James

James came into my office with penile discharge. I felt relieved because it was bound to be a quick visit—I’d test him for chlamydia and gonorrhea and give him the appropriate antibiotic.

But I was wrong. The twenty-two year old had already seen three doctors in the last three months about the problem. He had been tested each time, the tests were negative, but he was always treated with antibiotics anyway. And he was still having symptoms.

He explained that the symptoms began when he had a one-night stand with an anonymous female partner. Let me stop here and say that I’m always fascinated with the cause-and-effect relationships that patients formulate. I know that as humans we try to find a cause for everything. It’s certainly a hard-wired part of our brain that has helped us survive over time. (Eat the wrong berry, get a bad stomach ache. Make the connection, then avoid the berry in the future.) More than that, it’s a way to communicate. We need a beginning to a story. We need to create some place to start defining our experience. But many times we make an attribution or linking error: we match an incorrect cause to the effect we’re studying. Sometimes an attribution error is benign. But often it’s to our detriment. (Like believing that our last flu shot gave us the flu, and therefore never getting the yearly shot again.)

But regardless of whether the link we make is correct or not, I think it’s fascinating to hear what my patients think. The patients’ ideas tell me so much. I get an inside peek into who they are, since they must sort through their online casino lifetime of accumulated data in order to try to establish the connection. Their conclusions betray their education, superstition, biases, fears, and hopes.

I was interested in the fact that James linked his symptoms to his sexual encounter. I questioned James further. I found out that he had been in a relationship for two years before this one-night stand. He was just in the process of breaking up with his girlfriend when it occurred. And he associated the event with cheating on her. He liked to consider himself a very moral person and he was very disappointed in what he had done.

To make a long story short, I don’t believe James has a sexually-transmitted disease. He just thought he should because it would be fitting punishment for his behavior. And, in fact, he inadvertently created his own discharge. By becoming so obsessed with the possibility of infectious discharge, he “milked” his penis so often that he was able to create a reactive discharge. (The same event can occur if a woman regularly stimulates her nipples, fyi.) My hypothesis was further confirmed after I performed full urinary tests on James and they were negative.

With those results I had a discussion with him. I explained that he didn’t have an infection and should stop manually checking for one. He wasn’t happy with my diagnosis, since he was convinced of his infection. I find that when faced with a patient who is so adamant about a problem with his health, I have to seriously reconsider my diagnosis. I mean, what if the patient really is right? What if, in spite of repeat negative testing, he really does have something that I nor other doctors can explain? I don’t want to be pompous, but I don’t want to feed a patient’s psychosis. Although I reaffirmed my diagnosis to him, I agreed to send him to yet another urologist for further evaluation.

Am I just enabling his behavior? Is there any good solution to this problem?