The message showed up on my desk one day while I was seeing a patient. Its choppy shorthand read: “Admits to injecting testosterone. Now decreased libido. Call back to discuss.”
The caller was a 15-year-old lacrosse player who hadn’t been part of my practice long. Like many boys in his age group, he rarely came to the office.
When I responded to his message later that afternoon, the young man carried his end of the conversation with the typical terseness of a teenager. “Where did you get the steroids?” I asked. “On the Internet.” “How long did you use them?” “A few months.” “And what are you experiencing now?” He told me his nipples were sore and swollen. “I’ve been more tired and moody as well.”
My patient was experiencing classic side effects of steroid use. About 6 percent of teenagers admit to using performance-enhancing drugs, according to a recent survey, though it’s easy to assume that that number is low. How many teens would admit to using such drugs, even anonymously to a researcher? And yet here was one teen, forced by the drug’s side effect, having to make an embarrassing confession to me and his family. (Details of this case have been altered to protect patient privacy.)
Despite my patient’s fear, I was confident that a young, healthy teenager who briefly used steroids would bounce back, though it might take some time — and patience — for his symptoms to dissipate. When I explained this to my patient, he told me that he wanted his testosterone level tested, to make sure there wasn’t something more seriously wrong. I got the sense that he thought there was some way I could magically undo the harm he had caused himself. I paused and considered his request, which came across more like an order.
Taking anabolic steroids — which some people use to grow muscle mass and improve athletic performance — as this kid had been doing, causes a suppression of his natural testosterone. Even when the user stops, it takes a while for the testes to regain function after the slumber induced by juicing. No need to send him to the lab, I concluded, and I explained why. “Okay,” he said, finally, curtly.
The next day, I got another message, this time from his father, marked “urgent.” I called back within the hour.
“He needs a testosterone level!” the father insisted. As I listened and pondered my response, I grappled with a nagging question: If this kid had decided to put his body at risk, despite all he surely knew about the dangers of getting juiced, did I owe him a largely unnecessary test? Such a test, which can range in price from $50 to a few hundred dollars, would merely confirm that he had taken steroids, but it would not change how I treated him. I’d be ordering it just to make him feel better psychologically. I also secretly wondered whether giving the teen and his dad what they wanted was “rewarding” his poor decision to juice.
Saying “no” to a patient is a right a doctor has when a test or treatment is unnecessary or likely to cause harm. But what about saying no if you decide the patient doesn’t deserve it, because he or she made a bad choice? It’s an uncomfortable question but also a realistic one. Insurance, after all, is a pool of money. In the past, that pool was richly filled by employers and the government. These days, it has become shallow. All of us who work in health care know this in our heads. If a test is unnecessary, doing it is a waste of money — and time.
But one-on-one with our patients, doctors rarely utter such thoughts, in some cases simply to avoid confrontation. This often means that doctors order (whether appropriately or not) the latest and greatest in therapies and tests for our patients, even if we think they aren’t needed, thus driving up costs.
A much-discussed example of this involves smokers and lung cancer. In recent years, there’s been mounting evidence that having smokers undergo annual CT scans can detect early lung cancer, leading to earlier treatment and perhaps saving a smoker’s life. Some insurers have even started to cover the test. But some conscientious doctors have questioned it, arguing that using a CT scan to regularly screen smokers poses a potential health risk — and is too costly. Money to perform these tests will have to be taken from other, perhaps more crucial parts of the system. Given that smokers know that each puff brings them that much closer to cancer, do we owe them this money?
We all have hard choices to make about how and for whom our money is spent. Those choices ought to be driven by professional judgment and medical evidence. But — and it makes me queasy to say this — it’s unrealistic to believe physicians don’t inject their own values and biases in decisions.
This is just what I found myself doing with the kid who had juiced to bulk up. I had passed judgment on my patient. Still, I knew I had to look beyond my own prejudice. I decided to express a little empathy — trying to see this from the point of view of an impulsive young man who saw (and craved) an opportunity to improve his physique, without a clear head about the risks of his choice. I opted to negotiate.
I called his father and told him I’d consult a specialist. “It’s a tough way to learn a lesson,” I told the boy’s father. “I wish he had thought it through more before he decided to take the steroids. As I told him yesterday, it’s not going to be helpful to do any tests. His body is telling us that he has low levels of testosterone. My advice is we wait and watch him over the next few weeks to see how he recovers. But let me speak to an endocrinologist about it. I will get back to you.” His father agreed.
The next morning, I spoke with a specialist, who agreed with my assessment. But instead of picking up the phone and calling the boy and his father right away, I chose to wait. Part of it was because I wanted to consider how to parry any further demands they might have. But there was something more: I wanted my patient to sweat, just a little; maybe that would help keep him from being this stupid again.
Perhaps it helped, because when I got back to him and his dad, things had moved in a positive direction: Many of the boy’s symptoms were beginning to resolve as his testosterone levels returned to normal. To put their concern to rest, I scheduled a follow-up checkup, giving me a chance to examine him and a face-to-face opportunity to emphasize the risk he had taken by taking steroids. Seeing him also reassured me about his emotional state, since depression can be a side effect of steroid withdrawal.
It’s easy to see how my thinking in this case can lead us down a slippery slope at best and off a perilous cliff at worst. Maybe you can deny an annual visit to the CT scanner to a decades-long pack-a-day smoker or a blood test to a teenager who juices. But where do we draw the line?
The best we doctors can do, I think, is to be mindful of our own feelings while informing our patients of the risks they take and the limitations of medicine in helping undo the choices they have made.
Parikh is a pediatrician in Walnut Creek, Calif.