Crossing Ethical Lines

Crossing Ethical Lines

I signed in with the receptionist at 3:50. She got a copy of my license and insurance card, again. She handed the cards back and confirmed I had filled the required forms online. I was here last week for my bloodwork ahead of this appointment, so I wasn't sure why they needed the cards again. There was only one other person in the waiting room, so I took a seat and grabbed a magazine.

I hate going to the doctor, always have. But my blood pressure medicine had run out a couple of weeks ago and the nurse refused to refill it again until I came in. It had been almost two years since I last saw Dr. Sutton. The nurse I spoke with told me I may as well get my physical since it had been so long. They had an opening for 4:00 Wednesday this week and to prepare for an hour-long visit. Excessive I thought, but most of it waiting for the doctor alone in the exam room most likely.

I started thinking about what I was going to say. I hovered over that one box for a while before finally clicking and hitting submit. I know he will ask about now, so no way to back out.

I hadn't been sitting long when the door beside the receptionist desk opened.

"Mr. Carlson?" A woman's head appeared from the door as I stood. I looked at my phone and it was 3:58. Damn, they were actually early and it's the end of the day! That's a first. Once we got behind the door, she held out her hand.

"I'm Janice Foley. I'm a nurse practitioner with Dr. Sutton and will be taking care of you today."

I shook her hand. "Mrs. Foley, please call me "Jim"

"Okay, Jim, please call me Janice then."

She was in her mid-30s if I had to guess, quite attractive and wearing a wedding ring. I'd been noticing that more and more lately, not that someone 10 years younger would be interested in me. I followed her past the exam pods further down the hall and around the corner into an exam room.

"Don't we usually start off back there?" I pointed back down the hall to the pods with curtains. That's where they always take vitals and ask general medical questions. She motioned for me to sit on the exam table while she closed the door.

"Usually, yes. That's where the nurse or medical assistant take vitals before putting patients in a room for the doctor. But I'll be performing your physical today so I'll do all that back here."

"

You

will be doing my physical?" My voice cracked as this was unexpected. She pulled up her seat and smiled at my response, I'm sure she gets that often.

"Yes. Once Dr. Fleming retired last year, Dr. Sutton sold the practice to Concord Health System. They've been buying up practices all over town and are linking them with their hospitals. Your health insurance provider is a major investor in the venture. It's a new model for patient care and has been successful with a healthier census across the network.

Dr. Sutton is still your physician of record. But, office visits and physicals are now performed by NPs. This allows the doctors time to review our findings with the patients. I'm one of two NPs now in this office."

"You mean they can now book and turn more patients, saving the doctor's time. By using professionals that cost a fraction of the doctor, they can generate more profit." She grinned and nodded 'yes'.

"That makes sense, but I was prepared to see Dr. Sutton?" My nervousness was exaggerated in my body language.

"Not today. This actually

IS

a better care model if you ask me though. Since we do cost less than the doctor, we are able to spend more time with the patient. Patients like more direct interaction. This allows more time to review medical history and understand any issues patients may be experiencing. We have most medical equipment in the office. If we need to run a test not covered by insurance in the old model, we run it anyway. The system is taking a more wholistic approach to care and it's something I fully support. The NPs only see existing patients and do have prescription-writing authority."

"Sorry, I'm a little confused. Does that mean you are my new doctor?"

"No. Dr. Sutton is still your physician and reviews all my notes and any prescriptions I write. If there is something outside my level of comfort or you if need any type of controlled substance, you will see him. Otherwise, you will see either me or the other NP from now on during your office visits and physicals.

I trust that is okay?"

I was taken aback. I wasn't expecting a new doctor, or NP, or whatever. A woman no less. But it didn't sound like I had much of a choice at this point.

But I

had

finally mustered the courage to tell him about my problem. With Amy gone over two years now, I was ready to finally start dating again and wanted to see about a little help. There was no way I could have that conversation with her.

Shit!

I clicked that box in the questionnaire!

She noted my apprehension.

"Is your hesitation because you love Dr. Sutton, or is it because I'm a woman?" I nervously laughed at her perception of the issue.

