Across from me sits Don, a young, African-American internist. Those of you who read my book, might remember him as the first patient who asked me about all my medical emergencies during the time my husband was ill and dying. I answered honestly, which I came to see as both a help and a detriment to his treatment. In some ways it made it more difficult for him to talk about himself without feeling excessively guilty, but it also allowed us to focus more directly on the burden of guilt he carried with him.
“That would be a huge decision for you, Don” I say. “You worked so hard to put yourself through medical school. And I’m sure you still have lots of loans.”
“Funny. I thought were going to say my mother sacrificed so much for me to become a doctor.”
I smile at him.
“I know,” he says smiling back, “You’d never say that. That’s my voice. My mother did do everything she could when my father left us, but I know she did it because she needed me to succeed for her as well as for me.”
“Why are you considering leaving medicine?” I ask.
“Too much pressure. Dealing with constant staff changes and the never ending dramas and bickering. And the paper work. I don’t think the government and insurance companies could possibly come up with a more complicated record keeping system if they tried! And there are so many patients I can’t help. They’re just way too sick by the time they come to me. Or they’re non-compliant – not taking their meds, or smoking, or not losing weight.”
“How do you feel when they’re non-compliant?”
“Angry. Sometimes angry at them for throwing away their lives; sometimes angry at me for not being able to reach them.”
“That sounds familiar, Don, that harsh, judgmental voice that gets turned on either yourself or others.”
I suddenly find myself thinking of 2008, the time Don left treatment with me - from my perspective - both prematurely and precipitously. It was the year after my husband’s death, a terribly sad, painful time for me. I decide to follow my association. “Do you ever feel sad for these patients, Don?”
“Sad? I don’t know. More angry that they won’t take care of themselves.”
“This might seem like an unrelated question, Don, but I wonder in retrospect if you have any thoughts about why you left treatment with me when you did?”
“I don’t know,” he says shrugging. “I guess because I felt we’d hit a dead end, going over the same stuff – my critical voice, my unrelenting guilt. It didn’t seem we were getting anywhere.”
“How did you feel about me then? How did you feel about my loss, my sadness?”
Don looks downward. He shakes his head. “I tried not to think about it. I didn’t know how you were coping, working, listening to me go on and on about trivia.”
“So, in the second part of what you just said, you’re again feeling guilty and beating up on yourself, as in how could you be talking about yourself when I was dealing with such a major loss. But initially, it sounded as though something else was going on for you, as in maybe you felt sad and that sadness made you uncomfortable.”
“I don’t like feeling sad. Sadness feels hopeless, like there’s nothing that can be done.”
“Well, sometimes that’s true. Sometimes there is nothing that can be done other than feeling the sadness.”
“I hate that. It makes me feel powerless. There’s nothing worse than feeling powerless.”
“But sometimes we are powerless, Don. You were powerless as a child to keep your father from leaving. We also all die, age. Even a doctor can’t cure everyone. I wonder if that’s a problem for you as a doctor: you have to face your own limitations, your own powerlessness. As awful as it is to feel guilty, guilt often feels preferable to powerlessness. So you’d rather be angry at yourself or your staff or the insurance companies than to feel your sadness about only being able to do so much. It brings back all the powerless feelings you had as a child too, which makes those feelings all the more difficult.”
“So you think I should come back into treatment?”
“Yes, I do. It’s time to deal with the pain of that which you can’t control.”