If you are a woman therapist in your late 40s, about 5'7" (“but not too tall”), blond of hair, conservative in dress, self-assured, nurturing, non-flamboyant with a pleasant voice, I want to meet you.
Not because I need you. Clara is looking for you and has been for years. All primary care physicians have patients we call our albatrosses or crosses to bear, and Clara is perhaps my heaviest. If you fit the above description that she requires, maybe you can help me.
Clara is 46 years old, blond, sad-faced and cherub-cheeked, and has been my patient since March 1993, when she came to me for a referral to a therapist and relief of a skin rash. With a soft, hoarse voice, she detailed her complaints in quick outbursts, implying a desperate urgency. When she returned for a physical exam eight days later, she burst into tears several times as she told me the situation that has doomed her to perpetual unhappiness: she is lonely and has an overwhelming need for companionship, but she is too abusive and intolerant to have any close relationships.
She did not say this, because she does not recognize her abusiveness. She told me that she needed money. She was having difficulty finding a job that did not involve the public. “I don't like people” was her explanation at the time.
Berkeley, it turns out, has “too many weirdos,” whose frequent usage of the adverbs “basically” and “exactly” annoys her. She is also afraid of anyone who isn’t white.
She would move to an all-white area but can’t afford to. Instead, she lives in her one-bedroom apartment and broods all day about her loneliness, the “hellhole” she inhabits — the two “juveniles” living next door, students at U.C. Berkeley, make far too much noise — and whatever minor health concern over which she chooses to perseverate on a given day.
Nothing I do is more difficult than trying to develop a working doctor-patient relationship with people who cannot form relationships, and Clara has been my most formidable challenge. When she calls the office I know I’m in for a rough evening. Her calls always take a long time, usually 30 minutes or more, so I cannot answer them during the day. They start with her saying in a beleaguered tone, “Yeah, well, I just wanted to ask a question..." and then she asks the question. One of her frequent concerns is, “Can years and years of stress and anxiety cause me to have hypertension and heart disease?” She soon follows with “Am I going to die of a heart attack?”
This is typical of the worries she has. An internist who used to be her doctor once told her that stress can cause high blood pressure and heart disease. Clara has a normal blood pressure, usually about 120 over 80. She does not have any of the other risk factors for heart attack, which include diabetes, high cholesterol, cigarette smoking, family members with heart attacks, and menopause. I have therefore advised her that, despite her years of anxiety and stress, she is in fact at very low risk for heart disease.
We have had this conversation many times, and each time she tells me that internists are more expert in heart disease than I am, so I haven’t any business contradicting what her previous doctor said (never mind that I’m not contradicting what he said; I’m just saying it does not apply to her). This then leads to more insults. “You’re not like my old doctor, I don’t trust you,” “You don’t care about me anyway,” or “You’re too young to understand me.” She pushes my youth button almost every time we talk. It’s an insecurity I’ve had to battle ever since I began private practice almost five years ago. My balding head and recently acquired need for glasses have helped, but patients comment daily on my youthful appearance (I am 34 and look about that), which puts more than the usual pressure on me to make sage comments and assume my most fatherly countenance so my patients can convince themselves I am a worthy shepherd of their health.
I also have an expertise button. As a family practitioner, I have a specialty; the management of common medical problems in all age groups. To earn board certification in family practice, one must complete a three-year residency program, not the one year of internship that general practitioners used to do. So when patients ask, without seeking my opinion first, for a referral to a specialist to manage their acne, arthritis, asthma, or congestive heart failure. I feel insulted; these are the types of problems my training prepared me to manage. Patients often do not realize that I can handle these illnesses, and when I explain my training, they are happy to let me treat them. I'here are some, however, who insist on seeing a specialist. Because many of the managed care insurance plans require that I not refer problems I can manage myself, patients sometimes think I am obstructing them from the specialists they want to see. This, along with the misperception that generalists are generalists because we’re not smart enough to be specialists, can cause our patients to be skeptics and not follow our treatment plans, setting us up to fail. Few patients insult us directly, and none of mine do it as often as Clara.
Every conversation with her is a blindfolded journey through a minefield. I have navigated the field often enough to know when the explosives lie. but they often seem impossible to avoid. They derail most of our conversations long before we can form treatment plans. If I make the mistake of responding, “Clara, I...” she shoots back, “Don’t keep saying my name; that’s patronizing." That's an example of one of the most maddening aspects of these exchanges: her accusations often contain a small kernel or suggestion of truth. When I get annoyed with her, I address her by name. I think it is the same reflex my mother had (“James Edward, that’s enough!"). I fight it but never manage to suppress it for an entire conversation.
Explaining any concept is a dangerous mission. When I try to justify my conclusion that she is at low risk for heart disease, I keep my language basic and define all my terms, but at some point, she will interrupt with ‘Wait. Wait. Slow down. Your explanations are always confusing. Explain that again one more time." I always obey, bracing myself for another attack because at some point during the second attempt she will say, “Yes. You said that already. You don’t have to repeat yourself. Don’t talk down to me! You’re always so condescending. My old doctor used to talk to me. But you’re not like him. You don’t care about your patients.”
Newer mind that I spend hours on the phone with you and make home visits to check your blood pressure. I say to myself, attempt ing to summon my reserve of calm that prevents me from losing my temper. Who else would do this?
“So you don’t think I’m going to have a heart attack because I have a normal blood pressure, normal cholesterol, and no other risk factors. Is that right?” “Exactly.” I realize before the third syllable escapes my lips what’s coming next.
