The top five ethical dilemmas in medicine are breach of patient confidentiality, initiation of patient-doctor romantic relationships during treatment, malpractice and negligence, failure to obtain informed consent, and physician-assisted suicide. These are serious issues that are explored often in literature and discussed frequently in medical classrooms and journals the world over. Most cases where doctors are censured are fairly clear cut and, at least in the United States, a large majority agrees about the boundaries one should set in practice.

But what of the more common daily scenarios we encounter? The ones that test the limits of our patience and leave us feeling queasy with unease. I’d like to tell you a story about a patient.

My practice, although specializing in pediatric and specialty contact lenses, is really a hodgepodge of every type of difficult patient that other professionals care to send my way. When people ask what ages we cater to in the office, we say, “Diapers to Depends.” In a sense, a recalcitrant child does not much differ from a stubborn, old man, and a self-centered drama queen is much the same at age 12 as she is at age 55. The most important tool I need to help any of these patients is patience. Patience with a capital P. I am often told I have the patience of a saint. This “compliment” is frequently doled out by the very same person that has spent hours or days trying to test the outermost limits of this virtue. I have been at this for 27 years, not counting internship years, and there are days when I am ready to throw in the towel. As a Jewish atheist, I don’t really aspire to Sainthood and often wonder if a day will come when the silent soundtrack in my head will break through, and the overbearing helicopter parent, making my life a living hell, will get an earful of obscenities, rather than see the sweet smile born of teeth gritted so tightly they trigger a migraine. On those days, I’m pretty certain the aura I see is not a reflection of my halo.

On this particular day, I am demonstrating a bioptic telescope to a lovely gentleman with advanced macular degeneration. He is talkative and flirty. You will surely recognize the type: a tall, good-looking actor, graying at the temples, self-assured, and at age 75, an accomplished ladies’ man. He is difficult to examine because the way he deals with his severe vision loss is to make endless, hilarious, exhausting jokes. Arguably, this is the best way to deal with hardship. I am a huge fan of laughter as medicine, but sometimes, I just need to get through one test with a serious response rather than an uproarious one. The clock ticks on, there is a blue light in my exam room that turns on when the next patient is ready, which has now been burning a hole in my retina for at least twenty minutes, and we are still in the phase of making jokes about how attractive or not the bioptic telescope will be to the biddies at the opera….All jokes aside, I know deep down he is truly upset by the cosmesis of the device and my goal today is to teach the man to accept a visual aid I know will help him function independently and greatly improve the quality of his life. After all, it brings the acuity in his only usable eye from 20/150 to 20/25. When I finally get him to put it on and look, his blind eye wells up with tears and there is a brief but pregnant moment of silence. I smile, this makes me happy to the depths of my soul. I take a deep breath and draw sustenance for my next patient: an 8-year-old ocular albino who has failed to be fitted into contact lenses with three prior doctors. I am number four. She is understandably terrified of all eye doctors as she has had three strabismus surgeries and endless examinations which amount to torture since they involve shining bright lights into her helplessly photophobic eyes. To allay her fears and distract her from the inevitable, I dim all the room lights and start with a disarming conversation about her summer camp, ponies, gymnastics. She is shy. I wait till she starts to talk. I discover her weak point – she loves to ice skate. By the time we get to the point where I am ready to insert her lenses, I’ve even used some of Mr. Actor’s dad jokes to get her to giggle. I ask her to visualize a salchow and talk me through performing one, step-by-step, while I insert the first contact. This works like a charm and she giggles again. I know it will be a long haul to teach her to insert the lenses on her own, but with her +10.00-4.50×20 Rx, that giggle gives me the strength to persevere on her behalf. You get the gist.

