"No, Duke. No divorce"

A conniving patient reminds his physician that to practice medicine is a blessing.

By William S. Gould, MD
Orthopedist/Kirkland, WA

Despite 24 years in medicine and thousands of patient visits, only since last year have I been able to say that I've seen it all. That's when Dugan "Duke" Intol (not his real name), con artist extraordinaire, became my patient—and reminded me that we doctors have it pretty good.

On the downhill slide toward 60, I have a fledgling practice, covering the office of an orthopedist a couple of days a week. When we first became associated, I fought to evade fiduciary and managerial responsibilities. But soon I started to build a practice, fielding referrals from physicians who were disenchanted with patients hobbled by chronic back pain, substance abuse, or personality disorders.

I learned of Duke from an emergency room physician who prattled over the phone about an "interesting" patient he was turfing to my practice. I gave ear, albeit vacuously, while staring out my office window at the Olympic Mountains.

"Send over Mr. Intol," I told the physician. "Can he be trusted to hand carry the CT, MRI, blood work, and . . . ? He can't? I'll drop by the ER on my way to lunch."

In the cafeteria, I thumbed through Duke's thick chart, my dyspepsia deepening with each page. I stood to leave, two bites of a tuna sandwich still on my plate.

"Hey, Dr. G., what's wrong? You never leave food behind. Never," snapped my nurse.

It was a quirk I'd picked up in US Army commando school and honed as a reluctant guest of the Viet Cong. I hadn't cleaned my plate because I knew something profound was amiss. Late that afternoon, I met the source of my angst.

Duke was a wrinkled little man—5 feet, 4 inches in elevator cowboy boots, 111 pounds, 45 years old, gray-haired. He sat slouched like my teenaged son, and at the same time spun his legs as if they were counter-rotating blades on a Chinook helicopter.

Eventually, Duke peered up at me, sucked in a cleansing breath, and grunted. "Doc, this pain, man."

The engine revved, his legs whirled. "Oh, the pain."

"Mr. Intol, you look like you're dying. What's going on?"

"I hurt, that's what."

"How long?"

"Couple of days."

"Where?"

He struggled mightily to touch his midback. He drew his thumb slowly, laboriously along his ribs and punched deep into his abdomen.

Instantly I felt smarter than the bevy of specialists who had anguished over Duke. "Herpes zoster, Mr. Intol. Shingles."

Though Duke had no lesions on the dermatome, I explained that sores would soon appear, then fade. I anointed him with steroids, valacyclovir hydrochloride, and 30 oxycodone hydrochloride for dessert. He promised to return in a week.

Better than his word, Duke appeared 36 hours later, his legs spinning like a turbo. "No lesions yet, but they'll be there, Mr. Intol. No question."

"Thirty more Percodans?" he asked.

The request gave me pause. I'd always been scrupulous about dispensing narcotics, especially to anyone with a gin blossom and two packs of cigarettes in his shirt pocket. But I knew zoster was painful.

"Okay, I'll give you another prescription. Let's make 'em last."

"Doc, you don't have to worry. Ain't had a drink in a year."

Uh-oh.

"Even got a place to live and a car. I'm clean. Trust me."

Whoops!

As time went on, the absence of skin lesions began to worry me. Duke had appeared for his GI consult, follow-up CTs, bone scans, and physical therapy appointment. But he had ignored the follow-up PT visits and the psychiatry consult.

"Doc, they hurt me at that therapy place. And I don't need no shrink. I ain't crazy. I hurt. You could help me. See, I got into this jam right before I stopped drinking."

Beads of perspiration formed on my brow.

"Got two years hanging over my head. I'm due in court in three days. Can I be truthful with ya?"

"By all means."

"This time, I'm scared. I can't go to the joint again. I hurt too bad. Write the judge. Tell 'im I been off the booze. Tell 'im I ain't been no pain in the butt, neither."

Thunderclap. I'm feeding narcotics to a convict, and he's selling the drugs. I've been had by a pipsqueak felon.

I glared at Duke, and he shrank.

His fear sobered me, and suddenly I recalled the gray pall that often greets me at 2 or 3 in the morning and lies with me until dawn. It's the nightmare of my own lost freedom as a prisoner of war, of living minute to minute, of marching and trying to put one foot in front of the other before the tug of the Viet Cong's rope opens another bleeder on my neck.

