The Last Word: The Troll

“The mass of men lead lives of quiet desperation.”
-Henry David Thoreau – Walden

by Tom Black, MD – Publications Committee

As I reflect upon the thousands of patients with whom I had contact during my general surgery residency training, one stands out as perhaps the most important, at least in the sense that she is the one from whom I learned the most profound lesson.

I can see Sara Hardin in my mind’s eye. She occupied bed space 15, the middle bed of the three just to the left of the 2nd floor nurses’ desk, facing south. Sara was 49 years old, but she appeared to be at least 70. She was thin and bent. Her wrinkled and leathery skin spoke of a life none of us could hope to understand, undoubtedly spent out of doors and working hard. Her teeth were gone and she either didn’t bother putting in her dentures or didn’t own any. Her unkempt short gray hair and the dirt under her nails contributed to her derelict appearance. Sara was admitted to the county hospital for evaluation of intestinal bleeding. 

No one came to visit Sara, at least, no one that I was ever aware of. Whenever I saw her, she was generally napping or staring out the window. I don’t recall that she ever said a word to us as we rounded each morning and evening, but then again, I don’t recall ever saying much to her either.   

Once, when I was a senior resident, a new second year resident was assigned to our surgical service. We had never worked with each other and I knew nothing of him aside from the expensive watch he wore. I always thought it was in poor taste, if not ill advised, to flaunt something of such value in front of so many people who themselves had so little. One day during rounds at Sara’s beside, this new resident concluded his introductory remarks with the words, “She’s your typical troll.” All present nodded knowingly.

   “Troll” was Ben Taub Hospital parlance for a homeless individual, and the term carried with it, as one might imagine, a terribly negative connotation. It comes, I’m sure, from the Norwegian folktale of the ugly ogre who lived under the bridge that the Three Billy Goats Gruff had to cross. In Houston, as in many other cities, many homeless people live under the shelter of bridges and overpasses.

I am quite embarrassed now to admit that I neither said nor did anything at the time to set the young man straight regarding his opinion of someone of whose situation he was ignorant. But the label stuck in my mind, and it troubled me. In retrospect I can only hope that Sara either did not overhear that young man’s comment or did not understand his insinuation.

I suppose I had fallen, as do most students and residents, into the depersonalizing mindset of those who say, “the appendix in room five,” or “I admitted a head injury last night.” Most physicians-in-training are much more focused on the task of developing clinical acumen and less on humanity, but that’s a poor excuse. Nurses are often guilty, as they tend to report, “Four fifty-seven needs some pain medication.” HIPAA has greatly exacerbated the problem by disallowing the use of names in favor of initials or anonymous room numbers. But it’s a leap beyond depersonalization into cruelty to demean and denigrate another individual, particularly when he or she is in a debilitated condition and worse yet, when he or she is dependent upon you for assistance. 

What right did I have to do anything other than to exhibit the utmost respect for everyone as unique individuals of worth, while administering to them
the best possible care?

A day or two after the episode, I stopped by Sara’s bed. She was sleeping, which allowed me the opportunity to observe and to learn a bit about her. A book lay on the bedside table. It was a well-worn copy of the Bible. The bookmark and the pair of scratched and repaired eyeglasses nearby indicated that the book was read often and was of significance to her. A cross hanging next to her bed showed her personal devotion. Although she wore no jewelry, the proximal phalanx of her left ring finger was noticeably narrower than the same area of her other fingers, indicating that a ring had once held a longstanding position of importance there. Perhaps she had been recently widowed; who knew? And who even asked? I studied the lines on her face. They indicated that she had spent much more of her life smiling than frowning and spoke of happier and perhaps more secure days now past. Taped to the side of the bedside table, in such a manner as to be easily visible by her, but nearly invisible to casual visitors, was a simple crayon drawing with a crudely scrawled caption that read, “I love you Gramma.” Next to that was a small photograph of the type taken annually in public schools, of a little girl aged five or six years. I was even more ashamed of the callous attitude my colleague had displayed toward one of our fellow human beings and of myself for having remained silent. 

I may have been as guilty as others of depersonalization, but never of cruelty, and having witnessed that appalling lack of compassion was a wakeup call for me to reassess my own values. I began to appreciate the people who passed through the hospital in a new light and as being more than “clinical material” who existed for my benefit. Each became an individual. Each old man was someone’s father, and if not father or grandfather, then at least someone’s son. Each elderly woman was someone’s daughter and, as in Sara’s case, likely to be loved by someone. There were experiences etched into the wrinkles of each of Sara’s hand that I could not even begin to understand. What right did I have to do anything other than to exhibit the utmost respect for everyone as unique individuals of worth, while administering to them the best possible care?

Several days later, in a different location but similar circumstance, I heard the term “troll” again used in a similarly insensitive manner. This time I was determined not to allow the opportunity to pass.

“Stop right there. Everyone remember from this moment on that the word you just used is not acceptable on this service, at least as long as I’m here.” I paused to collect my thoughts, although I had mentally rehearsed my comments many times. 

I addressed the speaker. “When you applied to medical school, you were probably asked why you wanted to become a doctor, and you probably said ‘Because I want to help people.’ Well, either you meant it or you didn’t, but if you were honest and you do want to help others, start by treating everyone as a fellow human being. You wouldn’t appreciate someone speaking that way about your mother or grandmother.” There was some resentment after that over the reprimand, but I heard no more “troll” comments.

On the evening of the day Sara was discharged, the team assembled at the nurses’ station for rounds. “Dr. Black,” the charge nurse said. “This was left for you.” It was an orange mailing envelope with Sara’s name on it. Opening it, I pulled out a nice greeting card addressed to our team. I read the card aloud to the members present. “Dear Blue Surgery team. Thank you all so much for the kindness and care you gave to our mother and grandmother while she was recovering in the hospital.” I was gratified to see that the irony of the message had wounded a few egos. 

A few months ago, an essay by medical student Sneha Sudanagunta appeared in this journal. In it, Ms. Sudanagunta concluded that medical schools must do a better job teaching what she called “humanism,” (an ambiguous word for which I suggest “compassion” may be a more apt term). While I applaud her passion for this important topic, it is disconcerting that Ms. Sudanagunta felt compelled at all to implore physicians to teach more compassion. My experience leads me to believe that her observations represent an exception rather than the rule among practicing physicians. 

I suppose medical students and residents are much the same as they were forty years ago. Sometime between acceptance to medical school and the completion of medical training, one must resolve one’s personal standards regarding the treatment of others and the sanctity of human life. Of course, cruelty must be categorically opposed and compassion fostered just as strongly. While I am doubtful that compassion can be taught, per se, I am quite certain that it can be effectively modeled, and a receptive individual can be influenced to change his or her own behavior. 

I am convinced that we are surrounded by compassionate physicians; their names are in the TCMS directory. It is who we are, or at least, who we want to be. Nevertheless, it is wise for us to recall from time to time the wisdom of the Dalai Lama: “Be kind whenever possible. It is always possible.” We need to show Ms. Sudanagunta that whatever she experienced was the exception, not the rule.

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