“Fairy tale“, Taras Shevchenko, Public domain, via Wikimedia Commons
“To tell you straight doc, I’ve come to accept that everyone dies. Everyone dies at some point. My time might just be sooner.”
An imposing, bronzed figure sits in a comically undersized exam table. He is young with few wrinkles at the corners of his eyes. Both hands tremble in his lap but otherwise he seems calm. This morning, he abstained from measuring out the usual 16 oz of vodka he drinks to get through the day.
“Do you understand my quandary in continuing your treatment?,” the doctor asks him. The patient nods. He took anabolic steroids and testosterone until a cardiologist said HFrEF, or Heart failure with reduced ejection fraction. Now he’s back on the steroids after agreeing to manage testosterone with a physician and seeing improvement in his ejection fraction.
The doctor asks me what I should be looking for when we begin the physical exam.
“Tan lines?”
“Facial plethora from testosterone.” I learn it can be difficult to visualize the effects of polycythemia when skin is darker hued.
“I think I have gynecomastia,” says the patient. The thought hadn’t even crossed my mind.
I don’t notice how much he’s sweating until after the heart and lung exam. As he gets up, the paper from the exam table peels away. It sticks to his back. He pulls his shirt on quickly without removing the tufts.
My first patient of third year is not what I expected. His voice is measured and knowledgeable. He pronounces dehydroepiandrosterone better than I ever have. He knows he needs help.
“A psychiatrist told me I have body dysmorphia.”
The doctor asks, “Are you seeing a counselor now?”
“I wasn’t interested in talk therapy.” Something must have changed because he has a virtual visit scheduled with a counselor tonight.
We go through the usual questions about family history. Does his sister have any medical conditions?
“No, but she’s fat as [expletive].”
Later, the resident who was also in the room with us is unfazed. She sees this all the time.
Two decades ago, Dr. Carlos A. Rizo wrote that doctors should be good companions for people.1 What companionship can be offered to the person willing to die young to look and feel good?
Millions of Americans use anabolic-androgenic steroids.2 I have walked past them on the street or checked out next to them at Circle K. They seemed healthy and strong in their hard hats or their business suits. My curiosity was not piqued because the evidence was hidden behind a fresh tan or a friendly smile. I didn’t look for the shadow of a scythe even though we stood in the sun.
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Details of this story have been modified or omitted to protect patient privacy.
References:
1. Rizo CA, Jadad AR, Enkin M. What’s a good doctor and how do you make one? Doctors should be good companions for people. BMJ. 2002;325(7366):711. https://www.bmj.com/content/325/7366/711
2. AlShareef S, Gokarakonda SB, Marwaha R. Anabolic Steroid Use Disorder. [Updated 2023 Jun 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538174/
Sarah Brady is a member of The University of Arizona College of Medicine – Phoenix, Class of 2026. She was born in Georgia, raised in Florida, and currently lives in Arizona. She graduated from Arizona State University with consecutive degrees in English Literature and Biomedical Engineering. She loves to garden and particularly enjoys attempting to grow plants that are entirely unsuited to the Arizona climate.
Image © Ashley Lorraine Baker