This rhythm goes on and six patients later I introduce myself to a new patient. This 90-year-old man has been referred by an ophthalmologist for a refraction and new glasses. I have known the referring doctor for many years and breath a sigh of relief since her patients are usually a breeze. He is almost completely deaf and I am forced to strain my voice to make myself heard. He begins to tell me a long-winded tale of his optical woes to date, replete with all the jokes and inappropriate sexual innuendos that appear to be integral to many men who survive past that statistical measure of the average time an organism is expected to live based on its date of birth, gender, and level of intelligence. I try very hard to listen without rolling my eyes. Twenty minutes into this pointless diatribe, my halo now feels like a vise grip on my head. Finally, the soul-sucking refraction over, I extract Mr. Gripe-and-Hype from the chair and hand him over to my optician with strict instructions to make ONE PAIR of glasses ONLY, see if he adapts to the prism, and only then make a second pair, saving him extra expense in case the glasses don’t allow him to function any better than the several pair he already has and claims to be a useless waste of money. He seems pleased and nods in agreement. My lunch break has long come and gone, my cup of coffee is cold and stale on the lab counter, and I go on to finish the rest of the day.

A week passes and my husband, who is my master optician, tells me that Mr. Gripe-and-Hype called to say that although his double vision is gone, his TV subtitles remain illegible at 25 feet. As I am busy and running late, rather than calling the patient myself, I ask my husband to return his call and remind Mr. Gripe-and-Hype that his best-corrected acuity is 20/40 and he needs to move a little closer to the TV if he wants to read subtitles. This does not go over well. Admittedly, asking one cranky, old man to explain something to another, is not the most brilliant of ideas. I should have known better. Mr. Gripe-and-Hype comes back on a Friday, when I am out of the office, throws a big temper tantrum (you will recall my observation that old men differ little from diapered toddlers), and the staff, unable to placate him by any means, schedule him for a recheck with me. The dreaded appointment day arrives and he begins to recount the many grievances he has with me, my staff, the horrible man who called him and unceremoniously pronounced him blind, all opticians past and present who have conspired to part him from his hard-earned cash and steal his glasses, doctors who claim to have their offices open six days a week but aren’t there when HE needs them to be…the list goes on and on. Finally he ends with, “HOW DARE YOU CHARGE ME $825 DOLLARS for an examination I already had with another doctor?!” At this point, I decide to print out the receipt that clearly states the visit and refraction (I did not perform an exam since I had records from the referring doctor) was under $100 and the total charge, including the glasses, was under $250. “IS THAT SO?!” He demands. “WELL! How am I supposed to have been able to read that when you refused to make me reading glasses for over TWO MONTHS and are never here when I come in to pick them up? AND $200 FOR GLASSES?!! I COULD HAVE BOUGHT A CAR FOR THAT MONEY!” At a loss, the charge on my halo at 8% and losing power by the second, I hear someone in the waiting room inquiring as to the whereabouts of Mr. Gripe-and-Hype. Thrilled that a significant other with functional hearing and white matter might have arrived to assist, I turned around to be greeted by a designer-clad, surgically-augmented beauty queen of indeterminate middle age. Mr. Gripe-and-Hype perks up and introduces us, ”Now I’m surrounded by two beautiful ladies – Doctor – meet The Wife. Now you see why I need glasses!” Trying to ignore the increasingly annoying sexism that I know many old men consider adorable banter, I go through the whole demonstration again – vision without glasses 20/100, with glasses 20/40, explain the need to move closer to the TV….she appears to understand. He appears to accept…Prismatic reading glasses ordered, promised in three days. Crisis averted.

