A True Believer

On Being a Psychiatrist

A couple of years ago, my wife had a dream that she was planting tulip bulbs for the following spring, which we had never done before. She had this dream in November, for God’s sake! Don’t ask me where she got it. She’s a savvy psychiatrist, and full of hope; she believes in dreams, so next day we researched it at the garden center, and in the crisp autumn air, we planted the bulbs. I could feel the warm wind picking up and the sun beating down already.

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I had no idea who she was when I met her 50 years ago. The legs and the smile were all I saw. It’s been one surprise after another. When she empties the dishwasher, she puts each plate, utensil, and silverware in its proper place. The spatulas go in one container, the whisks in another, and even the plastic spoons have their own clean cup. I was a little bewildered and put out by this at first. I had always used one drawer for everything. Now I’m catching on. I can find things quicker, and begin to see the advantages.

She’s a hard-working kid from Oklahoma, 75 years old now. An Army brat, she was in 18 schools, one in Japan, and she can join the flow of talk with anyone. She used every grain of her experience to build a library of information about the world, the habits of men and women, the values she puts on each, and it’s balanced by her urge to care for many. This all goes by in a flash for her, she does it all by instinct, off the cuff, no need to stop and worry. “That’s obvious,” she says, except when she stops and makes a long pause.

Two shrinks like us, naturally we talk about the patients who puzzle or frustrate us, and it’s all on the fly, no total case reports or review of the literature, just the blood and guts of it, but somehow the spirit rises up, and knowing each other and a few pieces of the patient, we get the big picture.

One day she said, “Poor Kathleen.” I recognized the name from before.

“She went in the Stillwater post-crit unit, out in the sticks, and they’re giving her horrible care.”

“Did you talk with the shrink out there?”

“I called 3 times, but no call back. First her kidneys were shutting down, they blamed it on the lithium, and now they think she has C. diff.”

“That’s terrible!” I say, or actually in rather cruder terms. I want to give the green light to her anger. “You oughta make a complaint to the director out there!” She’s the kind of doc who would do it, too, if she thought it would help the patient. She nods and thinks.

“D’you know how I solved the situation with that cocaine addict,” I ask, “the flash trader?” I’m trying to shift the focus, and I never mind showing off a little.

“No, how?”

“This guy’s a speed demon, big business, very successful I guess-you’ve heard me talk about him before. He works till the market closes, tells his wife and kids he’s out to dinner, and then he’s off to a gentlemen’s club doing coke and ladies, till he crashes at home. Well, trades aren’t going so well lately, he missed his appointment with me, and he calls me to OK the 3-month script of the sleeper, big dose, the only thing that works, he says. He’s yelling that he lost the script, and can he have another? I already got him into a treatment center 3 months ago, a pricey place, but he signed out after a week. So he calls and says he’s strung out, can’t rest or work, and he’ll take an OD like he did before if I don’t help him out.” I pause to build suspense for the punch line.

“No way,” I say, “that stuff isn’t helping, and I’ll never prescribe it again.”

“That’s when he hits the roof, even on the telephone, and he yells if I don’t give it to him, he knows it’s all over, and he’ll blow his brains out with the gun he brags about.”

“How will you feel then!??!” he yells at me.

“‘It’ll be just another dead junkie,’ I say, like it’s business as usual. Of course, I know how he plays the audience, going back 2 years. That’s when he quiets down. We make an appointment, and he comes the next day, full of remorse, so we make a new plan for meeting weekly and back to NA.”

“It’s a tough situation, and a good response,” my wife says calmly, giving me credit for hanging in there, with just a spoonful of doubt too. We know that’s the way it goes with a lot of these hot-wire cases, there’s no perfect answer, and we trust each other when the handball volley gets going fast.

So the next time my wife mentions Kathleen at the “Home,” I’m quiet and listen carefully.

Two days later: “She died. The funeral’s on Saturday, and I’m planning to go.”

“That’s great,” I say, knocked out by the woman’s dedication, “but what’s the CPT code for that?”

She knows my wit and gives me the understanding look.

The more I think about it, however, I realize there must be something different about this case. It must mean something extra to her. To us, too, perhaps. Some things you have to do first, and then you know them.

“It’s a long way out there,” I say, “I think I want to drive out there with you.”

It’s 30 miles out in the country, first through the estates of the affluent, then into the rolling hills and the well-tended farms, fields with just a few well-groomed cows, the barns fresh-painted, and the cream-city brick houses with flower gardens.

It’s a pretty town of 2500, old-time country but gentrified, not too far for some commuters or people who work from home. The main street is 2 blocks, a couple of nice restaurants, and there’s 6 blocks of neat bungalows around that.

The funeral’s in a long, low brick school, part of which is the Catholic church, which puts me off. It’s a ranch-style church with no nave, the pews in a large semi-circle, and the altar looks pretty much like a table in the center.

The place is packed, the family dressed up and in the 2 front pews. I go to church weekly, but lots of it puts me off. I hate those homilies where the priest runs through a string of biblical quotes and urges me to love everyone and don’t forget the collection basket (the biggest form of love). But this guy is younger and low-key. He puts 3 wooden dwarfs on the steps, says they’re from his place; Kathleen liked them, and he knew the creatures wanted to come. She was a serious gardener too. She knew that every season comes to an end. The dwarfs on the step were something she loved and a way to remember her.

That’s when I fall into a dream, time stops, I’m just there, and I almost see the sense in it, the way we come together, the big design and the Omega point.

If I didn’t see it then, I’d chuck the license and script pad, do the flash trading myself.

The priest adds that the family wanted to remember her with the quote, “Every moving thing that is alive shall be food for you. I give all to you, as I give the green plant.” Ten people from the family are sitting there in the front pew. They look back and forth at each other, then turn their heads down.

After the ritual of the mass we get in line to go into the reception in the cafeteria next door.

Kathleen’s husband is standing at the front of the line, a tall bulky guy in a suit with a serious face. As soon as he sees my wife he takes her hands in both of his and says, “I want to thank you so much for coming.” The look on his face shows me it was worth the drive.

“She was getting poor care,” my wife says, “but her kidneys were failing and she didn’t have much quality left.”

He nods and smiles a little, he knows it. They hug and he shakes my hand with a “thanks” for coming too. We check out a bulletin board of photographs, but skip the cake and coffee.

As I’m driving home in the twilight, my wife tells me how Kathleen taught art for 20 years, had a breakdown, did some hospital time, then worked at the library, but wherever she was everyone loved her. My wife saw her for 30 years and it’s clear she loved her too. I remember some of the photographs on the bulletin board, Kathleen clowning in a Halloween costume and the kids yucking it up. She did some all-nighters at the bingo parlor too. The diagnosis on the books was “bipolar,” but that’s clearly the least of it now. Kathleen was the whole person, not just the label.

Of course there’s no procedure code for a visit like this. I can’t fault my wife for crossing a boundary and getting too personal. There won’t be any more treatment for Kathleen, not on this earth at least. The whole trip took 4 hours, but it all came down to the point when the priest talked and the clock stopped.

The science of psychiatry can only go so far. I had some run-ins with corporate powers. After that, I’m a firm believer that “small is beautiful.” All real power is local, the connection of one-to-one. There’s no randomized controlled study of a procedure like this. That’s where the medical art comes in. I’ll put my faith in that and my wife.

Next Monday, of course, we’re back to the usual procedure codes.

Disclosures:

Dr William Houghton is recently retired from the private practice of psychiatry in Minneapolis. He is grateful for the helpful suggestions, critical editing, and approval of Dr Mary Alice Houghton. He reports no conflicts concerning the subject matter of this article.