“Foot pain” was the reason listed for the appointment. A new patient, male, age 31. I had now been in the clinic long enough to prepare myself mentally for just about anything. A year ago a young women with the same complaint, also a new patient, had presented with an infected foot wound open to the bone emitting an odor so strong, that when she took off her shoe it made the medical assistant have to leave the room in a hurry. Turned out she had spina bifida, and got this often. Her decreased lack of sensation and frequent hospitalizations made her blasé. As we waited for the ambulance, I asked “Why didn’t you just go to the ER?” “I didn’t think it was that bad, and I don’t have my insurance yet.” She was later transported to a trauma center where she remained on IV antibiotics for 3 weeks.

The man was tall and thin with longish straight brown hair. He was wearing a gray tank top and jeans and the prison tattoo on his upper arm was displayed for all to see.  I took that as a conversation starter and made a guess. “Were you recently incarcerated?” It was a universal term, no matter a person’s first language or education level.

“Yes, got out two days ago.” I suppressed the urge to ask what he had been in for.

“Have you had a TB and HIV test?” I asked. It was pretty standard.

“Yeah, all that, I was negative.”

“We can test you again 6 weeks from now to be sure.”

“Yeah, okay whatever, but that’s not why I’m here.”

“So tell me,” I encouraged.

“Five years ago, I was working as a roofer and fell off a roof. Broke both my feet. Was in casts, the whole deal.” He grimaced at the memory. “But the docs said I needed surgery to really repair things and I didn’t have insurance.”

“Are you in pain?”

“All the time. That’s why I’m here.”

Now was the time to ask about why he had been in jail.

He looked sheepish. “Um, narcotics, a little dealing. It was all because of my foot, though.”

I was surprised at his honesty.

“Let’s do an exam first and then we’ll talk.”

He was meek as a lamb.

The exam was pretty normal. The soles of his feet were painful to the touch but there was nothing really to see. He had full range of motion, good pulses.

I took a complete family history and got ready to order some blood tests. “Oh, no, doc, I hate needles,” said the man with the crude prison tattoo.

We compromised. A urine test this time, including a tox screen and a return in two weeks for blood work and a complete physical exam. I gave him a prescription for high dose naproxen for his pain, with the appropriate caveats.

Surprisingly, he came back and became a model patient. He said he was not using and his tox screen was negative. He was depressed, not surprisingly, and I started treating that with medication. We were helping him with insurance so that he could see a specialist for his foot pain. I continued to write him scripts for the naproxen since he was having no ill effects and his labs were normal. This was during the early days of electronic prescribing and not all pharmacies were equipped for this. He told me his wasn’t and I gave him paper scripts.

Six months went by. The clinic was always swamped so it took me a while to realize he was coming less frequently. I placed a call to ask him to come in to monitor his depression meds. Left a message but no response. Next time I called, the phone was not in service. I sent a letter to the last known address. And then forgot about him.

Until two years later, when I noticed he was on my schedule again. The complaint this time was “medication check.”

After the initial greeting, I asked where he’d been, thinking he’d moved.

He had been in jail again. This time, I asked straight out.

He seemed to wrestle with how to respond. “You’re not gonna like it,” he finally said. I was sure I wasn’t. And waited.

“Prescription tampering. Well, not really, but those scripts you wrote for that medication—“

“The naproxen?”

He nodded, and added “And the other.”

“The medication for depression?” I thought I couldn’t be surprised anymore but I was. Shocked actually.

“But wouldn’t I have been notified?”

“Well, there were drugs in the car, they cared more about that. And I was never able to use any of the doctored-up prescriptions – guess my forgery skills weren’t up to par. And the way you wrote them made it hard.“ He chuckled a bit until he noticed my stony-faced expression.

“So what brings you here today?” I finally managed a neutral tone.

“Well this time, I do want help to see the bone doctor. What I told you about my feet – that was true. And um — nurse?” (patients always struggled as to what to call me.)

“Yes.”

“I’m sorry. I know you really tried to help me and I took advantage and screwed up.”

What do you say to that? I just nodded and began the exam.