Daniel Menaker

Onconversations XXVIII-Part Two

Tuesday, March 27, 2012

(My therapist/friend has prescribed Provigil for me. It’s a drug that is often used for narcolepsy and shift work–that is, basically, night-shift work–but also sometimes used for other situations where attention might flag or wander. Like, for most writers, writing, especially when they’re dealing with a medical issue like cancer, which according to the therapist/friend, often makes it hard for patients to finish projects. I take the prescription to the pharmacy. A day or so later I go to pick it up.)

ME (to practically somnolent clerk): I’ve come to pick up a prescription.
CLERK: Name?
ME: Menaker. Oh nine, seventeen, nineteen-forty-one.
CLERK:  date of–Oh. Right. Date of birth. You just said, OK. First name?
ME: Robert.
CLERK (after peering for quite a while at her computer screen, as if trying to see the future):  What’s the prescription?
ME: Provigil.
CLERK (after banter with fellow-clerk about taking a break): What’s the prescription?
ME: Provigil.
CLERK (peering at screen for a another minute or two): Here it is.
ME: Good. Is it ready to be picked up?
CLERK (peering at screen):  I’m not sure. There may be a problem here.
ME: Well, can you tell me what the problem is?
CLERK:  I’m not sure. Let me just … (peers at screen for an eon)
ME:  Well, what is the problem?
CLERK:  I’m not sure. (Turns around and says to pharmacist, protected by a chest-high bunker-like barrier) Jim–Mr. (peers back at screen) Mr. Menaker is here to pick up a prescription for Provigil. Was there something–
PHARMACIST (very nice guy): Oh, yeah. Well, his insurance doesn’t cover it.  Your insurance doesn’t cover it.
ME: Why not?
PHARMACIST: It has to be prescribed specifically for a diagnosis of narcolepsy.
ME: I’m getting really sleepy.
PHARMACIST (smiling): Or sometimes for night-shift workers. but the diagnosis has to be stated.
ME: Nothing about writer’s block, huh?
ME:  Well, can I just pay for it myself?
PHARMACIST: You can but for this prescription it would be … let me see (peers into his own computer) … uh, like four hundred dollars.
ME:  Well, OK–that woke me up.
PHARMACIST:  So do you want to do that?
ME: I thought there was a generic substitute on the market.
PHARMACIST: They said something about it but it must not be out yet. They said something about March.
ME: It’s March.
PHARMACIST: How about that! Well, yeah, I mean, I really would know if there was something else available.
ME: OK, well, I think I’ll just talk to the doctor again.

(Later the same day, in conversation with the doctor, I tell her what the pharmacist told me)

THERAPIST/FRIEND: I thought there was a generic available.
ME: Evidently not.
T/F: Well, let me look into it.
T/F : You know what you can do–if you want to pay for it yourself, just buy, like, five pills and see if it works to help with your writing.
ME: You can do that?
T/F: Yes–you can choose to fill only part of a prescription. You didn’t know that?
M: Not to be rude, but how would I know that?
T/F: I thought you must know it after all the pharmaceuticals you’ve been using over the past year during chemotherapy and radiation.
ME: Nope–I just give them my prescription and they fill it and the insurance pays for it, except for the hundreds and hundreds of dollars they don’t pay for, of course.
T/F: Yeah–isn’t that something!? The doughnut hole (the vernacular for the point at which Medicare and supplemental insurance largely stop reimbursing patients for prescription expenses until the total out-of-pocket costs for a year reach a very high level, like $4000, at which point, the ominously named Catastrophic Coverage kicks in at something like 90%.  An achievement both to look forward to and hope never to attain).
ME:  Well, what about Nuvigil?
T/F: Been poking around online again?  Just try the Provigil. Start by buying a few pills, and see how it works.

Me (back at the pharmacy and growing weary, the next day, after explaining the situation to the somnolent clerk and now talking to the nice pharmacist): So can I just buy five pills?
PHARMACIST: You can, but even that is going to be expensive–like more than a hundred dollars.
ME: Let’s just go ahead.
PHARMACIST: You know, if you buy five pills, you will blow the whole prescription.
ME: What do you mean?
PHARMACIST: You won’t be able to fill the rest of it.
ME: That seems very strange.
PHARMACIST: I know–right? Weird! But that’s the way it is.
ME:  Let me think. Wait.  This prescription is good for an indefinite period, right?
PHARMACIST: I think it’s a controlled substance.
ME: Meaning?
PHARMACIST: Well, it would be good for only a month. Let me look….. (the peering, again)   Yes, it’s a controlled substance, so it’s only good for a month.
ME: You know, I brought this in some time ago.
PHARMACIST:  Yeah–let me look … (more peering)  You brought it in thirty-three days ago. It’s expired! (He seems amused, in an acceptable, human-comedy-like way.)
ME: But wait. Oh, no. I’ll have to (fluttering my eyelids) … I’ll nnnnn (drooping my head) … you know nnzz (I lean to one side, as if about to fall) … zzzzz
PHARMACIST: Tell you what. Go back to your doctor, have a conversation with her, and do that right in the middle, and then maybe she will prescribe for narcolepsy.

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Onconversations XXVIII–Part One

Saturday, March 17, 2012

(Having completed full courses of chemotherapy and radiation treatments for small mailgnant nodules in my left lung–the whole process took about eight months altogether–I’m having trouble concentrating on a book I’m supposed to be writing. I talk about this problem to  a therapist/friend.)