Two days later, my staff plays a message for me from our answering machine. Mrs. Gripe-and-Hype is screaming from the tape that, “THIS IS AN EMERGENCY” – the month wait for the promised glasses is just absolutely unacceptable and the fact that every time they call the office we are closed is, “OUTRAGEOUS.” It is 10 am and the recording time stamp is 10:30 pm the prior evening. My staff checks and notes that the glasses are actually ready ahead of time and just need to pass final inspection. They call the number on file and after three rings hear, “We’re sorry, you have reached a number that has been disconnected or is no longer in service.. if you feel this is in error, please check the number and dial again.” Undaunted, we look at the caller ID name on the message from our answering machine, search the web for Mrs. Gripe-and-Hype, who left the message, but Google being what it is, we find not just the cell phone number for her business, but a link to a newspaper article from 2017, complete with half-page, full-color photos of the lovely couple and a scathing story detailing their indictment for embezzlement. Millions of dollars stolen from an elderly neighbor with dementia. There is no mistake. There are no alleviating circumstances. There is a full confession. Three opticians were looking at the screen when the link was clicked. There is no unseeing what we saw.

We take a collective deep breath and decide to call, notify Mrs. Gripe-and-Hype that her husband’s glasses are ready and hope for the best. My mind reels with scenarios of heinous yelp reviews, extortion, demands…my gut tells me we are somehow being set up. My brain tells me it’s just a miserable, senile, old man trying to manage his failing vision. I am torn between feeling that I should pretend not to know what I know and continue trying to help him and the knowledge that what I know is public information and I have no obligation to tolerate bad behavior from any patient, let alone one who has demonstrated a record of criminally sociopathic behavior. I opt to focus on my next patient and move on. I’ll go home and I’ll think of some way to get him back, after all, tomorrow is another day, Scarlett.

Another two days pass and the couple returns to pick up the glasses. The dispensing visit proceeds without incident, Mr. Gripe-and-Hype proclaims the glasses to be, “PERFECT! Not good, but PERFECT!,” and when he asks to “Say hello to the Doctor,” I hear my optician politely tell him that she will relay his greetings but the doctor is busy with another patient and cannot be interrupted. They say thank you, take the glasses, and depart. We wait. We look at our yelp reviews, which by the way, we never solicit, have not many of, and very rarely check. Nothing. Is this the calm before the storm? Anticlimactic, but the relief in my office is palpable.

It’s only been a few days. I don’t really know how this story ends. Perhaps it’s just over. Nothing more than a little extra angst and aggravation for myself and the staff, but I lie awake at night thinking. What are the ethics that should govern these situations? If this man were to complain of bad service online or to the referring doctor, could I share the article we found? It is in the public domain and speaks to character, after all. My husband insists I have no obligation whatsoever to tolerate bad behavior from anyone, ever. I tend to be more lenient, giving a wide berth to the young and old, alike. My husband has been doing this twice as long as I. His rope is considerably shorter, while I still have a frayed length that tethers me before the end is reached. I am fairly certain that the law would be on my side but I like to hold myself to a higher standard. There is a famous Talmudic concept of “building fences around the law.” Originally published in Pirque Avot (Ethics of the Fathers), “Moses received the Torah at Sinai and transmitted it to Joshua, Joshua to the elders, and the elders to the prophets, and the prophets to the Men of the Great Assembly. They said three things: Be patient in [the administration of] justice, raise many disciples and make a fence round the Torah.” Building a fence around a home prevents trespassing, and a guard rail at the sides of a road keeps the hapless driver from veering off course. I mentioned I am an atheist but the concept is sound. Placing fences around the law creates a buffer of safety.

I know that each of us grapples with these situations daily. They are not huge, life-changing moral dilemmas, just little situations that amount to inconsequential arrhythmias in the steady heartbeat of any normal practice. I believe that the way we deal with them, however, sets the tone for our staff and creates an ambiance for our patients. Walking the high road can be lonely. The air up there is sometimes so thin that the walk makes us feel cramped, headachy, and short of breath,  but then you arrive at the top and the view is remarkable. If I ever get to the apex, perhaps I’ll see a glimpse of God.

I wish my colleagues a very happy, healthy, and prosperous holiday season. I leave you with my practice’s mantra, my favorite quote from Dickens’ Hard Times, “Have a heart that never hardens, and a temper that never tires, and a touch that never hurts.”