If she only knew.

"Well, I've never liked coming to the doctor, especially for a physical. No offense. And I have been seeing Dr. Sutton for almost 20 years now." I shifted uncomfortably.

"He even accepts the lies I tell him about my golf game without questioning me." She snickered.

"But if I'm being honest, I've never been examined by a woman before and am more than a little nervous. I'm sorry?"

She smiled again and set her iPad on her lap, giving me her full attention. I could tell she was experienced. She knew what she was doing, because there was no discomfort whatsoever in her demeanor. She was also noting my body language and sizing me up.

"Don't worry Jim, I get that all the time with men given certain parts of the exam. For whatever reason, some of you get uncomfortable talking about your 'boy parts'.

But I am a medical professional and believe it or not, I have seen a penis before and know

ALL

about them. I've also been married for 15 years and have three little boys, so I'm very familiar with the male anatomy." I couldn't help but laugh.

"Can you pull your sleeve up? I want to get a reading before we get started, since we haven't had any readings in a while." I got a judgmental glare for not coming in as I pulled my polo sleeve. As she pumped the cuff, I couldn't help but notice how attractive she was. Despite her conservative appearance in her scrubs, she was a damn pretty woman. Her husband was a lucky man.

"Hmm, let me try that again." She pumped the cuff back up and I tried to calm my nerves, knowing being in the doctor's office wasn't helping to begin with. But knowing she would be examining me certainly affected my pressure as well.

After getting the reading, I got a disapproving glance as she typed the reading in the file.

"140/90. What are your readings at home?"

"I haven't been taking them at home lately, but know it's been running high. I get lightheaded and dizzy more often, but I didn't think it was that high though. Maybe it's nerves?" She looked back down and started scrolling through her iPad again.

"Some of it, but not all. Are you still taking your Lotrel every day?"

"Yes" She typed something and kept scrolling.

"Let's talk about what's going on then. Are you under an unusual amount of stress? Are you sleeping okay? Depressed?" I shifted uncomfortably again and took a deep breath.

"You could say I've been under a lot of stress lately. Um, my wife passed away from breast cancer a little over two years ago and our daughter recently turned 13. She's been an emotional roller coaster not having her mom. And she's also developing, so there's that uncomfortable dynamic to deal with as her dad. Between the stress at work and trying to keep things as normal as possible at home, I've got to confess, I'm spent. I don't sleep well at night and my appetite isn't the same either. I knew it was going to be tough, but I get overwhelmed sometimes." While I hated talking about losing Amy, this was at least taking my mind off other things.

"I'm so sorry to hear about your wife. That has to be tough on both of you, especially at that age for your daughter." She seemed sincere and looked back and scrolled through her screens again.

"We got your bloodwork back from the lab and everything looks normal. You cholesterol is also within the normal range. Do you have a family history of hypertension?"

"Yes. My father had high blood pressure and died of a heart attack at age 60."

For the next several minutes, we discussed in detail my family's medical history. We also went through my history and when I first started taking meds. Alcohol intake, or any recreational drugs, as they could impact various systems. I had to admit, she was very thorough.

"Let's get through your exam. But I believe I'll be increasing your dose of Lotrel and may move you to something else altogether if this doesn't work. Given your family history, we need to get this under control." She started scrolling again through the questionnaire.

"The other item you marked as not normal was erectile issues. Tell me what's going on there." She set her iPad back in her lap and looked back up, waiting for an answer as if asked how I like my coffee.

I took a deep breath and then exhaled, shifting on the table again. She noted my apprehension and smiled.

"It's okay Jim. You're 46 and have severe hypertension based on the readings I got. Maybe not that high normally, but you're hypertensive. You have also experienced the loss of a spouse, one of the most stressful things that can happen in someone's life. Having erectile issues at times doesn't surprise me at all if I'm being honest with you. But I can't help you there unless I know what's going on."

She was right. I'd have to be uncomfortable but needed to have this discussion. No, I wanted to have this discussion. I was still fidgeting and looking away, thinking of how to start.

