Provider Boundaries



I freely admit that I have always struggled with boundaries. I take things personally.  I worry about my patients when I should be taking care of my own health. I want to help my patients feel better, to move toward “wellness” whatever that means to them. I want to share everything I know about pain, depression, Big Pharma in the 10 minutes that I have with my patients.

Unlike the parent who can never admit that they have a favorite, I have no problem telling you that I have favorite patients. Of course, I enjoy the well-read, pleasant wellness focused patient who wants to avoid medications as much as possible. But some of my favorites are the cranky, rude, demanding patient who over time lets me see their broken and sad parts.  They are the ones that challenge me with their demands and don’t quickly accept my reasons for the proposed healthiest way to treat their illness.

Some of them hate me at first and they let me know that later.  One of those patients who hated me at first told me that he didn’t want me to violate principals that I hold dearly and so he was going to get his Ambien, Xanax, Soma and Percocet from the other provider, but wants to see me for everything else. He started to read the books I recommended. He started to talk about his fears of a life without all of those medications. We would make progress every visit on healthier choices. And we laughed a lot.  I looked forward to the visits where I could see those baby steps happening.

I have recently grown fond of a patient who actually convinced me to give him Ambien-( Including that patient I still have written fewer than 10 prescriptions for that drug in the past 7 years ).  We have this sort of inside joke about “playing the cancer card”.  I have been fighting with his demon insurance company trying to get a medication approved for several weeks without success. I actually wrote a  letter to the crazy insurance folks explaining why he needed a particular form of a medication he could use at home instead of coming in the office for injections and get exposed to all the contagion that floats around in community health clinics. So when I saw the name on the schedule I was surprised since I had just seen him a few days before. This time the “cancer card” got him. Very bad news, my MA cautioned me outside the door  I took four deep breaths outside that door before entering.  Still, I  took one look at his face and cried when I hugged him.

I am going to worry. I am going to search the inter webs in a vain search for some miracle cure that all the experts just happened to have missed. I pulled up the imaging that I don’t even know how to read and tried to imagine that they mixed up the films. Maybe all those spots are just some weird artifact. I am going to sit and cry more than once over this one.  I am going to send cards and books.  I am going to cheer lead. My heart is going to break.

Do I want to change this about me? I used to want to change it sometimes, but only for a moment or two. I do what I do because I feel deeply and passionately that we need to hear their stories. We need to understand their lives. We need to get close enough to be able to lead them out of that dark place of chronic illness when they are unable to even imagine that there is light at the end of that tunnel. When I meet them in that dark place, I get to celebrate that dance in the light when they fight their way back to health.

Yes, it hurts a lot today. But real life is messy. Problems don’t get fixed in 43 minutes and 8 commercials for fast food and faster pharmacological treatments for the diseases of fast food. So, tonight, I am practicing what I preach.  Having a cup of herb tea and a good cry before bed.

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