Yesterday was “one of those days.” We generally give our patients 15 minute visits and bank on the fact that some visits will be short and others will be longer. This rule works out the majority of the time, but occasionally the gods of medicine are angry at us and send patients who all need far more than 15 minutes to help their problems. That was yesterday.

Two of these “difficult patients” were back-to-back earlier in the day. They are both longstanding patients of mine with multiple medical problems. The main thing they both have in common from my perspective is that they both have gotten to the point that it seems I have nothing to offer them anymore.

The first of these is a woman in her 50’s with morbid obesity, diabetes, hypertension, significant depression, and persistent right lower quadrant abdominal pain. This pain has gone on for over 3 years and is always the first problem she mentions. I have done CT scans, MRI scans, and bone scans (looking for occult hernia, necrotic femoral head, osteomyelitis). I have done repeated lab work (always inconclusive), sent her to multiple surgeons, urologists, and orthopedists. I have sent her to pain management, used multiple antidepressants and multiple pain medications. There has been little change over the past 3 years.

Some may be tempted to discount this off as psychosomatic pain or malingering, but she has never had secondary gain and there are no other areas where she shows somatization. I actually feel that this pain is real, but I have nothing more to offer.

The second patient is a woman in her 40’s with morbid obesity, diabetes, hypertension, and multiple psychiatric problems. She was repeatedly abused as a child and has had repeated traumas as an adult. I sent her to get gastric bypass 4 years ago, but following initial weight loss, she has not been able to get under 300 pounds. She always comes in with multiple somatic complaints, most of which are due to the strain her weight has put on her body.

She got married about 3 years ago and seemed to be doing better, when 2 months after her marriage her husband (who was 40 at the time) had a dissection of his carotid artery and a devastating stroke. The stroke left him paralyzed on his right side and drastically changed his behavior. He became much more aggressive and uncontrolled in his behavior. She did her best to stand by her marriage commitment, but his behavior was erratic and he did not stay on medications.

She often comes to the office in tears, wondering why all of this has happened to her. I have told her that when I die, the first thing I want to ask God is what he was thinking to let all of these things happen to her. It just seems unfair. Everything we try for her seems to not work well. Yesterday she was in the office following an admission for asthma.

Both of these patients make me feel helpless in a lot of ways. I feel like there is not much else I can do for them. Despite my best efforts to make things better (and I have put out a huge effort for both of them), the just don’t get better. I can look at each one of them and find reasons to shift the responsibility for my lack of success on them, but they both have reasons for being the way they are.

Both of these patients continue to faithfully come to see me and often tell me how much they appreciate the care I give them. Yet it seems that I have failed in the main task I have as a physician, haven’t I? If the task of the doctor is to heal sickness and prevent death, we are 100% failures. All of our patients get sick and eventually die. We can postpone death and help sickness, but eventually we run across an impasse.

One of the main things I have learned being in practice for over 12 years is that often the best thing I can offer my patients is me. I stand by them through these trials, despite my own frustration at not being able to help medically. Yet I continue to try new things and continue to look for other ways to help them. They realize that I have limits and are not asking me for a fix, just a hand. They know that I will be there in a year for them if they need me. They know that I may not always be able to help, but I will always try.

In a certain sense, my patience despite my failures helps them to feel better. I try not to make them feel like a burden and I always try to encourage whenever I can. I don’t make promises I cannot keep. Yet they see me faithfully trying to help them, even in the face of repeated failure and are helped by that. Am I still frustrated? Of course! But I am encouraged by the fact that even when I am not successful and giving medical help, I can still offer valuable care that many people are missing.