NARRATIVE MEDICINE

Nerve Pain

Jon Lepley, DO, FAOAAM
Medical Director of Addiction Medicine
Penn Medicine Lancaster General Health

Lisa was a real thorn in my side as a patient in the Philadelphia jail 10 years ago. She was a twentysomething- year-old, mostly healthy female who somehow entered my chronic medical care clinic within a day of entering the jail. Urgent appointments in the chronic care clinic were typically reserved for someone with insulin-dependent diabetes or severe asthma. Lisa was placed on my schedule for “nerve pain.”

Although all detainees met with a nurse within four hours of entering the jail to identify urgent problems and continue existing medications, physician evaluations for chronic illnesses were routinely scheduled to occur three weeks after a person entered the jail. This timeframe provided a crucial advantage. The jail system routinely processed more than 30,000 people a year,1 but at least half were released within two weeks. Seeing every incarcerated person with a health problem before then was unfeasible.

Sometimes, persistence trumped procedure at the jail in the face of vociferous patients, no matter how minor the complaint. Bearing prominent and protruding brown eyes against a gaunt face — I initially wondered if she had a thyroid problem — Lisa confidently strode into the exam room. She offered to make the appointment easy for me.

She said, “You just need to prescribe me Pamelor, and then after I try that for four weeks, I will come back, and you can give me my Neurontin.” I was the one who prolonged the interaction by asking where she had pain, for how long, and how the problem was initially diagnosed. She helpfully pointed out that I had many patients to see and could get on to more meaningful work by following her lead and prescribing a low dose of nortriptyline.

I was the one who prolonged the interaction by asking where she had pain, for how long, and how the problem was initially diagnosed. She helpfully pointed out that I had many patients to see and could get on to more meaningful work by following her lead and prescribing a low dose of nortriptyline.

A noticeable cacophony of gripes from many older patients outside the exam room door waiting to see me validated Lisa’s observation. I was swamped and obliged, hoping she would follow the probabilities and leave within two weeks. The odds did not play out that way.

Lisa returned to my clinic after four weeks with a chief complaint of “nerve pain.” Her eyes were less prominent, and her face was fuller. Read more....