Anger, and Caring for Those who Made Poor Choices, from MCN’s Dr. Madaras

Tue, 01/25/2022 | by Laszlo Madaras

Clinician speaking with patient

By Laszlo Madaras, MD, MPH, Chief Medical Officer, Migrant Clinicians Network

Thirty years ago, on a late summer August evening during my trauma surgery rotation in 1991, I was called in to assist the surgeon with an 11-year-old girl who was in an automobile accident and was thrown through the front windshield of her parents’ car. Unfortunately, there was nothing much we could do. The trauma surgeon called the time of death and then asked me to stay in the room as more tearful relatives arrived to say their goodbyes. It was agony to see the suffering of the family members come in, one by one.

I was then called to sew up facial lacerations on another patient in the emergency room, also involved in a motor vehicle accident. The man was intoxicated and somnolent, and I repaired most of the facial lacerations without difficulty.

During my laceration repair, the chief resident came and let me know that this patient was the driver who hit the family car and killed the little girl in the other room.

I became very angry. Part of me no longer wanted to provide any care for the intoxicated patient peacefully sleeping in front of me. As doctors, we are trained that we need to provide care, regardless of who “deserves” care, but this commitment did not buffer my strong and immediate emotional reaction to this patient.

Ultimately, this man had no visible physical facial scars once the sutures were removed by me a week later. I do not know what kind of emotional scars he carried after that, knowing that he had killed a little girl. I had to see this patient recover over the next few days and had to present this case with the other medical students on the trauma service. I spoke very little about my feelings of anger during this time. I cared for the patient as best I could, regardless of these emotions.

This was not the only time that I have had to care for patients who were in situations that required my focused and immediate care, but still sparked my moral outrage.

During my ER rotation during residency, we often had gang-related shootings in Providence, Rhode Island. We did not ask who started shooting first, or whether the patient in front of us was an innocent bystander who just caught a bullet. We had to take the most serious case first and triage each patient according to severity and not on the level of the blame they merited for starting the gunfire.

In Rwanda in 1994, Rwandan Hutus killed Rwandan Tutsis in a terrible genocide. Just a few weeks later when cholera broke out in the refugee camps, I provided massive IV fluid hydration to many in the community, including some of whom were guilty of murder and rape just a few weeks before. This also weighed heavily on me.

But of course, I don’t frequently see murderers in my day-to-day work. I do, however, see many of my "noncompliant" patients returning to the emergency room, re-hospitalized by me after making poor choices since their last hospitalization. I could also be angry with them for using up resources and beds when they could have made choices that would have kept them out of the hospital. Those who continue to smoke while fighting lung cancer, or continue to eat poorly after a cardiac bypass surgery, all take up that space in the hospital, so indirectly affect the health of others who arrived there out of misfortune, not by making poor choices.

COVID-19 has forced me to look at these issues anew. Once again, I see how one’s personal choices – to get the vaccine or to not get it – are directly affecting the health of neighbors, family, the community -- much like drunk driving.

Over the years, I have learned that while experiencing true anger can be a healthy response to some situations, my anger doesn’t serve me in the direct doctor-patient relationship, and rushing to judgement cuts off a potential human connection to my patient. Part of this approach comes from my Peace Corps training which taught us to learn about other cultural, emotional, political, and religious views that differ from ours, and while not necessarily agreeing with them nor adopting those views as our own, we can perhaps rush to compassion and crawl to judgement.

Now, almost every day that I work in the ER, I care for patients who could have been vaccinated but chose not to. Instead of one patient that invokes anger, I have dozens, every week. In the ER, as they lie suffering and often dying of COVID, they ask for any help, any medicine or therapy that I can provide, to save their lives – when they had already forgone the vaccine, which is the best, safest, and proven method for keeping them out of the hospital. I admit, I do get angry. But I also realize that I am there to treat them, all of my patients, the best I can. I become their doctor during the course of their hospitalization at a time when they may die even with my best care, or be denied a ventilator simply because there are not enough to go around.

I believe that feeling anger in these cases is justified, but not directly helpful in the moment because to the sick and injured we offer an important service and there is work to be done. So, at the one-year anniversary of COVID vaccines becoming free and available in many areas of the United States, and as I head into the ER again this week to serve dozens of unvaccinated people who are struggling to breathe, I put aside my anger for now.* I am here to treat you, regardless of who you are or what you have done. I will continue to push to save your lives. Because that’s what a doctor does.

*Putting aside anger in the exam room for the short term may be necessary, but in the long term, it needs to be recognized and addressed otherwise it may express itself in other unhealthy ways. To address this, Kaethe Weingarten, PhD, Director of Witness to Witness, has developed this resource on how to deal with this anger.