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Sleep Apnea, Snoring, Narcolepsy,
Insomnia and Other Sleep Disorders.

THE SLEEP SITE  

CASE VIGNETTE - 2.


Waxman was sitting behind the door: hunched over part of a newspaper on his lap. The rest lay in a pile on the floor. His head snapped up abruptly.

"Well, well. Dr. Andrews. Glad you could finally make it."

Andrews bit his lip, struggling against the urge to fight sarcasm with sarcasm.

"So, how are you feeling, Mr. Waxman?" He flipped the chart open. "Looks like your blood pressure is coming under control--or at least, it's better than last time."

"Listen, doc. If you would teach your staff something about manners, it'd be perfect every time that you make me come into this damn place. Guess that'd be bad for your business, though--wouldn't it?"

Andrews refused to dignify that comment with a reply. For as little as he was paid to care for each MaxCare member per month, under his capitated contract with them, he would be better off if Waxman stayed away for a good long time...or at least, as long as the patient didn't come down with something serious in the interim.

Actually, he worried about that possibility. Waxman always looked lousy to him, somehow, but he could never put his finger on why. Nothing much had ever shown up on physical exam aside from hypertension and mild peripheral edema. Blood work wasn't bad--cholesterol actually was lower than one would have guessed after looking at this overweight 58 year old man. Overall, though, Waxman reminded him of an ex-football player, gone to seed. His mental status was probably another cause for potential concern. While he had a quick tongue, he rambled a lot and never seemed to remember what Andrews told him.

Andrews had wondered many times whether Waxman was a closet alcoholic, but he insisted vehemently that he didn't drink. On the single occasion that Andrews had met his wife, at the time of his initial visit some two years earlier, she had corroborated such. At the same time, given the way that Waxman had ridiculed her in a bullying fashion during that first visit, Andrews wondered if she would dare speak openly. At the same time, she had seemed to have more on the ball than her husband. She certainly seemed more interested in being helpful.

Waxman, on the other hand, was a miserable historian. He denied everything. Questions were wasted on him: he seemed to regard each one as an excuse for a hostile retort.

"How on earth could any doctor ever get to the bottom of this guy's problems in a "MaxCare One six minutes"?", Andrews thought to himself. He felt uneasy about the bad vibes he felt about this man, but he didn't know what to do about it.

Andrews cut off conversation and did a brief physical exam. Nothing earthshaking. Typical exam for an out-of-shape, hypertensive man who had let himself go..and who didn't seem like the sharpest knife in the drawer to boot.

"So, is anything bothering you today, Mr. Waxman?"
"No..I'm in great shape. You should know that. You're the doctor, right? Hey, look--actually, I did want to ask you about that drug for lousy sex lives."

Andrews launched into a quick discussion of medications for impotence, summarizing their pros and cons. He also mentioned their potential risks in patients with occult coronary disease: plus the fact that so far, MaxCare One had not been covering it.

"Look, doc. I'm healthy. You can't find nothing wrong with me or my heart, no matter how many times I come here. My heart's perfect. Even that treadmill you made me do last year should have told you that much. But, so give me a heart attack anyway and tell me how much those new sex pills cost."

Andrews gave him a ballpark estimate.

"Then, the hell with it. God knows who I would use it on, anyway!"
"What about your wife, Mr. Waxman? Is she OK? I haven't seen her in a long time."
"How should I know? Still lives at the same address as I do. Lives down the hall from me, actually. I don't know what her problem is. So, forget about it. She isn't worth it, anyway!"

Waxman paused and looked down. He seemed to be losing his train of thought. Andrews glanced at his watch, and at the telephone on the exam room wall. Five of the six lines were blinking. He had to get moving. Maybe Waxman was just depressed.

"Look, Mr. Waxman. I think I know of a drug that might help your problem, and Maxcare would pay for it." He pulled out a prescription pad and began writing for one of the newer generation antidepressants.
"Wait a minute, doc. What is this drug, exactly? What is it supposed to do?"
"Well, it's pretty safe. Better than the older ones we used to use all the time. You probably would feel better so maybe that would help. Could make your days go better. Lots of people who are under stress sleep better with it."
"Nothing is wrong with my sleep," Waxman retorted. "Does it have any side effects or anything?"
"Oh, not all that often. Could upset your stomach. Some people get diarrhea. Let's see...could make you sleepy."
"That's no risk to me, doc. I don't have time to get sleepy. Work hard and never slow down for nothing. If it'll make you happy, I'll try it."
"Annie will give you an information sheet about the drug..."
"Sure, whatever. Tell her to send it to my wife and she can read it. She likes that sort of stuff. I'll probably forget to give it to her anyway. I got too much other stuff to do since they downsized us."

"Sure takes responsibility for his health," Andrews thought.

"Mr. Waxman, what if I called your wife when I get a chance? OK with you?" Perhaps she could shed some light on whatever it was about Waxman that continued to trouble him.
"So, why on earth would you want to talk with her? I'm the patient, not her. She just goes to some female doctor. She doesn't know nothing...but...go ahead! I don't care. And tell her I said hello when you do." Andrews made a mental note to telephone her as soon as he had time.

There was a knock at the door. "Dr. Andrews, you aren't going to believe it. MaxCare One's Medical Director is on the line. He is actually returning your call!" Andrews jumped to his feet.

"OK, see you in a month, Mr. Waxman. Let me know if you have any problems."

He hurried to his office, loaded for bear. After forty minutes of arguing with a non-practicing physician whose prior specialty had been dermatology or something equally unrelated to his patient's illness, he landed the necessary preauthorization. At long last!...a minor victory.

The mental note to call Waxman's wife fell through the cracks. In fact, he didn't think about her again until the following Monday, the day that she tried to reach him.

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COLUMBUS COMMUNITY HEALTH
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