Medicine and the 'difficult' patient

Medicine changes people. For better or for worse, it has the potential to transform the most idealistic, I-want-to-help, good natured, hard working MS1 into a bitter, angry, and uncompassionate resident. For example, during conversations with my team in the hospital:

"[deadrocketcow], I swear I never used to be this mean. I never used to complain this much."
"I remember when I couldn't wait to be a resident. I thought it was all glamorous and helping people. But really, all you do all day is make calls and work with difficult patients. You're basically a glorified secretary."
"This sucks."
"Oh....no! Another admission? The Emergency Department admits everyone! Somebody shoot me."
"This guy [patient] is unbelievable! What does he want from me now?! Tell him to stop paging me already."

Looking at that, you might think I am surrounded by some of the most mean spirited people - doctors who don't care a fig about their patients. But after you have been working a 30 hour shift every 4 days for the past 3 months, on top of a 14 hour 'normal' work day, with no consideration for weekends, this does not sound all that unreasonable. Especially, when you have to work with the not so occasional 'difficult patient'...

Patient X, an active cocaine user, was admitted to the hospital with extremely high potassium levels (this is a dangerous thing as it can cause heart arrhythmias). He had been told for several years now that he would need dialysis, as his kidneys were no longer functioning correctly, but had decided he was not ready. Well, this time, his kidneys decided for him that he was ready since they could no longer rid his body of excess potassium. During his admission, he was beliggerent and rude to the nurses and our team, constantly demanding more pain medication, refusing to take his medication for his extensive co-morbidities, devising his own dosing schedule and demanding that we change his meds to that effect. He would also leave the hospital for hours at a time without telling his nurses, to smoke and engage in other medically frowned upon activities.

What is interesting were the contrasting attitudes my team had towards this 'difficult patient'. It was apparent that the further away you were from the start of your medical education, the more likely you were to be cynical and dismissive of this 'difficult' patient's needs, thinking "If he doesn't want to be treated, then why is he here? Let him leave."
Being fresh and naive on the medicine team, my thought was "this man is depressed about his life, his illnesses and the fact that he now needs to depend on a dialysis machine for at least 4 hours every other day in order to remain alive. He feels helpless, has no more control over his life and is expressing it by being difficult and rude to the team."
The intern, who is a 1st year resident, and still pretty close to medical school, thought "this man is understandably upset. He is very sick, probably depressed and hates being in the hospital. If he took his medications like he was supposed to, the diaylsis would probably help him feel a lot better. But what can you tell a crack head?"
The second year resident thought "this man is insane! Did he spend 10+ years learning to be a doctor that he can tell me what the correct dosage is for his [illness]? I know this must be hard for him, but come on! Maybe if he spent less time smoking crack, he would care more about his health."
And the 3rd year resident thought "He doesn't want to take his medication? Fine, that's his choice. Just don't call me at 3am because his [indicator of disease progression] is through the roof. If he wants to leave too, that's fine with me, just make him sign the Against Medical Advice form."

Let me just add: the members of my team are extremely hard working and go out of their way to be as helpful as they can for their patients, often at the expense of sleep, food and their own sanity. But working 90+ hours a week does have it's toll. Nevertheless, the medicine doctors and residents I have interacted with are very positive, taking time out of their hectic scedules to teach me, an ignorant medical student what is what. They find the time to sit with their patients and talk to them about their children, despite having 20 other patients they need to see within the hour. In the end, it works out. Somehow.