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“Dr. George!” my patient yelled across the sidewalk as we all filed out of our office building as the fire alarm blared in the background. She came hurtling at me, as fast as she could move her 400 pounds of body. “Why didn’t you ever call me?” I could see heads turn and stare. Tears were streaming down her face as I focused all of my energy on keeping an even tone and calm voice while secretly wishing I could melt into the crowd and have a security backup. I gently informed her that I did indeed get the encounter from the nurses saying she’d called, but it had only been a couple hours, and I had been seeing other patients that day. I sat her down and we talked about what was going on. She still had a headache, something that had been persistent for some time and started after her last boyfriend had hit her. She was on her way to the emergency room (ER) to get checked out again, and I couldn’t convince her otherwise.

Madison (name changed to protect patient privacy) was a 20-something-year-old who frequented the area emergency rooms for various complaints. I became her primary care physician my second year of residency. We got to know each other very quickly. I would receive ER report after ER report, call after call of various complaints. After the first several times I saw her, she came in with a case worker from an area mental health agency. The case worker joined us for the visit with the permission of the patient and interjected quietly but mainly supported the patient with simple verbal and non-verbal encouragers. Madison was every physician’s definition of a “difficult” patient. She was a frequent flyer, so to speak, to the point where I finally just scheduled her for an office visit every month to try to keep her out of the ER for complaints that were not emergencies. During her office visits, we would easily address 10 or even 12 complaints, many of which were minor or simply had no physical basis. Her case worker came more and more often, which was a tremendous help.

She called me after one of Madison’s visits to provide some more information that I hadn’t been able to elicit. Madison was pretty much on her own. Her family was not involved, and, ultimately, she should have been plugged into the MRDD Board’s system, but was tested in school. She lived in an apartment with no oven or stove and didn’t have a bed. She slept on the floor. The only thing she was able to “cook” were microwave meals. She had a difficult social life and, in order to find support and love, frequently provided herself for male and female partners. She had significant depression and anxiety that was under moderate control by a local psychiatrist.

Armed with this information, we continued our monthly visits together. She started passing out frequently and the ER visits piled up again. We spent 3 months discussing why she was passing out and what she was feeling before and after. Nothing abnormal showed up on testing. She came to the office one month, and I delved into how she was coping with her current situation. She immediately looked at me, closed her eyes halfway, and slammed back on the exam table. I made sure she was breathing and her heart was beating and checked her sugar and blood pressure, all of which was normal. Her case worker and I started talking to her. As we talked, she would peak open her eyes once in a while, but not respond. After a while, she opened her eyes, sat up, and started interacting. I told her that I thought that her passing out spells were a manifestation of how she was dealing with her current stressors, to which she immediately passed out again. We checked a couple labs and I let her go. The next month, she was in the ER less and less. She went to group therapy more and more. When she came into the office, there was a commotion in the hallway. Our charge nurse came and got me because she had passed out in the hall. I went out to her, talked to her quietly, got her up, and put her in a room. We made sure she was hemodynamically stable and gave her a drink of water. That visit, she was very open to how her stressors were affecting her physical body. She started to understand that when she was anxious or in loud places, she passed out. After that, it stopped. She stabilized. Her case worker helped her get a mattress. She was able to get moved into an apartment with an oven. I felt comfortable enough with her psychiatric stability that I referred her to bariatric surgery for surgical weight loss management.

We continued to have monthly office visits, addressed her many complaints, which, by that point, I could firmly say were psychosomatic, and much of the visit was just reassuring her that everything was fine, she wasn’t dying, and she would be back next month to see me. One day she showed up in the clinic hysterical. One of the medical assistants put her in a room and immediately got our behavioral health coordinator (BHC) to see her. The BHC came out of her room wide-eyed. Madison was having an acute psychotic episode. She was suicidal. She was saying she was demon-possessed and that the demons inside of her were trying to get out. Her eyes were blood shot from crying. She was screaming. The BHC said that she was fearful of Madison when she was in the room with her alone because of how aggressive she was talking. She didn’t try to hurt anybody, but she was making a ruckus.

Everyone could hear her. I went into her room and completed a medical assessment of her. As I moved to the psychiatric portion of my review of systems, she got agitated. I asked her to expound upon what she had told the BHC. She told me what she had said and then broke down saying that she didn’t want to get sent to the ER. She knew the path of what she had said.

As soon as I told her I had to pink slip her for her safety, she freaked. She yelled and screamed and cried. I told her that I would be back with a box of tissues for her and left the room, telling one of the staff to call security because she was going to try to leave. She did indeed try to leave, snarling at anybody who got in her way, but thankfully, the security office is right across the street, and they were in our office within a minute. They caught her trying to go out the office door, guided her back in, all while trying to de-escalate a screaming woman. It took four of them to get her in a room. She tried to grab one of their guns, so she had to be hand-cuffed. I wrote the pink slip and sent her to the ER for psychiatric assessment. While I was completing all the paperwork and calling the psychiatric resident and ER, I could hear from down the hall, “Dr. George, I’m going to find you and kill you,” followed and interspersed with a slew of expletives. I checked on her status in the ER throughout the afternoon (she had been my first patient of the day). The psychiatric resident saw her and discharged her straight from the ER. I couldn’t believe it. All of that screaming, talk about demon possession, hate, and threats that came from this woman I had taken care of so carefully and diligently for 18 months was just that, screaming, hate, and threats. She wasn’t psychotic. She wasn’t manic. She wasn’t suicidal. She wasn’t delusional.

I had a real internal struggle about how to process this information. I felt threatened. She knew where I worked, and I firmly thought she was capable of getting a gun and coming to find me. She didn’t have the coping mechanisms to deal with what she viewed as the forceful removal from my office to the ER. I talked to our medical director, a couple of my supervising attending physicians, and our department psychologist. They all encouraged me to dismiss her for her behavior. She put multiple people at risk, and if she came in and saw another provider after acting like that and it happened again, I would feel terrible. The behavioral health specialists in the office helped me the most. They had met with her multiple times and knew her disabilities and viewpoints. They affirmed that if the psychiatrist did not feel that she was psychotic, then she knew what she was doing while she was at the office, and that behavior crossed a line. Even though she had certain disabilities, she still had to be held accountable for her actions.

“Firing” her from my practice was one of the hardest things I did during residency. I was, simultaneously, relieved, exhausted, and disappointed in myself for not being able to be of more help to her. I had spent a year and a half forming a relationship with and doing what I felt was going above and beyond for this person who then threatened me. I did not know, still do not know, how to resolve the turmoil and disparaging feelings I was having.