Between a Rock and a Hard Place

[A note to our readers: This is a fictional account.]

I’m climbing up a vertical crack in a cliff, wedged between 2 walls, rocks far down below. There are no trees or grass, nothing green. My back is braced against the rough granite behind me, my cleats scrambling on the crumbling wall opposite, when my back slides down an inch, both feet begin to slip, and I start to fall, down-down-down!

I wake up with a jolt, neck cramped, and it’s lucky I’m a shrink-I know this is a dream and it has a meaning.

It’s the fiscal cliff, of course, my own personal fiscal cliff. I’ve got a huge mortgage and 3 little kids. My financial advisor just told me I need to figure on $100,000 a year for each child, by the time they’re old enough to go to a good college. I might prefer to think of a state-run school, but of course I want to give my children every opportunity.

Does the dream mean anything else? There’s no time to think of that now. I’m strapped into my magnificent oversized lounge chair with a laptop to my left, pen in my right hand, doing 15-minute med checks at the Behavioral Clinic (BC), 10 hours a day. Faces flash by, names forgotten, most of them miserable. You thought psychiatrists are rich and powerful? I’m a rat on a wheel! This is one of those Roman rowing galleys!

Some days there’s a funeral march of poor old women limping in, or shell-shocked old men, faces frozen masks, multiple-system diseases, holding their paper bags of pills, beseeching me for another, the miracle one they saw on TV.

Some of the patient appointments are easy, of course. A beautiful 25-year-old woman comes in and complains of anxiety at parties. I give her a script for the “social phobia medication, Popu-LAR,” (accent on the third syllable). She walks out, and she returns 2 months later to report she was the life of the party and may have a marriage proposal. Just like TV! It works that well a third of the time. (It’s only years later I find out how the diagnosis and ads were rigged.)

I had wanted to be a doctor ever since I was a kid and met Dr Nelson in grade school. I was terrified of going to the doctor and getting shots, and a couple of times I had to have an ingrown toenail removed. I hated having to lie down on the table. One callous doctor in the emergency department put me on the table, had the nurses hold me down, and didn’t say a word. Nothing is worse than someone causing you pain and you can’t do anything about it. Old Doc Nelson was better than that, however. He knew your mind, what you were thinking, as well as your body. He took the time to talk with me for a while. He asked if I wanted to do the procedure now or later, and I had the feeling that if I said “not now,” he’d just nod and put it off. Because he asked me, I said “yes” and let him do it. He kept talking slowly to me while he snipped away, about his dog and going on vacation, and it didn’t hurt very much at all.

Medical school was fascinating, because I was learning new things all the time. Best of all, I was allowed to sneak a peek inside the body, even encouraged to do it, to see the heart revealed, and to join people in their moments of crisis, when they are most open and honest. The weekends were fun, too, forgetting all the details of anatomy and chemistry, having a beer or 2.

I started to see the great chain of being, the huge branches of men and women, pulling rabbits out of hats, creating children and then those children having their own children, the branches spreading out and forming a canopy of trees. Then the leaves fall off, it looks like The End; then the leaves come back and everything is growing again. I saw a 14-year-old girl get tired and pale-the results of the blood tests revealed a diagnosis of leukemia. They pumped her full of the best chemo they had at the time, and she rallied a month; then she withered away and died. I stood there with the family at her bedside, and I knew that nothing would ever be the same again. A week later, I put it out of my mind and was back to books and chewing the fat in the dorm after dinner.

Later, I saw a grizzled elderly patient on the ward, in his 80s, puffing oxygen, couldn’t get his breath, and he asked me to hand him a glass of water. I did and he gave me a grin. “You’re having a tough day,” I sympathized, “it must get awfully discouraging.” He was still grinning: “Yeah, but I had some good times, too, Doc.”

The day after being handed my diploma (and $200,000 of student loan debt), I got married, and the real responsibilities began.

