7—
When a Doctor Hates a Patient

Case History: "Duchess"

Generally, physicians respond with a variety of emotions to their patients: some they truly like; others they do not like but still regard sympathetically because of their illnesses. In rare instances, however, a doctor actually hates a patient yet is forced to take care of him or her. That happened to me in one case when I was an intern.

Over a period of several years, one of the most infamous patients in our hospital was referred to as "Duchess," a nickname bestowed by the hospital staff. A fifty-two-year-old female who suffered from chronic kidney failure, Duchess was on peritoneal dialysis. This treatment not only demands very careful medical management by doctors but it also requires a lot of cooperation from the patients, who must monitor their diets and fluid intake. Patients on peritoneal dialysis come to the hospital to be dialyzed

as outpatients several times a week. They have to become inpatients only when they get into trouble. Without dialysis, they would die within a few days.

Patients on dialysis who do not pay strict attention to their diets often require immediate hospitalization with around-the-clock dialysis and meticulous medical monitoring to correct the fluid overload and metabolic status. Since Duchess habitually broke all the rules of her diet (e.g., she would eat enormous quantities of salt), she required periodic hospitalization.

Sometime during my second month as an intern Duchess was admitted to my service. At that time, I was working in the I.C.U. Naturally, all the nurses there knew Duchess. In fact, when I was going down to the E.R-to pick her up, they all warned me that she was one of the most difficult and obnoxious patients anyone could have.

But I was not prepared for just how bad she was.

The first thing I noticed after Duchess settled into the I.C.U. was that she was chewing a big plug of tobacco and periodically spitting tobacco juice on the bed. Being naive, I asked die nurses to take her tobacco away They told me they knew from past experience that if Duchess did not have her tobacco she would refuse to allow anyone to treat her. In fact, they said, when they had taken her tobacco away in the past, she had sat on her bed and screamed and cursed and refused to let any doctor examine or even come near her. And so, they advised me, it was necessary to bribe her with tobacco to take care of her. I therefore had to agree to let Duchess keep chewing tobacco and spitting tobacco juice on the bed so that I could examine net

Meeting her was something less than a pleasure. Because of her fluid overload, she was in congestive heart failure and, consequently, very short of breath. Though she could barely breathe, she insisted on chewing her tobacco and firing its juice like venom or a barrage of gunfire. Examining her was all but impossible. Because she refused to cooperate, I could not listen to her lungs properly. The few times I gently tried to force her to do something, like roll onto her side, she made a fist and threatened to hit me.

Duchess would not even cooperate verbally. Whenever I asked a question, she would refuse to answer; but not because she was short of breath, for at random intervals she fired volleys of the

vilest obscenities. Although initially I had felt a great sympathy for this woman and her condition, after several rounds of her obscenities I began to feel a rage within me which I had to struggle to control.

Finally, I gave up trying to examine her properly (I had done all I could) and told the I.C.U. nurses to begin her intensive peritoneal dialysis. They were very reluctant to proceed because during the past year Duchess had sent two I.C.U. nurses to the E.R.: she had bitten them and broken their skin. (An adult bite can produce a serious infection.) But they had no choice.

I came to hate taking care of this obnoxious patient. I found that the only way Duchess would let me do anything at all was if I threatened to take away her tobacco. After three days, we finally discharged her. That was about all I could stand of her anyway

Some three weeks later, Duchess was admitted again for the same problem. On this occasion, when I was drawing blood from her, she tried to bite me. After that, she tried to pull the needle from my hand and in so doing knocked down all the samples I had already drawn. The tubes broke and blood spattered on the floor, which meant that I had to draw her blood all over again.

A few weeks later, Duchess was again admitted for the same problem. Because she was in the hospital, she had to adhere to a very low salt and fluid-restricted diet. (She was supposed to be on that kind of diet all the time.) She obviously hated her diet. When the people from the diet service came to remove her tray after each meal, she would either spit at them or hurl a fork or knife their way

Needless to say, taking care of someone like that was very trying. My natural urges were to choke her to death. In fact, it gave me a lot of relief to fantasize how I would kill her.

Over the year, I had to minister to Duchess about four times. Each time was an indescribable ordeal of exercising patience and self-control. I had to constantly smother my rage to maintain an objective approach to her medical problems. Still, every time she was admitted to our hospital, Duchess got from all of us the best of modern medical care, which carried her through another crisis. As professionals, the doctors and nurses refused to let personal feelings interfere with the proper medical management of her case. But each one of us must have been secretly imagining her murder thousands of times over.

After my internship I never had to take care of Duchess again. About two years later, I learned from the medical house staff that she had finally died. I guess my predominant feeling was one of frustration, as though I had been thwarted in my desire for revenge.

Literary Parallels

Do other doctors sometimes hate their patients? We found companionship in two American doctor-writers, William Carlos Williams and Richard Selzer.