After a brief pause, she spoke again,

"While I've only been an NP for a little over a year, I was an RN for 15 years before that. I worked the last 10 years in urology. I've seen, herd and treated it all. Prostate exams, kidney stones, erectile issues, priapism, vasectomies, testicular implants. I've done them all.

This may be an uncomfortable conversation for you. I can assure you but it's something I'm

VERY

comfortable discussing. For an otherwise healthy man such as yourself, this is a treatable condition, one you don't have to live with. Sexual health is an integral part of your overall health. No different than any other system in your body."

I felt silly. She was right. It wasn't a severe case. But it was enough of one that I knew I wanted to have more confidence with before I started dating again.

"You're right, I'm sorry." Before I could continue,

"I know I'm right. So, stop being such a baby and tell me what's going on with your boners." She winked as she picked iPad back up.

"Do you always joke around with your male patients like this?"

"Not all. Only the ones who can handle it." She smiled and then continued.

"A lot of guys can't take it, so I have to keep my straight face on for them. Guys like you though? It's cute seeing a man such as yourself get so shy and vulnerable when we start discussing sexual health.

Especially

when I ask about quality of their erections and ejaculation. They usually fidget on the table and begin blushing. Like you are doing now."

I couldn't help but laugh. She did put me at ease somewhat with her bedside manner. The way she approached it did make me feel more comfortable and I took a deep breath.

"Before I get into that, may I ask you a question first?"

"Sure"

"Why did you leave urology after 10 years?" She nodded.

"Fair question. I went back to school to become a nurse practitioner, thinking I would stay in urology. But the doctor I worked for retired and sold his practice to this group too. Being so specialized, they spend more face time with patients. The new group now pairs them with LPNs for cost savings. My former head nurse is also an NP and is now my counterpart here in this office.

The transition to general practice is more responsibility and something I've enjoyed. While most of the female patients get their pelvic exams from their OB/GYN, we do that on occasion. I'll confess though, I'm more comfortable examining a man's genitalia as that's what I know best. So, spill it." She was speaking like a friend and not like a doctor, which put me more at ease.

"Okay, where do I start? I started noticing a problem staying hard shortly after she was diagnosed four years ago. I would lose it shortly after we started because I started thinking about 'what if' scenarios. I know that was a mental block. But it worsened from there to the point that I was having trouble at times getting an erection at all. Towards the end, there was no sex, so it didn't matter. Then she died." I trailed off and she gave me a moment.

"Again, I'm sorry to hear about your wife."

"Thanks. It's been rough but I'm finally ready to start another chapter in my life."

"Let's talk about your sexual history then. Are you currently sexually active?"

"No. I haven't been with anyone since Amy passed." I paused and nervously added. "But my daughter wants me to start dating again and is even trying to set me up with one of her friend's mom." She snickered.

"Why don't you?"

"I've never met her before. We do have a mutual friend with a daughter the same age and the three girls hang out. She is trying to set me up too."

"With the same woman?"

"Yes. From what I've been told, she's been divorced a few years and recently moved a few doors down from my friend's house. My daughter has been staying over at our friend's place while I've been at work most of the summer, so they are all very close."

"If your daughter is ready for you to start dating again, what's holding you back?"

"I've been hesitant to agree because of, well." She nodded.

"That's understandable. But let's address that now. Do you have morning erections when you wake up?"

"Most days, yes." She picked up her iPad and began typing.

"Tell me about them."

"What do you mean?" I wasn't sure how to answer her.

"Rate them on a scale of 1-4.

1 being not hard but not flaccid either

2 being hard but not enough for penetration

3 being hard enough for penetration, but not 100%

4 being rigid and erect

On that scale, how are your typical morning erections?"

"Um, I guess a 2 most days."

"Since you are not currently active, how about when you masturbate? Do you ever achieve a 4?"

This conversation was now more than uncomfortable. I know I had to turn several shades of red.

"Mr. Carlson? I mean, Jim?"

"Um, well, I haven't done that in a while either." I could feel the warm flush feeling in my face.

