And On The Flipside,

I went to the dentist the other afternoon. I arrived at 3:45 for a 4:00 appointment. A young man checked me in at the desk, said I was "all set" and they would call me in when the doc was ready.

I sat down and read a copy of This Old House magazine. I read another copy. I started in on Newsweek. I didn't have my watch on, and there was no clock in the waiting room, so I sort of lost track of time. But eventually I noticed there were no longer any other people in the waiting room. When someone came out and began vacuuming around my feet, I got up to go check on the delay. The young man had gone home, and a woman was in the seat. I craned my neck to see the clock above her-- almost 5:00. She said, "Oh, you never checked in!"

They got me in, and the dentist was good enough to stay late to fix my filling. The hygienist said, "When you hadn't checked in by 4:30, we put you down as 'Did Not Show'! We had the room all ready for you and everything, but we said, Well, he just didn't come!"

I mentioned that I had not only checked in, but had been sitting in the waiting room the whole time, mostly alone, in plain view. "Well, we didn't have you down as having checked in!", she explained again.

As I write this today, it's 5:20pm and I'm still waiting for my 5:00 appointment to show.

First Impressions

I had four new patients scheduled today, and every one was at least ten minutes late. One actually came in on time, used the rest room, left, and came back twenty minutes later.

But it beats other recent days when people have simply not shown up at all.

Short

Last week I started reading My Detachment, a Vietnam memoir by Tracy Kidder. It’s a strange war book, in that the author never even encountered the enemy (he was a “REMF”—or “Rear Echelon Motherfucker”), but in a way that is the topic. It’s also fascinating to hear a renowned journalist confess to dozens of youthful white lies, in the context of trying to create some meaning out of his meaningless job in an absurd war.

The peculiar nature of army deployments to Vietnam—in for a year, then home—meant that Kidder’s detachment consisted of a rotating cast of intriguing characters, each of whom starts off as “the new guy”, becomes, in a matter of months, the “old-timer”, then suddenly disappears. When Kidder arrives “in-country”, he encounters a soldier who shouts “I am so fucking short!” I had never heard this phrase before, and at first thought it might be synonymous with “so fucking drunk” or “so fucking high on opium”. But Kidder explained that “short” meant nearing the end of one’s tour of duty. When his enlisted men got “short”, they would start shirking duties around the base, stating “I’m too short for that shit.” When a short man left, nothing much changed. Someone took his place. The war went on.

The whole arrangement reminded me a bit of Green Acres, particularly with regard to the psychiatric staff. There is no specified “tour of duty” at the hospital, of course, but on average docs have stayed for two or three years, then quit, cracked up, retired, been fired, or gone on medical leave and never seen again. The shrinks come and the shrinks go. The war, as it were, goes on. For some reason, though, I kept re-enlisting. When I worked at a veterans hospital as a med student, I sometimes met vets who had volunteered for multiple tours in Vietnam. You sort of had to wonder about them. I wonder similarly about myself, now.

Strangely, as I walked down the hall last Friday morning to start my very last day at Green Acres, an older, seasoned staff member caught sight of me from a few doors down, stuck his head out, and said good-naturedly, “Hey, doc—aren’t you a little short to be going to staff meeting?” A week ago I would’ve been puzzled by the phrase and nodded politely, but thanks to the current reading I caught the meaning. “Matt”, I said, “I am so fucking short.” He laughed. I leaned on his office doorframe a moment. He told me that during his time in Vietnam, when a guy hit the 30 day mark to going home, he was allowed to wear the ribbon from a bottle of Seagrams on his hat or helmet. “When you got that short,” Matt said, “no one would give you any shit.”

But this was not so much the case at Green Acres. The night before my last day, one of my patients inexplicably snapped and “wailed the hell out of” [nursing report words] another much smaller, gentler patient, repeatedly pounding him in the face. I was asked to "do something" about it, but there was little more to be done that hadn't been done already. Another patient had run off while on a pass to his substance abuse counselor to scavenge and smoke cigarette butts out the gutter. And right up to the last I was being asked to write silly orders about headphones, Jell-O, and the Snoezelen room.

A few people wished me well. My medical director organized the traditional Green Acres cake-and-punch farewell gathering (a ceremony that is always announced by Administration as a “goodbye punch”—though I’ll never know if the double entendre is intended, or just another amusing Administration language gaff.) At the Punch, the Superintendent, who is a recreation therapist and not overly fond of doctors, stayed on the other side of the room and did not speak to me, as has been his habit. Back on the ward, a patient asked to see me, curious to know “whether you quit them, or they quit you?” Later the head of housekeeping stopped by my office to say that I “seem like a pretty good doctor”, as far as she could tell. One "patient advocate" stuck her head in and half-apologized to me for some truly egregious behavior over a year ago.

In the end, my hours wound down, and I just sort of packed my duffel and boarded the plane.

"Green Acres, The Beverly Hillbillies, And Hooterville Junction Will No Longer Be So Damned Relevant"

The immortal words of Gil Scott-Heron.

