Listen and listen hard…
This week, I refused to perform a vasectomy on a patient of mine. That is, until he saw a doctor about his sky-high blood pressure. Thirty years old and a father of three, he is a productive, hardworking member of society who just happened to never have seen a doctor as an adult. Unusual? Not at all.
Why does this happen? Is it because, in the words of Andy Rooney, that “death is a distant rumor to the young?” What is it about being young and male that instills this concept of immortality? For one thing, men do not have a monthly biological reminder of their health, similar to the female menstrual cycle. Second, the culture of men is imbibed with the “breadwinner” mentality that tends to equate illness with weakness. Lastly, men are terrible goaltenders of their own health. It is simply not on the radar of most men to think about their health unless something a) hurts, or b) is life threatening.
Lets delve into the last of these a bit as there is an interesting corollary to back this up. It is clear from many studies over the last century that married men uniformly outlive their single counterparts. In some studies, the difference in lifespan approached 10 years. Viewed another way, divorce affects a man’s health about the same as picking up a pack-a-day cigarette habit. So, it is clear that one of the best strategies to a longer life is to marry and stay married. If it is in your personality to gain immortality by this approach then so be it.
But that may not be the case of my patient, who in fact came back one week later for his vasectomy, feeling empowered, and with his blood pressure under perfect control. “And I thought the headaches that I had been getting were due to the stress I have been feeling.” He was a changed man, in control of his health for the first time in his life. He also understood the concept that life-threatening illnesses may be subtler than a broken bone.
After 17 years of caring for young men, it is clear to me that they are an incredibly underserved population. In fact, this is one the key points that I will make as an invited speaker to the Centers For Disease Control (CDC) upcoming summit on “Advancing Men’s Reproductive Health in the US” to be held in Atlanta next months. In my practice, I assume that men need help understanding how to take better care of themselves. I know that they would like to find out more about what health issues they may have inherited that can harm them, but they have trouble asking and knowing where to turn. Hence my practice motto: “The way to take great care of men is simple: just listen to them.” And listen quietly, as their voices are soft. Trust me, this hardly ever happens in the standard, 12-minute office visit that is currently de rigueur in this country.
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turek
September 2, 2010
An email sent to me by a UC Davis medical student:
So in response to your blog post about medically underserved young men, I have a recent story to confirm this idea. I’m here to tell this tale about young guys being medically underserved.
Josh has a passion for developing information technology in Africa after serving there for 1.5 years as a peace corp volunteer. He is very white, and speaks fluent Swahili. During his stint there, he got 5 bouts of malaria and one of amoeba dysentery. (He also told me about a case of ocular schistosomiasis that he witnessed there on our first date, without really knowing my tolerance level for grossness.) After he came back, he worked for 2 years as a computer engineer for a Silicon Valley startup, but he quit at the beginning of this year to start his non-profit organization to help grassroots organizations in Africa use technology to sustain themselves at the community level.
He’s just been nominated as a TED fellow (and naturally I agreed to proof his application the night before it was due.) About a month ago, on one of his trips to Tanzania, he emailed me in the middle of his trip with the news that he got malaria– again. This would be his sixth bout of most likely falciparum malaria. He failed a course of artemether-lumefantrine, and decided to email ME about whether to start a course of malarone! He was telling me he was dizzy and seeing things that aren’t there, and I was worried sick about cerebral malaria that can kill you dead in 24 hours! He wrote back and was all like: “oh, try not to worry about me, I’ve done this under much worse circumstances, hallucinating from the fever alone in a hut on my voodoo island in Tanzania where they only have witch doctors. And I was tended to by spice smugglers who rescued me from a corrupt policeman who tried to arrest me for appearing drunk because of the malaria. Now I’m actually in the capital, where you want to avoid the hospitals because you can get TB there.” Great.
Long story short, upon his followup with a doctor in the US, the doctor thinks he initially received counterfeit artemether-lumefantrine, which should bring down fever in <12 hours and didn’t after 72 hours. Fortunately he apparently got real malarone when he decided to give that a try, because “why not?”
His health insurance just ran out yesterday, I think. He’s already booked another trip to other parts of Africa (Uganda, Kenya) in October to expand on his technology development. I’m thinkin’ he should visit a travel clinic before he goes, to make sure his immunizations are up to date. I also thought maybe he should pack some anti-malarials, but insurance doesn’t cover those unless you have active malaria. Malarone is like $300 out of pocket. Doxycycline prophylaxis apparently failed, so maybe he should be on qWeek chloroquine or something. I think he should also establish whether he has baseline asymptomatic parasitemia, because apparently some people do and that can mess up the diagnosis of an actue febrile illness that may not be malaria. I’m also worried about all the other great parasites you could get in East Africa, like sleeping sickness and schisto and amoeba, but I guess there isn’t great prophylaxis for those. His BMI is about 19, and he unintentionally loses weight every time he goes.
Anyway, some doctors see patients and then date them later (yeah, I know on the USMLE you have to bubble the choice that says that’s sketchy ethics). Apparently, this is happening to me in reverse. He’s not my boyfriend and I’m not getting my romantic hopes up, but I just thought I should try to help make his frequent trips to Africa a little safer because he is in a way quite the stereotypical young male patient you’re familiar with.