Rising temperatures, seething anger…

Rising temperatures, seething anger…

Vijay Gopichandran

Yesterday during the weekly rural clinic, I almost lost my temper. I am reflecting on my experience in this blog. This experience taught me that balanced emotional expression is one of the most important skills of a good doctor.

It was a routine Sunday morning. Traveling in the train along with two very interesting gentlemen, who happen to be students in the college where I teach, we had some involved conversations. One of the students, speaking about the other, who is the class representative and leader, said, “Sir, this guy loses his temper a lot. A good leader should never lose his temper.” The discussion then revolved around anger, anger management and how a person in public service cannot afford to express his or her anger in a crude manner. As this discussion was happening, I was thinking to myself, I don’t have this problem. I seldom lose my temper and I am a cool person.

The clinic was a busy one as always, and we had seen patients uninterrupted until around 2 PM. Around 2 PM an elderly lady walked into the clinic with a notebook and a bunch of tablets in her hands. She was wearing glasses and looked very calm and composed. With a neutral expression on her face, she said, “I have been taking treatment for my diabetes and high BP from the nearby Primary Health Centre. The latest blood sugar test results are not good and so now I want to check out the treatment with you and see how things go” There is nothing wrong for a patient to “check out” another doctor. It is a choice after all. But somehow to my arrogant-doctor-pride, it did not augur well to hear those words. I started asking her history and making note of what she was saying.

“I have diabetes for the past 8 years. I have been taking treatment from my nearby PHC. Once I was admitted in Chengalpet GH and there they started me on Insulin. I am now taking insulin injections and some medications for my high BP. The latest blood sugar levels are more than 300 and so I want to see you and take your treatment to see if it works”, she said.

I took her notebook from the PHC and started flipping the pages. I was shocked to notice that the treatment was haphazard. She had been started on oral antidiabetic medication in 2014. A few months later it had been stopped and she had been started on medication against high BP. Then, newer medications have been added for high BP, without any consideration about diabetes medications. All this while she has had her blood sugars tested and it was consistently high. Then in 2016, she had been started on oral anti-diabetes medications again. Earlier this year, she had been diagnosed with tuberculosis and had been started on antituberculosis medications and at that time she had been switched over to insulin injections. This is a brief summary of how her treatment has been progressing.

Even as I was trying to read and get a hang of this nightmare of treatment, she was repeating her symptoms of body aches and pains again and again. I was getting frustrated over three things – firstly her attitude of “I am here to check out your treatment”, secondly the convoluted and irrational treatments that she has been given in the past by my colleagues working elsewhere and thirdly the constant repetition of her aches and pains despite telling her that I will talk to her once I understand the case history in detail. The weather was mercilessly hot, I was dehydrated, hungry and tired and I was on the verge of an angry outburst.

I was just going to shout at her and say, “Amma, will you keep quiet for a minute. I am trying to understand what you have been treated with. Your treatment history is a horrible mess and unless I understand it, there is no way I can help you. Your body aches and pains are inconsequential when compared to the mess of a treatment you have received over the years. Firstly, you decide to walk in at 2 PM when the clinic is almost closing and secondly you tell me that you are here to “check out” my treatment. Do you know I have not even had a sip of water since morning? I have been seeing patients nonstop. 2 PM is my closing time, I can just walk out now if I want. I am not even obliged to see you now. Who do you think you are? Will you now shut up and allow me to concentrate?” These words were seething and burning inside me, and I was just wanting to yell at her. Something stopped me, I politely excused myself and walked out of the clinic.

I walked to the doctor’s duty room and filled myself a glass of water. It was not cool, but it was water. Water always has the fantastic property of cooling everything, even the burning anger. As the water passed down my throat, I found the fire of my anger slowly getting doused. I calmed myself in those 2 minutes and returned to the clinic room. The two young students sitting with me and helping me in the clinic looked puzzled and were wondering where I had vanished. They did not know the storm that had been waging inside my head. But now the storm had crossed. I sat patiently in front of the patient. I saw the whole picture differently now.

Here was an elderly lady, being treated irrationally by the medical officers in the PHC. She has never had good quality, rational treatment for her condition. She also has multiple other problems like tuberculosis and body pains. She has probably experienced a lot of clinical encounters where nobody cared for her as a person but saw her just like a notebook with a lot of diagnosis and notes. In this background, how can I expect her to trust me? Unless she experiences my treatment how would she go beyond “I want to check out your treatment”. I understood that she is making a big leap of faith with a lot of skepticism. She is moving out of her comfort zone of her PHC to my clinic, venturing into unchartered territory in the hope for better treatment and better control of her blood sugars. She is probably not used to someone reading her notebook in such detail and asking her so many questions. So, she was getting afraid that in all that, her main symptoms of body pains would get missed, like they always do. So, she was repeating that again and again. She probably did not intend to irritate me and make me angry. She was just herself. I was the one who misinterpreted the whole situation. When I saw all this in my mind, I felt ashamed of my own previous thoughts. I was happy that I ran away from the situation for a brief while without creating a scene. I was grateful for that little glass of water.

I sent her home with a fresh prescription and some notes to her primary care physicians to rationalize her prescription. But this experience taught me a lot of important lessons. The medical fraternity of the whole country is seething with anger over the brutal attack on the medical intern in a hospital in Kolkata. Please read more about it here. This is a crucial juncture for all medical students, interns, doctors, and senior professionals to reflect on the role of emotional intelligence in clinical care. Whether we like it or not, the medical profession is one with high levels of emotions. Doctors must handle not just the emotions of patients and their kin, but also our own emotions. We as a professional group need to learn more mature ways of dealing with our emotions and the way we handle and express them. I am not in any way justifying the brutal attack on the young intern in Kolkata. It is unpardonable and there is a need for improved security and protections for medical professionals, especially the ones who work at the vanguard of the profession, the junior doctors. However, there is a simultaneous need to learn better emotional intelligence skills.

Little did I know that the chance discussion on anger management that the students and I had over the train journey would turn out into an anger management test for me in the clinic. Here are a few strategies to effectively manage an acute outburst of anger:

·         Leave the spot, take a short break, organize your thoughts before you speak. Drink water, it always helps!

·         Express the anger, but in a mature and controlled way. Use the help of clearly stated facts to express the anger. For example, “the clinic timing is 9 am to 2 PM. You can see it displayed clearly on the board. You cannot walk in here at 2.30 PM and demand to be seen”

·         All of us require time-outs and breaks. If you find yourself constantly in bouts of anger. Take a break from work and do something different.

·         Make small changes that may change the anger-producing environment. For example, if you are a person who doesn’t know to say “no” and so land up doing a lot and it frustrates you, start saying polite “nos”.

·         Always when talking to someone to express anger, please use “I” statements. For example, “I have been seeing patients all day and it has been hot and tiring. I wish to see patients on time and be thorough” rather than “You have come too late. Don’t you know that you have to come between 9 to 2 PM?”

·         Deep breathing, drinking cool water, repeating a favorite word in the mind – all these can help diffuse anger

·         Never keep anger pent up and carry the grudge. Express it at the right time and in the right way.

·         Always remember it is never bad to seek help. If you are over-worked and feel the anger and frustration building up, call for help.