick she felt, she was always well put together, with full makeup and a fashionable outfit. I couldn’t help but admire her for putting on a brave face to the world.
Alba was singlemindedly determined: She would zero in on a goal–-a medication or procedure she wanted–and pursue it relentlessly. On the rare occasions when I went along, we’d enjoy a pleasant visit. But most of the time, talking to her felt like playing tug-of-war.
She began every visit with the same dejected “Hey, ma.” Then she’d launch into a tirade about her current issue.
Early on in our relationship, Alba insisted that she needed an electric scooter because her arthritis was making it hard for her to walk. For weeks, I heard about nothing else. Finally, after many phone calls and letters to her insurance company, I succeeded in getting Alba the scooter.
The next time I saw her, instead of thanking me, she demanded opioid medications. Given the chronic nature of her pain, and her history of drug abuse and depression, I felt reluctant. There was too much risk of abuse or overdose. But when I tried to explain this, she cursed at me and shouted, “You’re not listening to me, ma!”
I offered her an appointment with pain management, but she said they hadn’t helped her in the past. I suggested a referral to orthopedics to plan surgery for her arthritis, but she angrily declined. Finally, I agreed to a very mild narcotic.
Alba threw the prescription in my face. It was Percocet or nothing.
As she rolled away down the hallway, she screamed over her shoulder, “You never want to help me!” On the back of her scooter I saw a “For Sale” sign. I didn’t know whether to laugh or cry.
I thought I would never see Alba again.
A few weeks later she walked in, leaning on a cane.
“I’m sorry about how I acted last time,” she said. “I was just giving you some tough love.”
“What happened to your scooter?” I asked casually.
“It got stolen,” she replied without batting an eye.
I kept trying to get her surgery for her arthritis. Somehow, between her missed appointments and the surgeons’ reluctance to operate while she was taking blood thinners for her heart condition, it never happened.
One day Alba called me in frustration.
“I’m in so much pain, ma!” she sobbed. “I can’t take it anymore! I’ve been staying clean, but all this pain is making me wanna use again!”
When I tried to discourage her from doing that, she hung up on me.
After several days of soul-searching, I came up with a plan. I called her on a Friday afternoon.
“Hey, ma,” she answered, sounding exhausted.
“Hi, Alba!” I replied in my perkiest voice, certain that she’d feel better once she heard my plan. “I have an idea. I can give you small amounts of narcotic pain medications, but just until you see orthopedics again and have your surgery. All you have to do is stay clean. As long as your urine screens show only the drug I’ve prescribed, I can give you the pain medicine.”
“You don’t get it, ma!” she cried. “I’m in so much pain! No one understands what I’m going through! I can’t deal with this right now!” And she hung up.
I was flabbergasted. I’d been so sure that she would agree–that she’d be grateful. I spent the weekend wondering, What did I do wrong? What did I miss? What more could I possibly offer?
I decided to call Alba first thing Monday morning and give her some “tough love” of my own.
“Alba,” I would say, “I’ve worked so hard to help you, and I’m at my wit’s end. Nothing I do seems to satisfy you, and you refuse to follow my recommendations. You need to stop hanging up on me, and you need to tell me exactly how I can help you. If there’s nothing I can do, then maybe this therapeutic relationship isn’t working. Maybe you need to see someone else.”
On Monday morning I opened the medical record to look up Alba’s number. But the first thing I saw was a message from the medical examiner.
“Your patient deceased” the subject field read.
The message could have referred to any of my elderly or sick patients, but somehow I was sure that it was about Alba. Maybe it was because I was thinking about her at that moment, or maybe it was some kind of sixth sense.
I read the message and found that I was right.
I phoned the medical examiner.
“She collapsed at a friend’s house,” he said. “EMS was called, but they couldn’t resuscitate her. Multiple drugs were found on the scene and in her system.”
I spent the rest of the day in a daze. Was this why Alba didn’t like my pain medication plan? Because she knew the drug screen would be positive? Would she have admitted to active drug use if I’d said the right thing? Should I have tried some tough love on her earlier, or would that have driven her away? Was an overdose her way of permanently stopping the pain? Am I partly to blame for her death?
