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Falling through the cracks

A matter of substance

Maurer, Brian T. PA-C

Journal of the American Academy of PAs: March 2019 - Volume 32 - Issue 3 - p 58
doi: 10.1097/01.JAA.0000553387.67637.16
The Art of Medicine
Free

Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com. The author has disclosed no potential conflicts of interest, financial or otherwise.

Tanya Gregory, PhD, department editor

Figure

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“I know it's Friday afternoon, but this mother insists that she needs an emergency appointment for a physical exam for her son. I guess he's been accepted into a drug rehab program and they need medical clearance before he can go.”

I look up from behind my desk into the face of our receptionist. Her eyes appear desperate. She fears some pushback. She knows the last thing I want to do is stay late at the office on a Friday afternoon. I manage to suppress my annoyance and mentally acquiesce.

“Okay,” I say, and leave it at that.

This family is well known to me. I can still recall the day this mother brought her first adopted son to the office for his initial visit. A second adopted son followed 3 years later. Over the years, each one became more and more of a handful for this aging infertile couple.

The older boy developed a sullen disposition; he would spend long stretches of time by himself in his bedroom with the door secured. A loner through his high school years, he finally graduated and moved on to pursue an undergraduate degree at a local liberal arts college.

The younger son had a bumpier ride. Early on, he developed generalized anxiety and eventually ate his way into obesity as a preteen. Later in adolescence, he came out as gay and endured bullying throughout high school. But I was unaware of his substance abuse, evidently the latest debacle this family stood poised to confront.

I glance at my watch, push my desk chair back, and head out to see the next scheduled patient.

True to form, my adolescent patient is late for his last-minute physical examination. “It was all I could do to convince him to get into the car,” his mother says. I give her a slow nod and step into the examination room as she heads back out to the empty waiting area.

Robert sits on the examination table. Beads of perspiration have collected above his upper lip.

“Your mom tells me you need a physical exam for a rehab program,” I say.

He shrugs his shoulders. “I guess she would know,” he says.

“Can you tell me what's been going on?” I ask him.

“I've been doing heroin,” he says without a trace of emotion in his voice.

“Mainlining? Snorting?”

“Both,” he says.

“How long?”

“A couple of years,” he says.

“How often?”

“Every day.”

“Expensive habit,” I muse. “How do you support it?”

“I sell sex,” he says.

Instinctively, I take a deep breath. “How much does your mom know?” I ask.

“Everything,” he says.

And so we proceed with the examination. I scour his skin for needle tracks but find none. “Where were you shooting up?” I ask him.

“Between my toes, or under my tongue,” he says.

I peer into his throat, listen to his chest and back, palpate his abdomen, and examine his genitalia.

“We should check some labs,” I tell him. “We need to screen you for sexually transmitted diseases. Is it okay with you if I talk with your mother about this?”

“Go ahead,” he says through a vacant stare.

I spend some time reviewing things with his mother privately back in my office. Unlike her second adopted son, she is considerably more emotional. “I've always wanted the best for Robert,” she says. “But our lives have become a living hell.”

“You're doing the right thing,” I assure her. “Right now rehab is his best shot. When do you need the medical clearance letter by?”

She looks down at the watch on her wrist. “Six o'clock,” she says.

I retreat to the business office, log on at one of the workstations, type up a draft on letterhead stationery, proofread and print the final copy, affix my signature, and slide the folded document into a blank envelope.

As I step through the doorway into the waiting area, the mother rises to her feet. Silently, I hand her the envelope. Late afternoon light streams in through the front bay window. Her eyes shimmer with tears.

“Oh, Brian, how could we have missed this all this time?” she whispers in a pleading voice.

Fifteen years later, her question haunts me still.

Copyright © 2019 American Academy of Physician Assistants