ME: I’ve written forty-two thousand words out of about sixty thousand altogether, but can’t seem to put my mind back on it. I don’t know why. Other than the fact that my publisher and editor have real reservations about the structure.
TF: What is it again?
ME: What is what–the book?
TF: Yes, the book.
ME:  A memoir. Do you want to know the title?
TF: Do I have a choice? (laughs)
ME: “My Mistake.”
TF: (laughs) A terrific title.
ME: Thanks.
TF: And you’re having trouble concentrating?
ME: I just don’t seem to care about it enough. I think it’s pretty good, but the idea of reorganizing and finishing it is really daunting.
TF: This isn’t an unusual problem in your situation.
ME: What do you mean, my situation?
TF: Cancer patients very often have a hard time finishing things that they consider important and that they want to finish. It’s pretty typical.
ME: Really?
TF: Yes. It’s a kind of unconscious belief that if they do finish something, it will be like– well, finishing their lives.
ME: Hmm. That makes immediate sense to me, but it never occurred to me.
TF: That’s the thing about the unconscious, isn’t it? The definition. In fact, you could say it’s the purpose–not to occur to us.  And also, on the other hand, if patients don’t finish whatever it is, they may unconsciously believe that that will keep them alive–to finish it.
ME: Well, it’s killing me.
TF: (laughs) There’s something you can take that might help you.
ME: Really?
TF: It’s a drug for narcolepsy–Provigil. Some people use it to sharpen their attention.
ME: Sounds good to me. More drugs, I say.
TF: Let me think about this a little.  You know, there are therapists and psychiatrists who specialize in talking to cancer patients.
ME: What a depressing specialty. Like I’ve never understood why someone would want to be a pediatric oncologist.
TF: I don’t know. The therapists I know who do this find it pretty rewarding.  You wouldn’t want to talk to one of them, would you?
ME: I don’t think so. First of all, I can talk to you. Second, I’m not really sick and haven’t been, except for the side effects of the treatments, and third, I think I’m petty well aware of the reality here and my responses to it.
TF: Except maybe why you couldn’t finish your memoir. For example.

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Onconversations XXVII-Part Two

Friday, March 02, 2012

(After twenty minutes or so in the lounge-like waiting room, with its odd mixture of mainly sad denizens, I’m called in to see the young radiologist who has overseen the radiation treatments for the malignant nodules in my left lung.  He is smiling er, radiantly and shakes my hand with energy.)

RADIOLOGIST: Congratulations!
ME: I get more congratulations? Thanks.
RADIOLOGIST: Well, after some hitches at the start, you made it through successfully.
ME: It really isn’t that difficult.
RADIOLOGIST: Some patients have real issues. So tell me–any fatigue in the last three or four weeks?
ME: Yes, a little–a few days when I felt really tired, took two or three naps.
RADIOLOGIST:  Wow! That’s a lot.
ME: But it didn’t last long.
RADIOLOGIST: Shortness of breath?
ME: No.
RADIOLOGIST: Chest pain?
ME: No.
ME: No.
RADIOLOGIST : No productive cough?
ME: Yuck. No.
ME: Only that dermatitis that you said wasn’t from the treatments.
RADIOLOGIST: Oh, right. You mean you had that again?
ME: Yes, it started again just after the second round of radiation ended.
RADIOLOGIST: Well, they aren’t related.
ME: How can you be sure, he asks again.
RADIOLOGIST: Because the skin problem you get from this procedure looks different–it’s like a sunburn, not splotchy.
ME: I don’t know. It seems so strange to me that I would get the same unrelated symptom shortly after ending each of the two rounds of treatment.
RADIOLOGIST: Well, they’re not related.
ME: Could they be indirectly related? Like a symptom that was the result of another side effect?
ME: I’m sorry–never mind. Over-engaged. What happens now?
RADIOLOGIST: You come back for a CT scan in a couple of months–at the beginning of April.
ME: And what will we see?
RADIOLOGIST: There won’t be much change in the scan, probably.
ME: Really?
RADIOLOGIST: It takes time for the nodules to be reduced and, hopefully, disappear. The more telling scan will be six months after that, which would be…
ME: Four and six is ten, which is October.
ME: April is the fourth month so six months after that is the tenth month, which is October.
RADIOLOGIST: Right–October.
ME: So why do a scan three months after the treatment?
RADIOLOGIST: Well, we may be able to see some change and we can check the whole thorax.
ME (shuddering): You mean, to see if … if–well, you know.
RADIOLOGIST (smiling): Right. To see if. Just as you said.
ME: Well, are there statistics?
RADIOLOGIST (with a faint note of triumph): I can tell you this–there is a ninety-per-cent-chance that there will be no recurrence at the sites we’ve treated.
ME (grateful that he didn’t say “There’s a ten-per-cent chance of recurrence at the sites we’ve treated” or even “only a ten-per-cent chance”): Well, good. So what do I do in the meantime–I mean, any other appointments?
RADIOLOGIST: Well, you might want to check in with Dr. ________  (My main guy–the thoracic oncologist)
ME: But what would be the point?
RADIOLOGIST: Well, really, there is none, unless you develop some new symptom.
ME: So maybe I’ll just let sleeping thoracic oncologists lie.
RADIOLOGIST: Probably just as well. For now (he leans forward and talks like funny tyrant) you are mine!

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