Four years of residency training went by with lectures, seminars, short rotations, and a variety of clinical settings, up and down the economic scale. For 6 months I worked in a psychotherapy clinic, where I saw the same patients week after week, and it seemed I had really arrived. I started to learn how each patient thought, who they were behind the usual social masks and customs, felt really connected. Then I graduated again, passed my boards, and it was time for a serious job. My wife Adrienne is a beautiful, low-key lady; she never buys high-priced dresses or pushes for a fancy car-she just looked worried, and I knew I had to work hard and make enough money, enough for our debts, our mortgage, and 3 growing kids.

I went on interviews for 10 jobs or more, got several offers, but thought I had it made when the famous BC, a big new outfit from Texas, offered me $225,000 per year, plus 1 month of vacation, insurance, and educational benefits. Who could refuse that?! I thought I was home free, secure. The first year was okay, learning the ropes, but once I got to know the ropes, I could see how they were tying me up.

This place is a big-box store! The front of the building has an atrium 3 stories high; you feel like you’re walking into a cathedral, or rather, a railroad station. In the bowels of the building are scores of decorous and trim clinics and tiny examining rooms with very classy wood floors. The counters of each clinic are long and broad, fortified walls. Multiple secretaries sit behind each one, with stylish slim earphones and mikes (well wired), watching their monitors, each doing her bit of data collection. Every counter has scores of nurses bustling about, each doing specialized tasks-blood pressures, weights, whatever sips of blood are needed. It’s the perfect assembly line, and with a highly antiseptic purpose.

Psychiatry at the BC is squeezed in between the Family Practice Clinic and Geriatrics, and we’re expected to process people as quickly as they do. The family docs and gerontologists (“geros”) should see everyone in 15 minutes, and I’m lined up on the same production line. I check the boxes on the laptop record for the symptoms described, and if the patient wants to talk, I say, “I don’t do that, but you can talk with a social worker if you want.” The “orthos” are at the top of the pecking order here (big costly procedures by the thousands); the family docs are rather down the list; the geros are near the bottom (they’re paid poorly), and guess where psychiatry stands? I didn’t mind at first, thinking of the $225K, but then I started to question what we were actually doing.

Everything is done by protocol on the assembly line. We deal with numbers, milligrams, codes, dollars, and not people.

The clinic manager (let’s call him John B) is a 42-year-old guy, athletic looking, always wears a tie, and I think he wants to rise in the system. He arrives in the morning at 9:30, afternoons at 3.
“How’s it going?” he asks, in the cheerful-est way.
“Just fine,” I invariably say.
“I see you averaged nearly 40 patients a day last week,” he says, beaming.
“It was busy,” I say.
“But yesterday you only saw 35,” he says, as he studies the daily ledger. He wears this quizzical look, like he’s really concerned for the welfare of patients, the essence of smarm.

“Mrs Kelly had a heart attack and wasn’t able to make it to her appointment,” I say with disgust, “but they’re pulling her through and I think she’ll be back next month.”

It’s his phony air of solicitude that really bugs me.

In my medical training, and with old Doc Nelson, it wasn’t like that. We were taught to schedule 30 minutes, even 45 minutes, and listen to what the patient said. If they talked about a conflict in a relationship, or a job they had lost-that might be important. Hearing them out, understanding what made the emotion difficult-that might help the person’s depression or anxiety. That’s what old Doc Nelson did; he would look you in the eye, know your story, get in the rhythm, and put you in control. Not at BC. The job of the shrink, it quickly became apparent, was to dish out pills.

(In fact, many people need to talk a lot about the pills, too-what they’re afraid of, what the adverse effects are, and what happens when you take them-would you put something in your mouth every day if you didn’t know what it did? But here at the BC we don’t have time for that. Anonymous surveys show a large percentage of patients takes the script from the doctor’s hand but don’t use the things, or use them according to their own recipe.)

Sometimes it works out just fine. There are plenty of routine cases, patients who have taken their medicine for years. Then the BC stands out like a star. We’re a model of speed and efficiency.

A patient like Tom, a 50-year-old middle manager and good citizen from the northern suburbs, is going along with the drill. Tom has been moody, between jobs, tends to stay by himself, and his wife told him to take an antidepressant. He’s willing, doesn’t feel he really needs much talk therapy, and he gets a benefit from the pill. He’s a pleasant guy, and I can treat him in 15 minutes.

