However, discussion of sexual matters in the seminar can make the subject more comfortable. Doctors attending seminars have said that it is a safe place in which to practice the discussion of sexual details, and they gain greater confidence to listen to, or to broach sexual topics with their patients.
Setting clear training boundaries that exclude personal sexual revelations and that tie all discussion to a specific case, allows for a study of those difficult moments in the consultation when a feeling of sexiness develops in the room. For the woman doctor faced with a man who produces an erection, the embarrassment can be great for both parties. It may be possible to see such moments as uncon-sicous defences on the part of the patient (Skrine, 1987). Certainly the doctor is usually de-skilled and has to retreat to the safety of the prescription pad, the ordering of tests or a referral to another doctor. During training the doctor can learn to cope with such moments with some degree of equanimity.
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Although doctor had a special interest in psychosexual therapy and some skill in this field, his personal feelings made therapy with this woman, or her husband, a potential minefield. The professional pride of this doctor nearly led him to embark on a dangerous offer of therapy. He could recognize that, because of his training, he had been able to stick with the real problem – that the woman wanted to change her method of contraception without the existence of a logical acceptable reason. He knew from his previous experience with similar encounters that an emotional reason was likely. He had several bright ideas: she might feel she was too old to be continuing on the combined oral contraceptive, or that she might want a less reliable method in order to risk pregnancy without taking a definite decision to start a family. The failure of these ideas to strike a chord with the patient reminded the doctor that each patient is unique and that experience gained from other patients is of no help in understanding what is happening with this particular patient. Only when he waited, in ignorance, for her to tell him what the problem was for her, did he discover the underlying difficulty. He knew, too, that if the husband had come to him with the problem of premature ejaculation, he might have been able to help him discover why it happened. Perhaps his first wife had taken too much from him and he wanted subconsciously to retain the sexual pleasure for himself; perhaps he had always had this pattern and could not see any difficulty, or any of the myriad other reasons why it occurs. Then he could perhaps help him to make the necessary changes to ovecome the precipitate ejaculation. The doctor’s difficulty was his nonprofessional partisan feelings, which made referral elsewhere a preferable option. He would have to propose this to Mrs S. without making her feel rejected.
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Sometimes any contact with a familiar doctor may be perceived as too threatening. A young girl may be unwilling to reveal her sexual needs to a doctor whom she regards as an extension of her parents, particularly her father, and therefore (she feels) bound to disapprove. The occasional publicity about parents being told about their daughter’s sexual activity by a doctor, or even the presence of a rumour about lack of confidentiality, will further discourage the timid or unsure. This part of the growing up process which has to be kept hidden from parental supervision and knowledge, the secret inner world, this search for the separate individual self which is the adult into which the adolescent is developing, prevents the not-yet-quite-adult from consulting those he or she views as being in the parental role. Doctors, teachers, school nurses, as well as parents, all recognize the difficulties of reaching past the defences of the often sullen and rebellious teenager or young adult. Particularly if there are difficulties – the unsuitable boyfriend, a fear of infection or abnormality, failure of erection, pain or dissatisfaction with intercourse – a stranger may need to be sought out. A clinic or doctor unknown previously, perhaps recommended by a friend as sympathetic, is consulted instead of the familiar family doctor.
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In the next two case examples, not only were the patients young at the time of their vasectomy, but there is the additional factor that with both men the procedure was undertaken for the sake of their partner.
A couple came for advice about their infertility. They were in their early 40s, the man dressed in a neat business suit, and his wife also formally dressed. She was so distressed that the overwhelming impression was of a woman with a mass of wild auburn hair and barely restrained emotion. They had married at 18 and had three adult children. After the birth of the third child, the husband, aged 22, had undergone a vasectomy in the puerperium. There appeared to have been no encouragement for him to discuss his decision with his wife. Initially the situation seemed acceptable, but as the years went on and the children grew up, the couple became increasingly distraught. They found adoption was impossible and fostering did not meet their emotional needs. They both regretted the operation and reversal was undertaken but pregnancy did not follow.
