Early in my medical student career, I was in a COPD clinic for a horizontal elective. All the patients had the same problem: COPD. Hence, they were all treated in basically the same way: inhalers, antibiotics, home oxygen… But they all had such different stories to tell.

The physician I was with was very skilled in this area. There was no doubt about it. He had these patients referred to him from the very beginning.

But there was just something about it.

It was as though he had given up.

Whenever a patient walked in, and revealed that they still had not quit smoking, he filtered out all that they were saying. He did not address any of their other concerns because he couldn’t. He told them there was nothing he could do to help them if they don’t quit smoking because that was the problem in the first place. All those other problems they were listing all stemmed from smoking.

When the appointment was over, the patient would take their prescription slip and leave, with a surprisingly neutral expression. To be honest, it seemed like the patients had given up as well. It was as though they were just part of a cycle, a cycle that strived to improve the quality of life. Even the patients who had already quit smoking could not escape this cycle. Granted, they looked happier in comparison with those who hadn’t quit, but still, it was a routine.

The idea of giving up is very subjective, so I thought that perhaps there was something wrong with me. I asked the physician about it afterwards, to which he replied “I can’t help them if they don’t help themselves.”

I was a bit shocked; it was like he had abandoned the patient and left them out on the curb to fend for themselves. Like he didn’t care at all.

It reminded me of a communications class I took in undergrad, where we had a standardized patient who was a distressed abused woman. When I went into the room, I saw her sobbing and I completely froze. I asked her if everything was alright, and if she needed a few moments to gather herself. Our facilitator stopped the interview and told me I had built up a wall with just that statement. She needed a few moments to gather herself. Suddenly it was her problem, and hers alone. This was not the right approach because she was here for support and for help.

Was this doctor building up walls? Did he even realise it?

Then I started to wonder, truly, what is the point of these patients coming anymore, looking for change? He said he wasn’t going to do anything differently if they didn’t quit, mostly because there was nothing he could do.

But really, was there actually nothing?

At the time I agreed; quitting smoking is the number one thing that is on the treatment list for COPD patients. We had learned and been stressed that so many times.

Now, I’m not so sure. Maybe there could have been some more that he could have done. I distinctly remember one patient who said they had quit smoking, but who I could distinctly smell the tobacco smoke on their breath as I listened to their lungs. I didn’t want to make any assumptions, so I didn’t bring it up. I remember looking at some of the patients and pondering their socio-economic statuses. Perhaps they could have used some help with social work? It’s very difficult to quit smoking too; maybe there was some assistance or resources he could have directed them to? They always told him that they were trying to quit, but couldn’t. Maybe they just needed a helping hand.

And the way he said it… “Just quit smoking. You need to quit smoking. Or you will die. Do you understand that?” He made it seem so simple. In reality, it is anything but simple. It becomes a part of your life, and you are consumed by it. It is as though you cannot live without it, a reality worse than death. But maybe that’s just what they wanted to do, die. Maybe this was a plea for attention, a window of opportunity that was missed.

I don’t know what was worse, hearing those words uttered by the doctor, or the patient being so numb and desensitized to that reality.

Perhaps I am being too harsh. Perhaps he had tried to offer resources for them to quit, and that didn’t work. Perhaps years of facing these patients made him realise that typical means will not solve the problem. It would just be a waste of time, and even ineffective. Maybe in these cases they just needed to hear the truth. Perhaps this snapshot of how he treated them now was the complete opposite of what it had been years ago. Perhaps he had exhausted all of his efforts and this was a last resort.

It’s difficult to not be judgmental in these situations.

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