The difficult patient.

I first met Sam during the third month of my hematology/oncology fellowship. I had just started the acute leukemia hospital service, and while getting checkout from the outgoing fellow, I was warned, “He is a handful.” I learned that he was 21 years old, had been diagnosed with acute lymphoblastic leukemia (ALL) just 2 weeks after getting out of jail for a sexual offense, had a history of drug abuse, and was giving the nurses fits. Sam’s family was also causing problems—his wife was 8.5 months pregnant, and his mother was not easy to deal with. He had become infamous after only 3 days in the hospital. I walked into Sam’s room to introduce myself, knowing that we would have 1 month together on the hospital service while he was undergoing induction chemotherapy. On top of that, the fellowship program’s policy meant that he would become my patient in my continuity clinic on discharge. Our first meeting was a disaster. He used foul language, made an inappropriate comment toward me, and made it very clear that he was going to be the bane of my existence for the remaining 33 months of my fellowship. During induction, neutropenic fevers, mucositis, and the birth of his child tamed his behavior somewhat. He was dismissed from the hospital, and started follow-up with me as an outpatient. My attending physicians were sympathetic to my plight. Although I was given the option to have one of my male colleagues take over his care, it was early in my fellowship, and I was determined to follow the rules and be strong. So I gave Sam clear boundaries for our patient-physician relationship—basic things like no cursing, no vulgarities, and being respectful to me and the medical team. We survived intensification and consolidation, along with the discovery that he was not the baby’s father, his subsequent messy divorce, and ongoing arguments with his mother that resulted in him getting kicked out of the house. His behavior continued to be a problem. I struggled to keep my sanity when he got a tattoo when still neutropenic, when the nurses from the hospital called me to tell me about his suspected involvement in missing cash from another patient’s room, and when his parole officer called to ask me for help with his conduct. Because he adamantly refused to receive intrathecal chemotherapy without my presence (and I knew that he needed it), I had to regularly leave other obligations to administer methotrexate. I often had to remind myself that my job was to cure him from leukemia, and not strangle him in the process (first do no harm). I do not know when the shift happened— when Sam went from being an inappropriate and demanding patient to someone who was respectful, considerate, and funny. I realized that in his chaotic life, I had become one of the only people that he could count on. The nurses, social workers, clinical assistants, and I had evolved into his extended family, his support system. I started to feel like he was my younger brother. Our appointments became a mixture of talk about his treatment, symptoms, and stressors in his life. I provided encouragement, and also was tough—we set goals for his life (get a job, finish parole without another offense, see a psychologist for ongoing therapy to help the anxiety), and at each appointment, we checked his list to monitor progress. It was give and take. I prescribed dronabinol to help with his nausea (“nothing else works,” he claimed), and he did his best to make it to every scheduled appointment. We celebrated his remission, and I tried my best to maintain his compliance with the maintenance chemotherapy. The successes came slowly, but they came. He got a job. He bought a car (although it usually broke down on the day of appointments). He started dating. He moved into his own apartment. And finally, he got his general equivalency degree (GED). Sam was granted the GED in December. He was proud when he told me. I was so happy for him, knowing the opportunities that would now be available to him. A few months later, he casually mentioned that he had been chosen for an award at the GED diploma ceremony in June, for overcoming adversity while seeking an education. I beamed like a proud mother. At the next month’s appointment, shyly, somewhat embarrassed, he said, “Hey, if you can make it to the graduation, I have to give a speech, and it would be cool if you were there.” JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y: When the Tumor Is Not the Target VOLUME 26 NUMBER 24 AUGUST 2