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Her situation was discussed and the importance of failure rates examined. Ann said that in the event of failure of the method she would find termination of pregnancy very difficult to even consider, as she felt it would indicate that she had no value. It was agreed that the injectable contraceptive would give her secure contraception and be the safest option in view of her total immobility. This method protected her against pregnancy and induced amenorrhoea which she found a blessing. Many times over the years the couple and their doctor have discussed the prospect of children. Ann and John have now decided that the risk to her health and life is too great. Ann has needed to feel that she had the choice and that she had the capacity to conceive like everyone else. Now, after discussion with her husband, she has made her own choice rather than having a decision thrust upon her by a well-meaning professional.
After some years on injectable progestogens she dreads the thought of periods again and she is currently discussing the possibility of sterilization and endometrial ablation. Further long-term use of the injections has to be considered carefully in view of the possible risk of osteoporosis, which is already a risk factor for her due to her immobility. It is important that Ann and John feel comfortable with the decision made.
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If you think you have temporal arteritis, you should see your doctor immediately, especially if you have experienced sudden blindness. He will conduct a blood test that includes a test for the erythrocyte sedimentation rate, or ESR, which will check how quickly red blood cells settle in the bottom of a test tube. A high ESR is an indication of an inflamed artery, as in temporal arteritis. Your doctor may also perform a biopsy of the temporal artery in order to make a positive diagnosis.
If you do have temporal arteritis, you will need to treat it with a regimen of corticosteroid medication such as prednisone on a long-term basis, possibly for months. This will help reduce the swollen artery to its normal size. In order to prevent future problems, however, you will need to continue taking the medication for a year or more; regular blood tests that monitor the ESR in addition to your symptoms will help your doctor to guide your treatment.
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Description and Possible Medical Problems
A sudden sharp, stabbing pain in your face that begins at your temple and radiates to your cheek or jaw can be frightening. But when the pain arrives for no apparent reason, occurs intermittently for up to several weeks, and then disappears completely for anywhere from a day to several months before striking again, you probably have a condition called trigeminal neuralgia.
Trigeminal neuralgia is characterized by its unpredictability and its sharp, sometimes brief ashes of pain. Men and women over the age of 50 tend to have the condition, and the frequency of attacks increases significantly over the age of 70.
The cause of trigeminal neuralgia is unknown. Though some studies point to a brain tumor or a blood vessel pressing on the nerve as the culprit, the exact cause cannot be determined.
Treatment
If the pain recurs with regularity and makes it difficult for you to functior your doctor may recommend you take phenytoin or carba-mazepine, anticonvulsant medications that may help reduce the number of attacks. You may need to take the medication for a number of weeks after the initial attack.
For severe cases of trigeminal neuralgia that don’t respond to anticonvulsants, your doctor may suggest you undergo an operation that either destroys the trigeminal nerve or reduces its sensitivity, though the final outcome of the operation is difficult to predict and may lead to permanent paralysis of one side of your face. However, in the entire time I’ve spent working as a physician, I have never seen this surgery performed. In addition to the anticonvulsant medications I’ve mentioned, some people with trigeminal neuralgia can also take the antidepressant Elavil to control their pain.
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Twenty years ago, when a person was diagnosed with an intracerebral hemorrhage, many doctors often opted against treatment since the condition almost always meant certain death. Today, if the intracerebral hemorrhage is caught early and treated with microsurgery, the person can be saved. Once in the emergency room, the doctor will examine you for signs of an intracerebral hemorrhage with a CAT scan and maybe do a lumbar puncture (see treatment under “Headache in the Morning, Made Worse by Sneezing, Coughing” above, for more information about this procedure). Once the diagnosis is confirmed, surgery can begin to repair the blood vessel or aneurysm. If the aneurysm is caught early, you will recover fully.
I have a 52-year-old patient who experienced a severe headache on a subway platform one morning. She also felt weak, and she passed out. She later told me that she had had a constant headache for several days before she passed out, and she had never suffered from headaches before.
