Patient #7: Mr. Ipulator

     Right after we say hello and shake hands he says, "I've heard great things about you."
     "Glad to hear that," I reply.  "What can I do for--"
     "You've got a helluva place here," he interrupts. "I mean, it's First Class--"
     "Thank you.  So, where have you gotten your medical care before today?"  I ask hurriedly, breaking the rule about allowing patients plenty of time to talk.  When I was in medical residency an embarrassing study reported that patients were given an average of seventeen seconds to speak before the doctor interrupted them.  I hadn't wanted to be "that kind of doctor"--but here I was, breaking in after only five seconds.
     "I've been a lot of places--where haven't I been!" he laughs.  "Mostly South Florida.  But to tell you the truth, I wouldn't go back to my last doctor."
     "Why not?" I ask automatically, then regret it.
     "He just didn't care that much.  It was like, in-and-out.  This place is different, I could see that right away.  You spend time with your patients, you care about them, like a real doctor.  It's hard to find that these days."
     I watch him carefully.  "What was your last doctor treating you for?"
     "Mainly my back.  Man, you wouldn't believe what I've been through.  Wish I could just trade it in, that's how bad it is."
     "I'm sorry to hear that," I respond.  "But are you comfortable right now?"  Mr. I.  is leaning forward in one of the upholstered chairs, with his elbows on his knees,  and I can't help thinking about the long stretch of this back-curving position.  It doesn't seem to be causing him pain despite the demand on the paraspinal muscles, especially in the lumbar region.
     "'Comfortable!'  I haven't used that word in years.  It just doesn't apply.  My back is killing me twenty-four-seven."
     "Do you know why it hurts?"  I ask.
     "Oh, yeah," he shakes his head ruefully.  "I was young and stupid.  Motorcycle wreck, going ninety-five miles an hour on wet roads.  Broke three vertebrae.  Nonstop pain since then."
     There is a minute of silence as we contemplate that tragedy together.  Mr. I. is gazing at the floor with a melancholy expression.
     "I notice your blood pressure is up," I comment.  "178 over 96--that's too high."
     "It's because of the pain," he explains.  "When the pain is controlled, my pressure is down."
     I ask to examine him and he agrees, climbing up on the exam table with the heel of his right hand on his lower back, as if to brace it.  Whereas he seemed physically normal in the chair, now he moves like a man crippled by arthritis.  He flinches when I touch his back, and I withdraw my hand.
     "Go ahead," he nods with stoicism.  "Do what you have to do.  It hurts, but I know you've got to check me out."  When I ask him to lie down he does so stiffly, grabbing the railings to use as a fulcrum.  "Just take it easy," he admonishes. "My muscles are in spasm."
     I spend several minutes palpating his spine, then check his reflexes, sensation, and a straight-leg raising test.  His heart rate is higher than normal and his skin is damp, but otherwise the exam is unremarkable.
     "Your back seems okay," I say reassuringly.  I'm not sure why you're in pain."
     "My last doctor said I had 'regenerative disc disease'--whatever that is," he says helpfully.
     "A lot of people have that," I answer.  "Tell me, how do you deal with the pain?"
     "The only thing that works is oxycodone," he informs me.  "I've tried all that other crap, and it just doesn't cut the mustard."
     "What about anti-inflammatory medicines?"  
     "Can't take 'em," he says.  "They give me acid reflux."
     "I'd like to get your old records and see what's been done for you in the past.  There's no sense repeating studies if you've already had them.  Can you sign a release today?"
     "Yeah, sure.  But what else can you do for me?  I need something bad."
     "I think we ought to address your blood pressure.  Do you have a monitor to check it at home?"
     "No, I'm telling you, my blood pressure is only high when I'm in pain.  I need something for the pain," he insists.
     "I won't be able to prescribe something today," I explain.  "I need to know more about you.  Besides, oxycodone has a lot of side effects, and it can be dangerous."
     "It's never given me a problem.  Can't you give me enough to last until you get my records?  You'll see--the MRI shows major problems.  And I mean major."
     "I'll be happy to review it, but for now let's talk about the rest of your health.  You have a number of risks for heart disease, including smoking and your blood pressure--"
     "How many times do I have to tell you, I don't have high blood pressure."
     The nurse pokes her head in, and hands me a lab report.  She ran a urine drug screen instinctively, and it's positive for a number of controlled substances, as well as an illicit one.   I rest my head, which feels very heavy, in my cupped hands.  I pause to think,  then look up at him.
     "I wonder if there is any way I can really help you," I say to Mr. I., trying not to look weary. This is beginning to feel like a bad re-run. 
     "Just give me something to relieve my pain, and I'll be out of your hair," he suggests.
     "I can't do that, but I could help you--"
     "Yeah, you can.  What kind of doctor are you, anyway?"
     "I'm here to help you, not to cause harm.  Oxycodone causes harm."
     "What are you talking about?  You've never been in pain, I guess.  You obviously don't know what I'm going through."
     He stands up and suddenly appears quite sturdy.
     I also stand up, and find that I am holding my breath.
     "C'mon," he says conspiratorially.  "Just a few Percocet.  At least 'til you get my records.  I'm really hurting.  What's it gonna cost you?"
     "I can't do that," I repeat.  "I don't think pain is your underlying problem."
     "You're no doctor!" he shouts.  "You're nothing but a quack!  I thought you cared about people.  Where's your compassion?"
     Another nurse comes in, the one who used to be a bouncer.  "Do you need help in here?" he asks, staring menacingly at the patient.
     "This place is bogus!"  Mr. I. spits at him, then strides with renewed energy out of the room.  "I'm reporting you to the Medical Board," he yells, slamming the door so hard the chart holder rattles on its hinges. "This place oughta be shut down!"
     We hear him demanding his copay from the receptionist.  We hear him notifying patients in the waiting room that they're wasting their time in this cuckoo's nest.  We hear his car screech out of the parking lot, at last.
     "Almost the weekend," the bouncer-nurse says with a note of sarcasm.  "People need their party drugs."
     "That's not very compassionate,"  I reply, walking toward another exam room where the next patient is waiting.