He was there for a common acute problem when the dilemma caught me off guard. After I had explained the likely cause of his six weeks of sore throat (allergic post nasal drip) and treatment options, I asked if he had any questions and he answered that he would like a prescription for Cialis.
He had mentioned minor issues with erectile dysfunction (ED) at his most recent comprehensive health review, but had elected not to pursue it. He had explained that he traveled a lot for work, and described his relationship with his wife of 15 years as “Not so good. We’re more like friends than lovers, but without the friendship part.”
“What can you tell me about the problem and how it’s affecting you?” I asked. He looked uncomfortable, as do most men when talking about sex in a venue that doesn’t allow for locker room bragadacio. He told me that ‘things had changed’ and that the problem maintaining erections ‘long enough to actually do anything’ was ‘getting in the way.’
“So, sounds like things at home are better than last Spring?” I asked. “No.” he replied, looking intently at the wall behind me. “About the same, really.”
I paused, both to decide how to proceed and partly to encourage him to continue. Pauses and silence are among the most powerful history taking tools. Patients generally fill them with valuable information, but he seemed content to let the silence stretch on. “Well, there’s no medical reason you can’t take Cialis. We checked your thyroid, blood sugar, lipids, testosterone and PSA less than a year ago. We should get a testosterone level to make sure there isn’t an issue of low testosterone that would make Cialis unlikely to work. You should know that Cialis is expensive and payors have limits to the numbers they will cover. How many do you think you will need?”
Obviously relieved, he began thinking out loud: “Let’s see. I’m on the road for 5 days every three weeks, so 8 should last until my next physical.” The little tingling of discomfort in the back of my mind grew past ignoring. “So, your wife travels with you now on your sales trips?” His discomfort returned. Looking away and clearing his throat he said almost inaudibly, “I shouldn’t have brought it up. I feel really weird about this. I travel with this new woman at work, and, well, she’s younger...and she’s nice about it, and all, and doesn’t complain, but it’s embarrassing.”
The discomfort in the back of my mind threatened to drown everything else out. He was asking for Cialis to make it easier to have an affair with a woman at work. His simple request was no longer simple, at least for me:
- Now I needed to talk about risky life-styles, safe sex, multiple partners, and std testing. (And we were already well past the 15 minutes allotted for evaluation and treatment of his throat symptoms.)
- What is my obligation to help him engage in potentially self-harming behavior? I certainly ‘tell’ patients to lose weight, quit smoking, never text or use a cell phone while driving, uses a helmet when biking. I tell patients about the risks of multiple partners, unprotected sex, poor nutrition, excess stress. But I also give birth control pills to women I know are having multiple partners, inhalers to patients who continue to smoke, and NSAIDS and pain medication to patients who are making their musculoskeletal problems worse with occupational or recreational activity.
- His wife is a patient in our practice (which he knows). She usually sees one of my female colleagues, but sees me on occasion where her primary is unavailable. This will be uncomfortable for me. There is no question that what transpires during my visit with any one patient is absolutely confidential and cannot be shared with another - but that doesn’t mean I don’t know it or that it cannot color my judgement or approach.
- (I learned later that the woman from work is also a patient in our practice, but that was not part of this visit’s confusion.)
- Though he and his wife are not close friends, we see each other periodically in informal social settings in town.
Stalling, I asked if he had thought about the risk of sexually transmitted diseasees or bringing something home, to which he replied that they usually used condoms, but that anyway, he and his wife didn’t have much sex anymore so there was little chance he’d infect her.
I told him that his request made me very uncomfortable, partly because it put me in a position of helping him engage in potentially unhealthy behavior, but also partly because it put me in the position of potentially knowing something I (or my colleagues) could not share with his wife if she came in to be evaluated for complaints that could be related to an std. I added with some careful emphasis that I was not trying to tell him what was right or wrong in his situation, but that I was concerned that this would make me uncomfortable enough to have an impact on my ability to provide care, and suggested that if he wished to pursue this, we could easily refer him to a local urologist.
His response was “Never mind, I shouldn’t have asked. It was dumb.” I was surprised both by his response and by how little it did to make me feel better about the exchange. And three weeks later, my nurse sent me a phone note. He had called and asked her to let me know that he had ‘taken care of that matter we talked about last time’ by going online.
Thinking about this since the visit, I remain unclear about my feelings and how best to manage circumstances like this, where a patient’s behavior and my standards conflict. I don’t prescribe ineffective (antibiotics for a viral illness) or inappropriate and dangerous (narcotics for minor pain) medications even when patients request them. I do attempt to change life styles (tobacco, obesity, high risk behaviors) but simultaneously try not to impose my values or make recommendations based on my perspective (quit a stressful job, relieve financial stress by trading to a less expensive and more fuel efficient car). I care for (and am deeply attached to) patients with very different political and religious beliefs from mine, but have asked a few patients to find another source of care when their behavior made me sufficiently uncomfortable (filling each visit with overtly anti-Semitic or racist remarks, using obscenities or being beyond-the-pale demanding and rude to office staff, lying to me about the timeline of their illness to make it work related).
The best I can do, thinking back about this and other episodes, is recognize that my job is hard. In fact, I firmly believe that the difficulty is a good thing, and that if I ever start thinking it is easy, I should retire.