Then the shroud began to diffuse, and I told myself that Duke wasn't the enemy. I'm free, lucky to be here taking care of him. I'm free.

When I finally spoke, Duke jumped.

"Mr. Intol, I'll write the letter."

"Man, I thought you were angry at me."

"Nah. But look, I want you to go to that psychiatrist. It'll get him off my back."

"Doc, I ain't nuts. You know how many shrinks I seen? Started at 10, when they caught me sniffin' gasoline. Then later, when I was sniffin' glue. In the Air Force, they put me on pills. Couldn't get it up. The Air Force shrink told me my career was more important than my ding-dong. I told him to shove it. Got a dishonorable, even though I was STRAC."

"STRAC?"

"Standing ready around the clock, spit-shined."

I sniggered inwardly until my eyes drifted to Duke's starched cowboy shirt, pressed jeans, and polished cowboy boots. It was the first time I'd really looked at him. He nervously dipped his head to re-engage my eyes.

"I just drank a lot," he blurted.

"What'd you do when you got out of the service?"

"One job after another. Always wound up punching the boss. Judges sent me to a bunch of shrinks. One visit, and then I get that letter sayin' I had 30 days to find another doc. I've spent my whole life getting those letters."

Duke's eyes reddened. "I'll go see the shrink," he mumbled. "Just promise me, no divorce."

"No, Duke. No divorce."

Duke got 10 days—instead of two years—and the bottom bunk, courtesy of my missive beseeching the judge to accede to Duke's medical exigencies.

The first day out, Duke returned to my office. He was two pounds lighter, legs a-thrashing.

"Doc, good to see ya. Hey, I need something for the pain."

"Mr. Intol, you've got to understand. With your history, I can't keep you on drugs. I won't be responsible for turning you back into an addict."

"Doc, I can get drugs on the street. Then you'll be responsible." He exhaled noisily, rustled around, stood, paced, then retook his seat, glowering.

"Don't threaten me, Mr. Intol."

"Doc, you're my only friend. 'Cause of you, I ain't gone back to the drinking. What you give me is nothing. I used to get 30 Percodans every other day from that doctor in Seattle. Then I'd go home, drink 15 or 20 beers and half a fifth of gin. I don't want that. Just fix me, and I won't start drinking again. And I won't ask for no more pain pills. Can't you stop this pain?"

I balked. I had no answer.

The state of Washington has said physicians can treat noncancer pain, albeit in the appropriate patient, with narcotic analgesics without regulatory reprisal. But Duke lacked an elemental ingredient: the propriety.

I got Duke down to two hydrocodone a day, yet his theatrics continued. I suffered projectile sweating when I thought of having to answer for his treatment someday.

I went to my colleagues. "Careful, Bill. Duke's the archetypal addictive personality. Substance abuse. Dishonorable discharge. Prison time. Export him to a pain clinic. When he gets tossed out, write him a 'Dear John.' Document it, and no jury will . . ."

Duke's psychiatrist called me at home. "Bill, Duke's a challenge. Personality disorder and depression. There's not a lot you're going to do. Try an antidepressant. Just document . . ."

The next morning, Duke arrived. "Doc, I need something for this pain."

I ignored his plea. "You know, I got a call from your psychiatrist. He mentioned that you seemed depressed."

"Hey, Doc, wouldn't you be if you hurt all the time, and all you can do is sit in a recliner and keep from drinking? Anyway, the guy was an ass."

"That's funny. He said you were a good guy."

Duke's face brightened.

"He said that? Well, maybe he isn't so bad. It's just the pain. What'd he say to do?"

I would like to proclaim a miraculous cure for Duke, but I must be factual. He takes Prozac regularly. He's a bit happier and somewhat less threatening. But he continues to clamor for his two codones du jour. He still has two packs of smokes going at the same time, talks incessantly about drinking. He hasn't gone back to work, to PT, or to the psychiatrist.

Duke's insurance case managers have buried me under a mountain of documents. They want to know why I've failed.

But I refuse to dwell on that. Life with Duke—and my other patients—is eminently better than my life 31 years ago, when I was without freedom, starving, rarely seeing the sun. We physicians should be thrilled to provide care for the Dukes of the world.

So I'm not sniveling about my practice or my patients. And no, Duke, there will be no divorce.

 

William Gould. "No, Duke. No divorce". Medical Economics 2001;16:74.