"When was the last time you ejaculated?"

"It's been a while." She put her iPad down again and tilted her head back up.

"Ejaculation is a normal function and healthy for prostate health. Especially as you age. There are many studies to back this up. If you are not active with a partner, you should be masturbating on a regular basis. You don't have to tell that to young men or boys, but you?"

My jaw dropped open.

"Really? I never knew that."

"Yes. Many practitioners are as apprehensive discussing this with their patients as their patients are. Fortunately for you, I'm not shy about it at all. If a man is healthy enough, they should be ejaculating daily if possible, with a partner or not." I shook my head, surprised at her candor, but she continued.

"Yale recently published a study on the effects of ejaculation on prostate health. They found men who ejaculate 21 times a month are 31% less likely to develop prostate cancer. There are many factors in the data. But study after study does point to ejaculating more, rather than less, for better prostate health.

It clears out any bacteria or blockages in the reproductive system. It's a natural way for the body to cleanse the system." I shook my head in disbelief and couldn't believe what she was telling me.

"So, when was the last time you ejaculated?"

"I don't know, several weeks, a month? Maybe longer? I don't do that too often." She nodded and made more notes.

"A month?" I nodded.

"Between being covered up with work and taking care of my daughter, I don't think about it much. I have so many other things on my mind that take my time. And I haven't been motivated since Amy passed away, if that makes sense.

Also, my daughter and I spend a lot more time together as I'm trying to fill that gap. She has nightmares at times and still asks if she can crawl in bed. Even though she's 13, she's still my little girl. I know she won't be doing that much longer, so I let her. That's probably not the best parenting." I trailed off.

She put her iPad down again and made direct eye contact.

"Given the circumstances, that's great parenting. You sound like an awesome dad. That's a pivotal age for her and she needs that comfort and security from her dad. You sound like a good guy. I can see why your friend is trying to set you up. You're quite the catch." Smiling again, she looked back into her notes.

"I don't know about that. But with school starting back, things seem to be getting better with the emotional mood swings. I don't know. The other mom and her husband are good friends. Both have been nagging me about dating again and meeting this other woman for weeks now. Lauren even called me this morning and is planning a cookout Friday night with the girls so I can finally meet her." She smiled.

"Why don't you then?"

I fidgeted again, not sure how to answer. She stared at me for a moment and then nodded in understanding.

"It's just us Jim, it's okay. Would you like me to prescribe something to help you with erections?" My eyes lit up. I was trying to figure out how to ask for that and she came right out and offered. To be honest, I was pleasantly surprised.

"If that's okay, yes. Not that I'm expecting to, um, well, you know immediately or anything." I looked down and away again and she smiled.

"I get that part. Your testosterone levels are at the low end of normal range, but nothing to be concerned about.

Even with normal erections, sometimes need a little extra help is needed. Especially with a new partner. That is if you do start dating again and get to that point. The pill can give a certain level of confidence and I don't mind prescribing it. I even have a couple of samples you can take home before you leave."

I couldn't help but smile a little. She not only offered the prescription, but even gave me the exact excuse I had been planning to use with Dr. Sutton. This wasn't as bad as I thought. She then shifted the conversation.

"What about when you urinate, is there any pain?"

"Not really. Sometimes I'll get a feeling that isn't pain but, how do I describe it? The best way is you know when you are on a roller coaster and you have a weird sensation in your groin? Well, at least I do." She nodded in acknowledgement.

"How often do you get that feeling?"

"A few times a week I guess."

"When you pee, do you always feel like you get it all, or do you have to pee again after a short while?"

"Sometimes I have to go again."

She typed more and spent a minute looked through the rest of the file.

"What about at night? Do you wake up and have to pee?"

"Sometimes" More notes.

"Have you noticed any blood in either your urine or semen?"

"No"

"What about pain in your groin?"

"No. Just that feeling I told you about. It's in that general area."

"Do you feel it in your scrotum as well?"

"Yes" More typing. Finally, she looked up.

"Is there anything else you want to discuss before I start the exam?"