Tag Archives: difficult patients

Testing Your Limits

We genetic counselors take great pride in our role as patient advocates. Everyone is equally deserving of our best professional skills and unbiased support. Rich, poor, immigrant, homeless, transgender, disabled, non-English speaking …. we like to think that none of it makes any difference. We give them all our best non-directive shot.

On occasion, though, we encounter a patient who compromises our desire and ability to provide unbiased, empathic care. This may stem from subtle counter-transference issues, like the patient who evokes your ex-spouse or a client who is overly demanding and obnoxious. With professional growth and supervision, we can learn to deal with such situations.

But eventually you find yourself with a patient who makes you stop and say to yourself “You know, this one is crawling under my skin. I’m not sure I can be a good genetic counselor for this person.” Let me give a (hypothetical) example of patients who might evoke such deep feelings.

Osama bin Laden and Ayman al-Zawahiri, the two leaders of al-Qaeda, are arguably America’s greatest and most reviled enemies. Both men also have families. One of bin Laden’s 22 children, Abdul Rahman, was born with hydrocephalus (1/22 is approximately equal to the semi-mythical 3% risk we are so fond of quoting to our patients; congenital anomalies blindly cross all religious and ethnic boundaries). bin Laden flew his son to the UK for treatment, but declined a shunt, and instead chose to treat him with honey, a common folk remedy in the Arabic world.  al-Zawahiri ‘s fifth daughter, Aisha, had Down syndrome, born after nearly 20 years of marriage (the effects of advancing maternal age also are oblivious to culture and creed). Aisha died at age 4 of exposure to freezing temperatures the same night her mother was killed in an air raid as the family fled Afghanistan during the early days of the war.

What if one day you walked into your office and there sat either bin Laden or al-Zawahiri, seeking your clinical help? Could you dispassionately provide your best genetic counseling skills to these men? I, for one, would have a hard time. But our ethical system only works when it works for everyone, not when it is selectively applied.  Lawyers know this well, and that is why they defend even the most evil criminals.

The example is admittedly extreme and, not least of all, unlikely.  However, the information about bin Laden’s and al-Zawahiri’s families is neither fictional nor a wild Internet rumor; it is taken from The Looming Tower, Larry Wright’s superb Pulitzer winning book about the rise of al-Qaeda. I use the example to illustrate the point that we all have our limits, but those limits may be very different for each of us.

Which patients challenge your ability to provide genetic counseling? Would you be deluding yourself if you believed that your ability to engage all patients knows no limits? I encourage you to leave comments below – I am interested in hearing your thoughts and experiences.

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