Leaving the attending to treat the patient who was autodestructing his lung(s), I went into exam room #2, a sinus infection. Easy enough. Confirm the diagnosis by physical exam, write out a Z-Pak or some Bactrim, and we both would be on our way. Upon questioning as to why he was missing his nasal septum, he admitted to me that he regularly snorted cocaine. Again, awesome. I waited for the attending to finish admitting the first patient to the hospital, and explained the situation. She came in, and unleashed a lecture which would not be allowed in a managed care facility.
"You stupid asshole. You think you can just get away with this habit? You will lose your job, your wife, your kids, and end up in jail. If you are lucky. If not, you will end up in my ER and die, because there is not one thing I can give to to treat a cocaine overdose. Or worse, you will end up a vegetable that can't wipe his own ass."
I guess that's an advantage of being in private practice. You can say whatever you want to the patient.
"Also," I added, "your sinus infection will never clear up if you keep snorting."
The attending and the patient both stared at me, and then laughed and laughed. The guy said he understood what we both said, and left with a prescription and resources on treating cocaine addiction.
I was not trying to be funny. I know in the scheme of all the (true) life-threatening adverse outcomes the attending told him, the minor matter of sinus trouble was laughable. But it seemed to me that the reason this man had taken time out of his day to see the doctor was because he was bothered by his sinuses. So, if that was what mattered to him most, then that's how I would point out how his cocaine use affected his life. Plus, it was true. They wouldn't clear up if he was using, no matter how many antibiotics I gave him.
Nevertheless, it was a funny story out of a very un-funny situation. And a very good reminder that patients are often much more complex than how they present.