Despite her drama and all that she put me through, Alba wormed her way into my heart, and I feel a real sense of loss. I spent so much time worrying about her, it seems strange not to be doing that anymore.
And I can’t shake the feeling that if only I pick up the phone and dial her number, I’ll hear her voice saying, “Hey, ma.”
About the author:
Maria (“Masha”) Gervits is a family physician in the Bronx, where she grew up and attended Albert Einstein College of Medicine and Montefiore Medical Center’s Residency Program in Social Medicine. “It was at Einstein that I heard a professor read a story about one of his patients. He encouraged us to keep a journal to honor and remember our patients and reflect upon our clinical experiences. I took this advice to heart and have been writing ever since.”
9 thoughts on “Tough Love”
Thank you sharing this story with such openness and honesty.
I agree with everyone else that you are a gifted writer and compassionate physician. From my perspective, 30 or so years away from residency, the most precious lesson I learned, when caring for a similar charming but addicted patient, was when it was pointed out to me that I was working much harder than the patient to get her well.The patient had gamed the system and gamed me, essentially playing me for the caring but naive resident I was. I wanted to get her well – she wanted the goodies I could dispense, like a scooter or Percocets. How did you feel when she told you the scooter had been stolen. Disappointed, as if it were your fault perhaps? Or did you realize she may have sold it to get her drugs, then lied to you.The answer to patients like this is not to become cynical, but to become wiser, and to learn to step back and let the patient take responsibility for their healing. Caring for your own energy will prevent premature burnout.
I love this story, and I find it very timely. People don’t always accept our help or our answers. And now there is going to be a big swing back away from opiates, with the new CDC recommendations for chronic pain; and this is going to be hard for the doctors who keep caring, and keep trying. I remember the first time I was told that someone rolled themselves up in a rug with a bunch of fentanyl patches, so the heat would melt the patch dose into them at a higher dose intensity. And they died, inside the rolled up carpet. With all the patches stuck to their nude skin. I sometimes wonder if giving doctors the power to do assisted suicide will help patients who are tired of living with chronic pain. I think this power is scary, and a big worry, about doctors who cannot stand to live with non-efficacy, and struggling and juggling. This patient will stick to me– with that “hey, ma”. Thanks for writing this story.
Great story – well written, thanks. I’ve had a few patients like this myself. She made her own choices. Even alcoholics who continue to drink, smokers who continue to smoke, diabetics who won’t take treatment – all need primary care doctors. We as caregivers do was much as we can, but it’s on their terms – cheers
Wonderful account of the unceasing, brave and humane efforts to connect with a person who never made it easy. Please Dr Gervits–no guilt!: as the others have posted, you stuck with her and were honest and forthright, creative and committed, not put off and not egotistical, and held her to a realistic standard. The relationship with you was a distinct success in a tough life, and you must not let the sad end of that life blind you to this no matter how tempting her flawlessly awful timing may have been.
Your story put me in mind of Neil Young’s “Needle and the Damage Done,” which ends with the line “But every junkie’s
like a settin’ sun.” You captured the maddening frustration and the inevitable heartache very well, dealing with the bottomless need of the chronically addicted. Whether it’s a patient, a friend or a family member, there’s “a little part of it in everyone.”
You did the best you could. I’m a retired psycholgist but the tougher patients, the ones who continued to get into trouble over snd over but had that scrappy loveable quality about them are the ones I still remember most. They climb into your heart and settle there.i’m glad you wrote about this relationship. The love shows.
I echo Dr. Kemp’s comment. It’s hard to realize that despite our best attempts to “connect” with each patient, they may not be truthful nor tell you everything. And with addiction, there’s no middle ground. I credit you for caring for Alba. And her returning to you is proof that you were the best physician that she could have found!
Hey Ma—You did the right thing –all we can do is try and never forget there is still an art to medicine. No medication could help the pain she was in –but you never gave up trying. We need more doctors like you.