Arthur is different. He is a 60-year-old retired teacher, arguing every political issue he can think of, a dyed-in-the-wool Marxist, and he wants his SSRI, plus a stimulant for a boost. I see he knows the ropes and probably won’t overuse. I’ve been through the pluses and minuses with him, and I hand over the prescription speedily, without much sweat.

It’s Jonathan who pushes me over the edge. He is a clean-cut 21-year-old college student, sitting calmly in front of me. He gives a perfect classical history of ADHD (DSM 314.01, get that code right for billing purposes)-restless, distractible, and falling grades. He has had this problem for years, he says, and now it’s getting in the way of his premedical studies. He wants to be a doctor, and that naturally catches my interest.

Jonathan is wearing a button-down blue shirt, Land’s End I think, the kind I wear, and he talks with an educated vocabulary. I think I am seeing myself, back 20-plus years ago, and I want to help him along. I give him the script for Adderall. Next month he is back for more, says he studies better and his grades are perking up. I get a buzz of satisfaction; I’m getting some results.

This goes on for several months, and he always looks calm and pleasant at our 15-minute appointments.

Then I’m driving into the BC parking lot one day, and a guy runs across the blacktop to me. He’s well-dressed but rumpled, sweaty, and out of breath.

“I’ve got to talk with you, Doctor.”

I know it’s Jonathan’s father from seeing him in the waiting room. He is too upset for me to ask him if he has an appointment.

“We’re worried about Jonathan,” he says. “We think he’s taking too many pills. He talks too fast, can’t stop. He says he’s writing a novel, and he stays up all night, sometimes several nights in a row. We wondered where he got the pills until we called several nearby pharmacies, and found he gets the same pills from you and 2 other doctors. That pill may be okay at the right dose, but we’re scared he’s getting out of control.”

I can see he is frightened, really worried for his son, and I catch the fear, too. I know the feeling, thinking of how I worry about my son drinking (although he’s only in junior high). Who can tell what a kid in that state will do?

“I’ll take care of it,” I say, and I put my hand on his arm.

I’m no fool. I realize what Jonathan’s been doing. He is using the pills to get high, which a lot of students do, and he simply told me the typical story he learned from the Internet.

That day I stopped Jonathan’s supply of Adderall. I was worried, but busy with 15-minute med checks, and I rushed on to the next patient.

The next month when Jonathan came back, he was calm and pleasant again, and I wrote another script, forgetting to ask about his father. I was doing my “med check” business, but that was a big mistake.

I should have taken more time and set up a meeting with Jonathan and his parents, discussed the dangers of getting high on that stuff, listened to what he and his family thought, and coordinated with the other doctors (all of that might have taken more time than John B wanted).

Two weeks later Jon’s father called and said his son got high again, went on a rampage, crashed into 2 days of sleeping, and then hung himself. They found him strung up in the closet, and nothing more could be done. He wasn’t yelling at me, blaming me, he just said things got out of hand, they couldn’t keep up with it, and I asked about the memorial service.

That’s when I recalled the dream, went through it all again, climbing the cliff and falling, cleats scrambling on the crumbling wall, falling away and sinking forever, faster and faster. My heart gave a thump-felt like it never would go again. The dream was months ago, but it is always with me, ready to flare up, the chance of losing my grip, flipping out, going bonkers myself. Seeing a good kid like Jonathan go off the rails reminded me it could happen to me. Jonathan and I are one, the same in many ways, it hits me now. For a moment I felt I was him, falling off the cliff. Then I shook my head and I was back in the BC.

The next day I resolved to put in my resignation, walk out, tell them there are some jobs I cannot do. I need to figure out which branch of the tree I want to live on.

I don’t want to climb any more cliffs. I’m looking for a slow job in a small town on the prairie.

[Editor’s Note: This commentary is a work of fiction. Any resemblance to any person or entity, past or present, is purely coincidental. The characters and scenarios are fictional and of the author’s own creation. Dr Houghton states, “I retired from 42 years of practice last October. Having grown up in the ‘leisurely’ days of psychiatry, I had some taste of the fast and efficient brand, and I have pondered in this imaginary tale the kinds of binds early career psychiatrists may find themselves in, as here.”]