She was rushed from the subway platform to a large New York hospital where the doctors were able to quickly diagnose that she had a brain aneurysm that was bleeding; her different-sized pupils gave her condition away. The doctors performed emergency surgery to clip the bleeding vessel and stop the hemorrhage. Since the surgery, she has had no residual side effects and has been carrying on with her life as usual. After surgery, she spent two weeks in the hospital, and after two months she returned to work. A year later she shows no signs of the aneurysm.
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If an adult child brings in an elderly parent and complains that the parent has been confused and forgetful lately, I ask the parent to draw a clock face, to both diagnose the adult and reassure the child. If the parent can draw a clock and hands and place the numbers in their proper place, I tell the parent and child that there’s nothing to worry about. With normal aging, an elderly person’s concepts of space and time gradually become more difficult for them to grasp; I feel that as long as they include all of the numbers as well as the hands, they are okay. If, however, you notice that an elderly relative has become increasingly confused over a long period of time and that it’s beginning to affect the quality of her life, the first step is for her to see her physician, who will probably conduct blood tests to check for vitamin deficiencies, thyroid disease, or another underlying treatable illness. If, however, the doctor determines that your relative does have Alzheimer’s disease, treatment will depend on the severity of the disease.
If placement in a nursing home is not necessary, many people with Alzheimer’s disease will thrive in a day program at a specialized center. The daily activity, as well as regular treatment, can help ease the underlying depression that is a common problem for many people with Alzheimer’s.
Recently a new medication called Cognex or Tacrine has been shown to help some people with Alzheimer’s. These medications seem to slow and even reverse some of the cognitive changes in these patients by improving the response of the neurotransmitters. In the beginning, the doctor will start a patient out on a low dose of the medication and slowly increase it over a period of several weeks. But the effects are usually not dramatic; slowing the speed at which Alzheimer’s progresses can take months to occur. Cognex or Tacrine can also be highly toxic to the liver, so a patient needs to be monitored regularly with blood tests to check the degree of toxicity. Even though these medications are a bright light on the horizon for Alzheimer’s patients, I don’t consider them to be a panacea, as I’ve seen them work well in some of my patients while they’ve had no effect on others.
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Even though modern medicine has enhanced the health and extended the lives of people who would have otherwise perished without it, the advances have come at a price: the amount of money that is required to research and develop these new techniques is enormous, amounting to billions of dollars each year. Someone has to pay for high-tech medicine, and it eventually filters down to the point where it’s paid for by the consumer. And since research must continue so that we can improve on the type of medicine we currently practice, the cost will continue to rise. It is for precisely this reason that the price of medical insurance has gone through the roof since the 1970s and ’80s and it has become impossible for working poor, middle-class, and even upper-middle-class Americans to take advantage of these incredible advances. Only people who are on welfare and receive Medicaid or are elderly and benefit from Medicare are able to benefit directly from the system—that is, besides people who have employer- or self-funded health insurance. Even then, people who have private health insurance are frequently shocked to discover that their insurance sometimes doesn’t cover everything they think it does. Of course, we hear about the great numbers of Americans without health insurance, which is estimated to be 37 to 40 million people. These Americans learn to keep their fingers crossed and maintain their own health; in the case of an injury or major illness affecting themselves or a family member, they either draw on their savings or go into massive debt.
As if all these changes weren’t enough to influence health care in America and point out the need for reform, it is also important for you to realize that even as the medical technology has made significant advances, the type of physician who graduates from medical school has also changed. When I finished medical school in 1975, everyone in my class chose a specialty like plastic surgery, ophthalmologic reconstruction, or another extremely narrow field of medicine. Back then, graduating physicians quickly realized that the glamour and financial rewards of medicine were primarily in doing specialty work, not in general practice. Even those physicians who chose to go into general medicine became specialists in family practice or primary internal medicine. Most physicians also opted for private practice, many times in partnership with another doctor who was in a complementary specialty, like an OB/GYN who shared an office with a pediatrician. And specialists also earned more money than generalists, which undoubtedly helped many new med school graduates with hundreds of thousands of dollars of student loans staring them in the face to decide their destinies.
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