Billy Rubin, The Patient

Over the past year I have been having increasing difficulty with my breathing, having frequent episodes of wheezing and chest tightness, to the point where over the summer I could no longer exercise. I had never had such a problem before, but knew enough to know that albuterol would temporarily halt the symptoms. I stole some of my son's albuterol nebs, and the incredible relief they brought made me realize that I shouldn't be self-medicating and so I arranged an appointment with my doc. His take (after noting my room air pulse oxygenation of 93%--abnormally low for a 40 year-old with no major medical problems) was that I had new-onset asthma probably due to reflux, and while I was skeptical, I duly arranged to take a battery of medications, including the acid suppressor protonix, a steroid nasal spray, a steroid inhaler, and most importantly at that time, a two-week tapering course of prednisone, which by the end had me feeling like a million bucks and allowed me to get back on my bike again.

Two months later, though, despite being nearly completely faithful to the medications, I was tightening up again. Each week exercise became harder and harder, and I got more and more reliant on the albuterol (which helps symptoms but doesn't fix the problem). I went to see an ENT doc and he found nothing. My doc shrugged and suggested that I see a pulmonologist. When I called to make an appointment, though, the first opening they had was in mid-February, and I was getting worse by the day. Finally, by last week I had reached the end of my rope and decided to prescribe myself a steroid taper. Treating yourself as a doctor is definitely not considered smart, but I felt I had little option. When the pulmonologist had a cancellation a few days later, I came in and sought to apologize for the self-medication. After she listened to both my story and my lungs, though, she looked me straight in the eye. "You sound terrible, even now, a few days after you've started the prednisone," she said. "You absolutely did the right thing; I just can't believe you waited as long as you did." Well, how about that, I thought, Billy Rubin, model patient!

Then came the conversation about cats.

I knew it was coming. Anyone who suffers from asthma is advised to minimize exposure to a variety of allergens known to (or at least suspected of) drive the pathology in the first place. So my pulmonologist asked me if I had cats. I replied I had three. She paused, then said, "you may need to consider placing them somewhere." (Disclosure--I can't remember if those are her precise words but it's damn close.) Place them somewhere?

Doc, you seem nice and all, but I ain't getting rid of the cats.

A story leaps to mind. Back in med school I had a classmate whose wife had just delivered. She had two cats who had lived with her for about ten years and regarded them as "her kids," but the process of having human-based children had a profound effect on her. "I just came home from the hospital and looked at them," she told us, "and I said, 'Oh my God, they're just cats!' It was like I never really realized it until I had my own."

The family joke around the Rubin household is a bit different: I'm fond of saying that I have two and a half children and two and a half cats, the third cat being a good deal more than just some friendly fur that eats food and wants its box cleaned. This little feller sleeps with us, cries when we leave, comes right to the door as soon as we walk in and jumps straight to my shoulder. The other two are your basic cats, and while I'm very partial to them I suppose that I could banish them if my life were threatened. But this third cat? My baby? Oh, you must be kidding.

During my infectious disease fellowship, I had a clinic with a few patients who had advanced HIV and owned cats. Cats, especially the outdoor ones, carry a parasite called toxoplasmosis that's harmless to them and is in general harmless to us. However, those with compromised immune systems have to be careful--thus warnings against changing your cat's litter box if you are pregnant, are a transplant recipient, or you have advanced HIV. Usually there's some easily found solution so that the person at risk doesn't have to change the box, but twice I had patients who simply didn't have options: it was change the cat's boxes themselves or get rid of the cat. Both times I suggested they consider getting rid of the cat.

I remember both of these moments because I remember the looks I got in response to my suggestion. It was the same look I gave Doctor Pulmonologist last week.

In medicine, sometimes the equations are simple and so is the advice. But the solutions (and the docs that give them) have to take into account the whole of the person: knowing what's adjustable and what's non-negotiable. I don't blame my doc for her advice--it is, after all, the right initial advice to give--nor do I have any trouble with the clinical detachment  that she delivered it. She's supposed to be detached! As we continue to visit, though, I'm hoping that she'll come to appreciate how very un-simple the equation of getting rid of some cats would be for Billy Rubin, The Patient.
--br