Dear Doctor: Behind Your Patient's Anger Might Be Grief

You seem quite exasperated with me today, Doc. But I’m tired out on every level and I can’t summon the energy to be concerned about your feelings.

We’ve known each other for about two years, and during that time you have been very professional, thorough and at moments, quite understanding. You’ve tried to coach me through the steps of recovery from surgery, chemotherapy, radiation treatment. As it became clear that I was one of those rare women who would not recover from this long-term side effect, you were empathetic in your business-like manner. I’ve appreciated how you have tried to connect me to resources, medication, and communicated with my family doctor to help guide her along. Until yesterday, I was confident that you were an ally I could trust.

Today? I’m not so sure. See, that last set of tests — you know, the ones that were meant to close this chapter of outpatient care, the final mammogram and check in with you — turned into something different. The results of one test indicated a mass near the original tumor site. More tests raised more questions, and then I was told I needed a biopsy to rule out relapse. After five weeks of clarifying the need for a biopsy, on the day of the actual biopsy, the radiologist refused to do it.

And it made me angry, because I really wanted definitive evidence I was no longer at risk. Evidence that didn’t rely on statistics, or odds, or even an interpretation of an image on a screen, because I was learning first-hand what “professional difference of opinion” means. When it appeared that the doctor in the position to provide that proof would not, it was the first time in five years I was obligated to advocate for myself. Yes, I was livid. Yes, I forced the radiologist to pursue more testing, not less. No, I was not told what would happen now that the biopsy was cancelled. No effort was made to communicate the next steps in my care. So yes, in that void of information and leadership, I stepped in.

These acts — taking charge of my own care and expressing my anger — have unsettled the lot of you involved in managing my case. Rather than focusing on the “biopsy screw up,” and how to improve communication, delivery of services and patient satisfaction, I find myself being chastised: “Most people who receive clear MRI results would be ecstatic, but you are not. What’s wrong with you?” “Your anger is consuming you. You need to move on and let this go.” “Stop talking in circles.”  And then, my favorite: “Do you need a referral to a social worker or a counselor?” Sigh. Nope. I’ve been seeing a therapist ever since my diagnosis, Doc. Here’s what he would tell you about me:

Underneath the anger? Lies grief. The emotion is a natural, healthy response to a series of significant losses sustained as a result of treatment. Survivorship has come with an enormous price tag, and our patient needs time to grieve, and permission to express feelings, and then be supported with each step towards recovery. There are no short cuts, and she must be allowed to actually feel grief before she can “get over it.” Admonitions to “let go” are condescending and unhelpful. All that does is betray your own discomfort with and poor understanding of the grieving process. No, she does not need medication, as she is not dealing with a chemical imbalance in her brain. This is, simply, grief — raw emotion that will subside over time as she faces all those losses.

When you raised the possibility of relapse, you triggered quite a complex psychological and emotional process. It’s trauma, reignited and re-visited. No one should be surprised, at this point, by the range of feelings that engulf our patient. That lack of joy at the MRI results? It’s just exhaustion, the result of being worn down by the arduous process of testing and then conflicting opinions about how to interpret those tests. And now the outrage of her doctors that she dared to intervene and force faster movement towards definitive answers.

My patient has been fighting for five years to reclaim, and now rebuild, her life. She does not need medication. She needs to tune into her grief if she is to overcome it, not anesthetize herself against it. That’s a messy process that has not been made any easier by either the testing debacle, nor your reaction to her.

What our client needs is permission to engage in the grieving process. If you can lower your defenses long enough, and look objectively at her, you will see the truth of this: it’s grief. Nothing more. Not a power trip, not an unhinged or needy patient being demanding for the sake of creating drama. She is a survivor who has suffered many, many losses. She deserves your fullest support, especially now as she works out the grieving process. You can help her by focusing on her physical symptoms and communicating hospital processes more clearly. And frankly, if you can’t find anything supportive to say, then say nothing at all. If you ask her what her needs are, but are unwilling to listen to her, or give her the time she needs to explain herself — then don’t ask the question in the first place.

Because, really, Doc — this isn’t about you. In the end, this is about your patient, and her fight to not only overcome cancer, but learn to live as a totally disabled survivor. That in itself deserves your respect, even when she dares to hold you and the hospital accountable for lapses in communication and procedural missteps. She shouldn’t have to educate her health care team about the grief process and its influence upon her. That’s your responsibility as a professional, to understand the impact of cancer treatment upon your patient’s recovery. Your interaction with her needs to reflect a compassionate grasp of the entirety of your client, not just test results.

Something else you should know about our client: if you can’t get behind her, or continue to put obstacles in her way, she will find a way to work around you as she rebuilds her world — with or without your support.