Dr. Santell's Rounds: The Ticket

Every doctor sees patients with diseases related to substance abuse, both legal and illegal. The other day I looked at my hospitalist census and realized 65% of the patients I was seeing had illnesses either caused by or worsened by alcohol and tobacco abuse.

Now that I've been doctoring for several years, I find myself less fearful of confronting a patient about substance abuse. People don't seem to mind my impertinence; "I know you have to ask," they say. So I've gotten bolder--not only do I ask them if they're using, I'll read them the riot act about their abuse. Shooting heroin? I'll tell you all about hep C, endocarditis, HIV. Pack a day smoker? Never mind lung cancer, let me tell you about end-stage COPD and what life is like after a radical neck dissection for squamous cell carcinoma. Snort a bit of meth first thing in the morning to get your day rolling? I'll be happy to introduce you to your future peers, affectionately known in Rural as The Young and the Toothless. 

After I'm done with the riot act, I ask, "Do you want to quit?" and if the patient says no, I let the subject drop. I can't make people want to clean up. All I can do is plant the idea and hand them a list of local AA and NA meetings so they know where to go when they're ready.

I'm afraid these experiences have hardened me. I once told a man I didn't care if he ruined his life with drugs. "I mean, you're a nice guy, we get along, I appreciate your honesty," I said, "but, let's face it--if you drop dead in the parking lot ten minutes from now, I'm going to say 'Aw, that's too bad, he was a nice guy,' and then I'm going to move on to the next disaster because that's what I do. I'm a doctor, I got a hundred guys like you. So I don't care. But I bet you do, and I bet your kids do, so think about that. You need to get honest with yourself and quit making excuses for using."

I remember these words, because I went home that day appalled at what I'd said. I didn't mean it unkindly, but I was tired of being endlessly positive and upbeat about the abuse I was seeing. No more of the "today is the first day of the rest of your life" crap for me.

Sometimes I'm tempted to abandon these miniature attempts to counsel drug abusers into going straight. Truth is, most people go right back to using, some quit for a while and relapse, and only very rarely does anyone kick and kick for good. I get tired of making the attempts. What am I accomplishing? All I seem to do is create a space for the possibility of change without actually achieving any.

Dr. Santell knew all about drug abuse and its consequences. He'd seen more complications than I ever have, and I remember his dispassionate attitude towards patients with these problems. He never approached them with judgement and yet he also never succumbed to the urge to save them with unwanted offers of rehab programs, AA flyers, or fatherly talks. He just provided them with the information he thought they should know, and told them to make their own decisions.

I thought his position towards drug abusers was admirable, but cold. I was super-idealistic in those days, I wished he'd show a flash of anger, make an impassioned speech, escort a hard case to the AA meeting down the street. But he wasn't that kind of man. Or so I thought.

Doctors are not immune to substance abuse. When I was a resident, one of our community doctors was caught at a pharmacy, picking up Schedule 2 prescriptions she had written for a patient but was using herself. Dr. G lost all her privileges and went voluntarily to a residential recovery center. She called me while she was there, asking for help securing some of her belongings because we lived in the same apartment complex. 

"I'm just so ashamed," she said, "I can't believe what I did. I don't know how I'm ever going to show my face back there again."

"Just get better," I said. "Just get better and come back, and you'll figure out what you've got to do."

A few months later, she returned to work, on a part-time basis and weekly drug testing. We all welcomed her back, but cautiously. She had to earn back the trust she used to have, but we cared about her. She was a good doctor.

Dr. Santell was his usual polite self with Dr. G. He didn't mention her absence or the reason for it. I remember wanting to talk to him about G, about other doctors he might have known with the same problem, but I didn't dare. I didn't want to bump up against his impassivity, especially when the rest of us were all so worried about our friend we hardly knew what to say.

Graduation day was approaching and the residents started advertising and selling tickets to the great event. I asked G if she was going to attend.

"I can't," she said. "I just can't. I don't know who I'd sit next to. Who could I sit next to? It sounds stupid, but that's why."

I tried to persuade her, but she wouldn't budge. This depressed me. I moped around the rest of the day, and perhaps it was this low mood which provoked me to tell Dr. Santell about what she'd said.

"Dr. G won't go to graduation because she's too ashamed to sit next to anyone," I said. "I mean, no one would get up and leave her sitting there, but how am I supposed to convince her?" I realize now I was challenging him, although I'm sure he knew what I was doing.

He looked at me solemmly. "Well," he said finally, "Tell her to sit next to me."

There are moments when what is right is so immediate and clear, you feel perfectly serene. There is no anxiety about what to do next. This is how I felt that afternoon, when I handed G a ticket to graduation and said "This is for the seat next to Dr. Santell." 

At graduation a few weeks later, they sat side by side, drinking punch and talking about inconsequential things, like two normal, happy people. That was years ago. Last I heard, G was still clean and doing well. Maybe Dr. Santell's cool, undramatic act of generosity helped her recovery, but I know he'd be the first to deny it. "It's just a seating arrangement, Theresa," I hear him saying, but then why does the memory of that graduation make me want to cry with gratitude?

Weary or not, I still make a point of telling drug users the information I think they need to know. I'm less dramatic these days, a bit more like Dr. Santell, although every once in a while I do make an impassioned speech to a person in trouble. I can't help myself. It's the way I create space, the space for the possibility of change, even if the space is only as large as the seat next to me.

Comments

[Colleen]

I work on a smoking research study. I've screened a few people who had an impressive cluster of health problems related to obesity and smoking. Diabetes, high blood pressure, COPD, asthma, sleep apnea, multiple joint replacements, and often the accompanying script for antidepressants. I often wonder how much a lifestyle intervention would do for their overall quality of life. Most of the people we enroll lament how terrible an effect smoking has on their lives, and are jittery messes when we ask them to abstain for their study visits. I have come to appreciate how nicotine addiction is the same as any other addiction. Just because it's legal and kills you more slowly doesn't make it better than any other drug of choice.