Joshua Shadd and Judith Belle Brown
Marcus was almost a typical 19 year old – scrawny, baggy clothes, unkempt hair and restless eyes. He and his girlfriend, Angie, had recently moved to town in order to attend the local community college – he for a career in IT, she as an esthetician. Marcus enjoyed school and loved Angie, but his real passion was playing his bass guitar. “That’s how I decompress,„ he explained. He was like his freshmen classmates in almost every way – except that Marcus had undergone more cancer treatments than anyone Dr. Boice had ever met.
Marcus’s previous family physician introduced him to Dr. Boice via a referral letter. Marcus was diagnosed with Wilms’ tumor of the left kidney at age six. Despite aggressive, curative-intent therapy, his first recurrence appeared at age 12. Since then, Marcus had undergone seven more operations in addition to multiple cycles of chemo and radiation therapy. The letter identified pain as Marcus’s primary concern and cautioned that much effort had been expended to find an acceptable analgesic regimen. The unspoken message was clear: common ground had not been found easily. Medication changes were risky.
The notes from the local pediatric oncologist added valuable insights. Marcus declined a repeat chest X-ray to assess progression of his known lung metastases. When the oncologist raised questions about the future, Marcus closed the discussion. Further chemotherapy, it seemed, was not in his plans.
Dr. Boice’s goal going into his first encounter with Marcus was simple: to build rapport. It was clear that Marcus’s malignancy, while not causing major problems at the moment, was progressing. Marcus was new in town with no support except his girlfriend, and there were storm clouds on the horizon. Dr. Boice suspected their relationship would be an important one for Marcus in the not-too-distant future.
Marcus attended his first appointment, like all of his appointments, alone. He discussed his story comfortably, often recalling specific names and dates. He was obviously well-practiced in providing his medical history. When asked about his family, Marcus confirmed what Dr. Boice had read in his chart: parents separated but supportive, one healthy younger sister. Marcus didn’t elaborate further. When asked how he felt about his illness, Marcus politely but unequivocally declined to discuss it.
Marcus’s analgesic regimen was the kind that raises a yellow flag – regular use of short-acting oxycodone alongside scheduled long-acting oxycodone.
During that first visit, Marcus reinforced the message from the referral letter – it had been very difficult to find an adequate analgesic strategy, and he wasn’t interested in changing anything. He was greatly relieved when Dr. Boice confirmed his willingness to continue prescribing his current pain medications.
Marcus came to clinic once per month. He was always alone. The visits quickly fell into a pattern. He would talk about what he was learning in his networking or web design course. He mentioned his girlfriend often, but his family never. They would discuss his pain. At every other visit, Dr. Boice would gently probe about Marcus’s emotional state and coping. Marcus would immediately close the door, and Dr. Boice would respect this by not bringing it up at the next visit. As Marcus was functioning well overall, this defense mechanism seemed to be adaptive and Dr. Boice saw no reason to challenge it. Marcus ended every visit the same way: “Thanks for being there for me, oc.„
When Dr. Boice proposed initiating an adjuvant analgesic for the neuropathic component of his pain, Marcus had only one question: “Will I still be able to play my bass?„ Marcus’s fluctuating degree of engagement with his music proved to be Dr. Boice’s one narrow window into Marcus’s illness experience. The pain improved somewhat, and his opioid dose remained stable. At the beginning of the winter term, things seemed to be going well. Marcus decided to pick up an elective course in biology, and at each clinic visit he wanted to learn a new medical term to take back to his professor.
It was late January when the clinic nurse interrupted Dr. Boice between appointments. “Marcus called,„ she began with a concerned expression. “He says that he needs another prescription because he dropped his pills in the toilet.„ Dr. Boice’s heart sank. Marcus might as well have said “the dog ate my homework.„ This could make it much more difficult to help Marcus. Dr. Boice asked him to come to clinic that afternoon.
During that visit, Dr. Boice expressed his concerns. “Marcus, I’ve been your doctor for almost six months now, and you’ve never given me reason to doubt you. But I need to tell you how concerned I am about the loss of these pills.„
Marcus was visibly upset. “Doc, I’m not lying to you! You have to trust me on this – you have to! I’m not selling my pills! Look, I brought in the pills that fell into the toilet. I can use them if I need to.„
Dr. Boice’s response was gentle but firm. “Marcus, I do trust you and I will give you a prescription today, but you need to understand that I won’t be able to do so again.„
“Thanks, doc.„ Marcus sighed. “You gotta believe me. I wouldn’t lie to you.„
Marcus seemed relieved as he left the office. Despite his statement of reassurance to Marcus, something still didn’t seem right to Dr. Boice. Marcus
had given over the pills recovered from the toilet, but they were far fewer than needed to get to his next scheduled prescription. Dr. Boice asked the clinic nurse to call the pharmacy to confirm what had been dispensed. This time, she hung up the phone with a smile. It turned out the pharmacy had dispensed only a two-week instead of his usual four-week supply. Marcus’s story was vindicated. Dr. Boice was relieved. Trust in their relationship was important for him too.