“There’s that word again. ‘Exactly.’ Why do you and everyone else here use that word so much?”
Even when I avoid the “no trespassing” zones, she keeps me off balance. “A doctor recently told me that Medi-Cal is like a marriage. What did he mean by that?” she once quizzed me. I had no idea, but I knew I couldn't pause to think unless I wanted to hear once again that I never listen to her nor answer her questions. I would also have to avoid implying that she had anything in common with any other patients who have Medi-Cal as their insurance. nor could I use the term “Medi-Cal patient” because “I’m not like those people, and it’s very demeaning.”
The truth is that about 20 percent of my patients use Medi-Cal. They are usually poor and mentally ill, and although the reimbursement rates for adults are pathetic (they pay the doctor $16.56 for the usual appointment), I take more of them because they are as deserving of medical are as anyone else. I do not use the term “Medi-Cal patient" as an insult.
So what was the answer to the riddle about Medi-Cal and marriage? I have never figured it out, and I can’t remember what I told Clara, but I do know she hung up the phone in disgust, which is how she terminates about a third of our conversations.
Three years ago, I was dating Jane, a student at the Wright Institute at U.C Berkeley; she was getting her PhD. in psychology. Jane followed my progress with Clara from the skin rash that prompted the first appointment, through the several months when Clara became more uncomfortable coming to my office, until her anxiety attained such intensity that she was, and is, no longer able to come to my office. Clara’s anger and hostility toward me intrigued my friend. “She wants to fuck you," Jane informed me.
That’s another one of my buttons. I was a virgin for the first 24 years and nine months of my life, and as I was approaching a quarter century of celibacy, I remember thinking that the only women in this world who would ever want me were of unsound mind. Those thoughts have almost disappeared, but when prompted, the bitterness resurfaces. Fortunately, if this is a source of Clara’s frustration, her mind is too disorganized to allow her to make that connection, so given that I do not know any other doctors in this community who would accept anyone like her into their practice, I continue to he her doctor.
Perhaps sexual feelings intensify the minefield when she talks to me, but Clara has problems interacting with everybody. She went to a dentist this month and began asking detailed questions about the method he uses to sterilize his instruments. As with most of Clara’s concerns, this one had some legitimacy, given the newspaper coverage in recent years of HIV transmission through dental instruments. After the dentist explained that he used chemical sterilization and gave a brief outline of how that works, she did what she always does: she asked for more details. I am so familiar with this pattern of hers that I know what happened next; he tried to give a quick summary of how the chemical works, to which I’m sure she replied, "Wait. Wait. Slow down. Explain that again so I can understand.” At some point, he gave up and told her he could not answer any more questions.
“He’s so arrogant” was how she characterized the experience. To compound matters, Clara said there were two women in the waiting room gossiping about how cute the dentist was. “How do you fell about that. Dr. Eichel?” she demanded to know.
She caught me off guard, as this did not strike me as the kind of situation that would require my professional opinion. “About what?”
“There you go again. Were you listening to me? About two women doing that in the waiting room. How does that make you feel?”
I thought for a moment “that isn’t something a dentist or doctor can control, so I wouldn’t give it much thought or attention. I’d prefer that it didn’t happen, if that’s what you mean."
“Yeah, well, I guess I should just find a different dentist I really didn’t like him.”
Nobody likes her either. Her most recent crisis came up two weeks ago when her last friend, a middle-aged man whom she has known for over ten years, decided he did not want to talk to her anymore. She says he would never see her unless they met at her place, where he always made unwanted sexual advances. She wanted to meet him at a restaurant or other outside location to give herself a chance to get away from the misery she feels at home and to prevent the physical contact. They had a romantic relationship that ended years ago. More recently, they argued whenever they talked, and the last argument led him to end their association. Clara wept during our discussions of this situation, and it was impossible not to pity her, a poor, plain-looking, mentally ill woman of average intelligence begging me to help her win back her only friend, a man who won’t let anyone see them together. This pity is part of the empathic force that prevents me from dismissing her as my patient.
After enduring the usual litany of insults, I advised her to write him a letter telling him how much she values his friendship, which she did, but this has yet to yield any positive results. So what can she do now? Her mother died many years ago, and it is her mother that Clara is trying to replace with a therapist.
She fired her last therapist in 1986, and she hasn't found another who suits her. I did find a psychiatrist in Berkeley last year who had all the characteristics on Clara’s wish list, but Clara hated her office staff and will not go back. Heather, a middle-aged female psychologist who works with many of my patients, just finished searching all the resources in our region to find anyone who might see Clara. Part of the problem with referring Clara is that if Heather or I send her to someone who does not know us well, we will never be able to refer anyone to that person again after sending such a patient. We were not successful; Clara won’t see Heather, and the only other possibilities would require Clara to work with training interns, many of whom have professional experience and are doing internships to broaden their expertise, but Clara refuses to see an intern.
All of which leaves me as her only source of care, something that happens to primary care physicians when problems are beyond the scope of specialists or when specialists aren’t available. I will do what I can for as long as I can withstand her relentless attacks. I’m getting better at it. Last night she called to tell me how angry she was that I had dared to characterize her as introverted. In a recent conversation, I tried to help her figure out how to improve her social life. After less than a minute, she hung up. I’m happy to report that my first response was not anger but relief at the brevity of our exchange. Many longer ones await us.