William Carlos Williams

The eminent poet William Carlos Williams (1883–1963) received his M.D. from the University of Pennsylvania in 1906. Four years later, he returned to his hometown of Rutherford, New Jersey, to practice medicine—and writing. "When they ask me . . . how I have for so many years continued an equal interest in medicine and the poem, I reply that they amount for me to nearly the same thing," he wrote in his Autobiography.^[1] He stayed in active medical practice until 1951, when a stroke forced him to stop.

Williams spent part of his internship at Nursery and Child's Hospital ("Sixty-first Street and Tenth Avenue . . . just across Tenth from the most notorious block in the New York criminal West Side, San Juan Hill or Hell's Kitchen, as you preferred to call it").^[2] There he spent a lot of time in pediatrics. "I was fascinated by it and knew at once that that was my field," he said.^[3] In his works, in fact, we sense his fascination for children, even—perhaps especially—for the most difficult and obstreperous ones. Mathilda in "The Use of Force" is such a case.

In this story, the doctor-narrator goes to the patient's house. The mother, father, and girl, "an unusually attractive

little thing, and as strong as a heifer in, appearance,"^[4] are huddled in the kitchen for warmth. Just from looking at Mathilda the doctor knows she has a high fever. She has been sick for three days, yet has been denying that her throat hurts. The doctor and Mathilda's parents are concerned because they know there have been several cases of diphtheria in her school. But she absolutely refuses to let the doctor examine her throat. Not only that: when he moves his chair closer to her, she tries to claw his eyes and, in so doing, knocks his glasses onto the floor. It becomes a battle.

If you don't do what the doctor says, you'll have to go to the hospital, the mother admonished her severely.

Oh yeah? [the doctor thought.] I had to smile to myself. After all, I had already fallen in love with the savage brat.^[5]

Despite his "love" for Mathilda, the doctor finally grows furious with her.

I grasped the child's head with my left hand and tried to get the wooden tongue depressor between her teeth. She fought, with clenched teeth, desperately! But now I also had grown furious—at a child. I tried to hold myself down but I couldn't.^[6]

When he finally gets the tongue depressor behind Mathilda's last teeth, she bites down so hard she reduces it to splinters. He orders the mother to give him a smooth-handled spoon.

The doctor's anger is now beyond control. Rationally, he knows that if he leaves and returns in about an hour he will probably be able to examine the girl. But he also realizes that he now relishes his anger and hate: "The worst of it was that I too had got beyond reason. I could have torn the child apart in my own fury and enjoyed it. It was a pleasure to attack her. My face was burning with it." Naturally, the physician tries to rationalize his behavior to himself: "The damned little brat must be protected against her own idiocy, one says to one's self at such times. Others must be protected against her."^[7] But he knows there is more. Cou-

pled with his fury and desire for muscular release is his shame at being defeated by a child.

[A] blind fury, a feeling of adult shame, bred of a longing for muscular release are the operatives. One goes on to the end.

In a final unreasoning assault I overpowered the child's neck and jaws. I forced the heavy silver spoon back of her teeth and down her throat until she gagged.^[8]

And there he sees it: her tonsils covered with membrane, the terrible sore throat she had been hiding and denying for days.

In the end, the doctor is glad of his victory, yet he also feels compassion for the child's defeat. His final words reveal his sense of triumph as well as his sympathy for Mathilda. "She had been on the defensive before but now she attacked. Tried to get off her father's lap and fly at me while tears of defeat blinded her eyes."^[9]

For several reasons, Williams' anger and hatred toward his pediatric patient do not last. First, he has conquered this seemingly unconquerable creature. Second, although he has vented his anger on her, he has the satisfaction of finding her unhealthy. Thus, the negative implications of an act potentially comparable to rape (the story's title alerts us to this hideous violation) are safely dissipated. Third, his feelings about her are ambivalent: a combination of hate and love, resentment and admiration. The doctor always reminds himself that this patient is just a child, smaller and weaker than he. And we sense that the doctor-narrator likes his patient's wildness, willfulness, and stubbornness as much as—or maybe even more than—he hates it. Perhaps it reminds him of the fierce and persistent qualities in himself, of the very fierceness and persistence that eventually enable him to conquer his patient.

What happens, however, when a doctor faces and vents his anger at a wild and powerful adult male patient? Such a full-blown fury—both the doctor's and the patient's—is described in a story by Richard Selzer.

Richard Selzer

Born in Troy, New York, in 1928, Richard Selzer received his M.D. from Albany Medical College in 1953 and practiced general surgery in New Haven, Connecticut, where he was on the faculty of the Yale University School of Medicine. He is the author of several books of fiction and essays that deal, for the most part, with medicine.

"Brute" is Selzer's narrative of an event that happened twenty-five years before in an Emergency Room of a city hospital. It is the story of a hate-filled patient and a hate-filled doctor, each of whom, in his own way, is the "brute" of the title.

