Tales from the office

Jim wasn’t the typical “Chelsea Boy” — a somewhat disparaging moniker given to gay, muscle-bound, intellectually-challenged men living in the west-side Manhattan neighborhood of Chelsea. He was sure trying, however. He had lost fifty pounds over the last two years, accomplished at the expense of sagging skin trying in vain to conform to his abdomen. But he otherwise had the requisite Chelsea Boy attitude, haircut, and wardrobe. And the drug habit.

Jim used crystal meth, mostly at his weekend Fire Island timeshare. I had seen him many times to discuss quitting. But he couldn’t do it. The sex was too good. Once, while I was examining a sore on his large penis, he somehow felt inadequate and explained that, when erect, it swelled to even larger proportions. And, because of that, he was popular with the boys. The sore turned out to be a friction burn — a product of crystal-fueled sex sessions that went on for hours. Even penis skin has its limits.

Jim was in the clinic for another HIV test. He tried to always use a condom, but sometimes the hits of “Tina” made him feel invincible and convinced him otherwise. There was a possibility that he had HIV.

He had another big party coming up over the weekend. His main concern for the visit was his erections. Although strategic doses of crystal, as a stimulant, could keep him awake and horny for three days straight, it oftentimes led to erectile dysfunction. He requested a prescription for Viagra to synch his dick to the crystal high.

I felt anxious about giving him the Viagra. If he were HIV positive, he could spread the virus all weekend long. But if he were negative, the Viagra might be the unfortunate catalyst to catching HIV. Would I be enabling his behavior? After a discussion about my concerns, I gave him the prescription.

I am on call every other week. If patients have a medical need outside of office hours, they can reach me on my pager.

Mary’s mother, Alice, paged me. Mary is my patient; her mother is not. Alice frantically explained how her twenty-two-year-old daughter was spiralling out of control. Alice reported that Mary was suddenly looking disheveled and dirty and acting irritable and abrasive. Mary had just stormed out of the house without indicating where she was going or when she’d be returning. Alice didn’t claim to know anything about Mary’s condition or treatment, but assumed that Mary had a psychological problem. She expressed concern that maybe Mary wasn’t taking her medicines or checking in with her psychiatrist. Maybe she was using drugs. Alice wept. She desperately wanted me to help Mary.

I wanted to help, but the case was complicated. Should I be taking information from well-intentioned family members? Since Mary hadn’t asked me for help, should I even get involved? What would she think about me talking to someone about her care, even though I didn’t reveal any medical information? I had to wonder if I could even help someone who doesn’t want it. In fact, I wasn’t even sure she needed help. At her last visit, just a few weeks prior, Mary acted normal and talked about her great job and attentive boyfriend. She was taking her medicines and seeing her psychiatrist. Ultimately, I had little recourse. In the eyes of the law, her autonomy disallows forced treatment or confinement unless her behavior poses an immediate danger to herself or others.

I called Mary the next day from my office. She sounded well. She agreed to come in for an appointment. At the visit, she did look mildly unkempt, but otherwise acted normal. When I mentioned her mother’s call, she became upset and accused her mother of having mental problems and trying to transfer them to her. She requested that I not talk to her mother anymore.

Two weeks later, Alice paged me again after hours. According to her, Mary took a turn for the worse and started behaving more erratically. Alice cried and pleaded that I help her daughter. She was slightly irrational and mostly inconsolable. At that moment, I started getting the eerie feeling that something was amiss. I no longer knew who needed the help. I couldn’t figure out who was telling the truth and who was decompensating: the mother or the daughter. I didn’t know what to do next. I asked Alice not to call back again, but rather to call the police if Mary posed a danger to herself or others. I called Mary but she declined my requests for further appointments.

5 responses to “Tales from the office”

  1. brooke says:

    Damn, it’s hard out here for an MD. Those are both very difficult decisions to make. But I’m impressed with how you interact with your patients, particularly in the first instance. The second instance sounds like a train wreck, and I think the patient made a mistake by not keeping up with you.

    There is a comfort level between you and your patients which is pretty cool. They feel comfortable talking honestly about their behavior, their concerns and their needs.

    It seems like that is a rarity these days. Seems like people don’t have time to establish relationships with their doctors because their health care providers shift, resulting in a revolving door of doctors. And I know a few people who are scared to speak candidly with their physicians for fear that their behavior will find its way back to their health care provider and their premiums will jump or they’ll be cut off.

    Anyway, nice post, Doc.

  2. my favorite part of this entry, cedric, was how it flipped your persona from being the guy with all the answers to a guy who deals with grey areas a lot of the time.

    what’s the protocol for prescribing viagra? can anyone claim ED and get a bottle? do insurance companies cover it in all cases? what if someone like your patient just wants it to minimize his down time and maximize the number of times he can get off in a night (or a three-day tina spree)?

  3. trixie says:

    nice post, cedric. it was my favorite so far.
    your pal, trixie

  4. Cedric Cedarbrook, MD says:

    There is no good way to objectively measure erectile dysfunction in a primary care office. So a doctor has to choose to take the patient’s word for it. Based on current research, Viagra seems relatively safe (except for some patients, usually geriatric age, taking certain medicines). So, even though there are many causes of ED (physical and psychological), it’s oftentimes simplest just to try Viagra first, then perform other tests if the medicine doesn’t work to a patient’s satisfaction.

    My office accepts “dozens” of different insurances. Some will automatically cover the medicine, some only cover it with a clear medical indication (diabetes, high blood pressure), and some never cover it. And the insurance companies constantly change their rules. Quite frankly, once a patient has left my office, I don’t have any way of knowing if they ultimately pay out of pocket for the medicine, or if their insurance ends up covering it.

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