I could not discern
if each had reached his own conclusion
or if the theme of disbelief
self-propagated within the chart.
—from “The Difficult Patient” by Kendra Peterson

Neurologist Kendra Peterson explored reactions to “The Difficult Patient” in her poem (Fall 2017 Intima) nearly a decade ago. Long before chart cloning and copy forward worked their way into the documentation of the clinical relationship between patient and physician via the keystrokes and dot phrases of the electronic medical record, caregivers have developed shortcuts of stereotyping and rapid assessment that make their lives easier. Clinical gestalt is often celebrated, while bias is treated as something separate from it. And is the label “difficult” any different than the convenience of using yesterday’s assessment as the foundation for today’s decisions? Is propagation of a name or a label such as ‘difficult patient’ a type of plagiarism?

My reflection features a “difficult patient” who is also a “frequent flier” at our hospital. Like Peterson, I prefer to use quotes to distinguish the commonly used term from my preferred vernacular. The emotional weight of institutional responses to brokenness is not limited to patients. Narrative propagation changes not only how we see others, but what future interpretations become available to us.

In my essay “Settlers,” one of the undercurrents is the consequence of how narratives about clinicians begin to self-propagate through systems of review. The analogy is not meant to excuse the provider, but to challenge the notion that people always act in the same way. It is difficult to remain open once systems begin labeling people.

“And no one mentioned that you were suffering,” Peterson writes.

Thomas Robey is a nocturnist emergency physician in Everett, Washington, where he leads a street medicine program focused on low-barrier care for people with substance use and behavioral health needs. His clinical work spans the emergency department and community settings, often in situations where decisions are made without clear alignment across systems. Robey’s writing reflects on these experiences, with an emphasis on setting, perspective, uncertainty, and the practical realities of care.