It is 2:00 a.m. and the surgeon-narrator is on call. He is bone tired. The police bring in a new patient, a "huge black man" with a gaping wound "deep to the bone" across his entire forehead.^[10] Fuming and murderous, the man seems to the surgeon like a wild horse or some mythological beast.

At the door, the mans rears as though to shake off the [four policemen] . . . who cling to his arms. . . . Again and again he throws his head and shoulders forward, then back, rearing, roaring. The policemen ride him like parasites. Had he horns he would gore them. . . . The man is hugely drunk—toxic, fuming, murderous—a great mythic beast broken loose in the city^[11]

After the man has been tied down on the table, the surgeon examines his wound. It will take at least two hours to fix. Although the doctor is exhausted, he is strangely exhilarated: almost in love with the untamed man. "I am ravished by the sight of him, the raw, untreated flesh, his very wildness which suggests less a human than a great and beautiful animal."^[12] The surgeon is "ravished"—enraptured but also seized, as if sexually—by the man's wildness and by the wound in which he sees not ugliness but greatness and animallike beauty.

When the surgeon starts to cleanse and debride the wound, the man groans, lifts his pelvis from the table, and

rolls his head from side to side. "Hold still," the surgeon says. "I cannot stitch your forehead unless you hold still." The man rages, and the surgeon-narrator remarks:

Perhaps it is the petulance in my voice that makes him resume his struggle against all odds to be free. . . . But why can he not sense that I am tired? He spits and curses and rolls his head to escape from my fingers. It is a quarter to three in the morning. I have not yet begun to stitch. I lean close to him; his steam fills my nostrils. "Hold still," I say.

"You fuckin' hold still," he says to me in a clear, fierce voice.^[13]

The surgeon loses control. "Suddenly, I am in the fury with him. Somehow he has managed to capture me, to pull me inside his cage. Now we are two brutes hissing and batting at each other. But I do not fight fairly." For the surgeon explains how he takes some heavy, braided silk suture and sews it through the patient's earlobes and also through the mattress on the stretcher. Now the man's head is sewn taut onto the table, into the position the surgeon needs for stitching.

"I have sewn your ears to the stretcher," I say. "Move, and you'll rip 'em off." And leaning close I say in a whisper, "Now you fuckin' hold still."

I do more. I wipe the . . . [clots of blood] from his eyes so that he can see. And I lean over him from the head of the table, so that my face is directly above his, upside down. And I grin. It is the cruelest grin of my life. Torturers must grin like that, beheaders and operators of racks.^[14]

Vanquished, the patient stays still. From 4:00 until 5:30 a.m. the surgeon stitches. Then, he snips the silk threads from the man's earlobes and helps him to sit up. In the doctor's eyes, the patient now appears beautiful, powerful, and regal. "The bandage on his head is a white turban. A single drop of blood in each earlobe, like a ruby. He is a maharajah."^[15] The police pull the man away.

It is twenty-five years later, yet the surgeon still feels guilty about that case—not for having sewn his patient's earlobes to the mattress but for his vindictive grin of triumph. "Even now, so many years later, this ancient rage of mine returns to peck among my dreams. . . . How sorry I will always be. Not being able to make it up to him for that grin."^[16]

Because the surgeon was ambivalent about his patient, his terrible grin, the sign of his avenging anger, comes back to haunt him. After all, Selzer implies, although that patient felt no pity for the surgeon (or for himself), he still deserved some pity. For the doctor, who was stronger, not physically but just because he was the doctor, expressed his anger cruelly or at least unfairly. The surgeon has exchanged guilt for the hatred he expressed.

Reflections

William Carlos Williams, who felt love and hate for the fierce Mathilda, vented his anger on her and conquered her. Richard Selzer, who loved and hated his raging patient, continued to feel guilty about his act a quarter of a century later. Both these doctors could feel ambivalent or guilty about their anger precisely because they had expressed it.

The doctor in Duchess' case was different. Since he never did vent his anger on Duchess (except in his many private fantasies), he did not feel guilty for hating her and for continuing to hate her years after her death. But he did feel sad about it and wished that his recollections could be otherwise.

Naturally, Duchess' physician did—and does—feel sympathy for other people on dialysis and for other patients suffering from a variety of medical, sociological, or psychological ills. But he felt no sympathy for Duchess, who always received the best modern medical care and who always

tried to disgrace, disgust, or destroy the medical staff assigned to her.

It is distasteful to think that a physician can hate a patient. But a doctor—like any other person—can sometimes, when pushed to the extreme, return hate for hate. Although it is not a praiseworthy reaction, it is perhaps an understandable one. In fact, on those rare instances when a doctor is forced to take care of a particularly abusive patient, hate may be the only refuge or defense the physician has left. On those occasions, the doctor's hate may be strangely healing because it enables him to face, not reject or refuse to treat, his patient. Still, this curiously healing hate, whether expressed toward the patient or suppressed, is itself—as hate always is—a kind of wound. It mars the physician with scars of guilt or sadness which not even many years can erase or ease from the memory.