Carbon Offset

Nurse: What have you been driving back & forth from the Smallish City to Green Acres?
Dr. Turbo: A Subaru. It’s been pretty good.
Nurse: How is the gas mileage?
Dr. Turbo: I can squeeze out 33 on the highway.
Nurse: I had to buy a Denali.
Dr. Turbo: “Had to”?
Nurse: Well, we have two kids, and three springer spaniels. And we needed something big enough to tow the camper. Plus if we don’t have the camper, we usually need to bring the kids’ ATVs. And the kids like to bring their friends. Our other car is an F250, so that’s big enough to tow the camper, but it’s not very comfortable to ride in.
Dr. Turbo: I see.

When I was a very little kid, my parents had two cars-- one was a VW Beetle, and the other was also a VW Beetle. (They should’ve had bumper stickers reading “MY OTHER CAR IS A VW BEETLE”.) Somehow we managed to go on family camping trips in a Beetle. I guess ATVs hadn’t been invented yet, so we didn’t have to tow anything. I remember on long rides I sometimes would sleep in the little behind-the-rear-seat compartment, right over the engine. In retrospect, lucky that I wasn’t smushed like a bug. Guess child seats hadn’t been invented yet, either.

Resurrection II

My avid reader(s) may recall that last summer saw the resurrection of of my 17-year-old Cannondale road bike. I've repeated the feat this summer by reanimating my 16-year-old Schwinn mountain bike.

I bought this bike, which I call "the beast", during my first month of medical school. I had just moved to northern New England, rented (with a classmate) a small cabin on a hill with fire-fly meadows out front and thick woods in the back. We had make strange choices, sometimes.

A few years later I was living in Major Metropolitan area, my car had died, and I couldn't afford a new one. I resolved to live with The Beast as my sole transportation. I got a rack and some bags to carry groceries. I got a loud horn. To deter theft, I took The Beast out to the back deck, murmured an apology, and spray-painted her entire frame with flat, rust-colored primer-- an act I have regretted ever since. But The Beast served well. Some weekends I would bash over 10 miles of urban mayhem to the bus station, where I'd catch the bus to New York City to see my girlfriend-- or meet her on the incoming bus, then watch her get on the subway and see if I could beat her back to the house.

Like the Cannondale, The Beast has languished in the cellar of the Turbopalace these recent years. There are a few country spots around where one might ride a mountain bike, but it just isn't the same as the sweet rural scene from my student days. Meanwhile, I've been driving a car back and forth to Green Acres, 116 miles round-trip, almost every day. It's not been fun.

Green Acres is coaxing one more week out of me-- my last day there postponed to June 22nd-- but soon I'll be downgrading my commute from 58 miles to 5.6 miles, and looking for an office even closer. Excited to return to bicycle transport, I hauled out The Beast and have given her a once-over. She has a new chain, new cogs, and new slick puncture-resistant tires with reflective sidewalls. New fenders. A new derailleur cable. I couldn't locate the old baskets, and had to buy a new set. But deep in a shoebox in the cellar, I found the loud, old horn.

A Green Acres Interlude

Nurse: We found some of Arnold’s meds hidden under his mattress.
Dr. Turbo: What were they?
Nurse: Five Risperdal tabs.

=========================
Later:

Dr. Turbo: Arnold, the nurses told me you’ve been hiding some of your Risperdal instead of taking it.
Arnold: Yep.
Dr. Turbo: So, why are you doing that?
Arnold: I was leaving them for the Risperdal fairy.

Life If Possible, Art At Any Cost

My age is a closely guarded secret, but I can tell you that when one begins to approach my age, one begins to have an inexplicable craving for original art. It sneaks up on you. One day you’re fine with tattered Who and Clash posters and a map of the Smallish State tacked to the wall-- the next, you are in galleries looking at 60 x 46” canvases with four-digit price tags thinking, hmm, that seems reasonable.

But really, why is art so expensive? I mean, I understand why art by well-known artists is expensive, but there seems to be little available between “I painted it myself” and “I paid three thousand dollars for this.”

A couple years ago in my neighborhood a young man set up a studio in his living room. I think he had just graduated from the local art school. I admired his paintings through the windows, and dropped by one day he had an “open gallery”. I later emailed him about one of the paintings. It was a local scene, and I thought, “This will be great-- I can support this local artist in his struggling days, and have a nice painting of a local scene in my home, and because he is in his struggling days and selling out of his living room without a middle-man it will surely be affordable to me even though I chose psychiatry instead of neurosurgery.”

As it turned out, though, his price for the piece was $5,000. It did not find its way to my house.

I’m not saying that artists should be starving. I’m just wondering, seriously, why, with so many talented people out there, artwork is so unaffordable? I don’t care if it isn’t collectible, doesn’t appreciate, and no one but me has ever heard of the artist. I don’t want it for prestige or to show off. I just want attractive, original, discussion-worthy things on the wall. If I can patronize someone who needs a boost, so much the better.

A Rare Political Statement

Shrink Or Fade supports the Portinsula movement. At least we do at present. Once we know more, or really anything, about it, we may change our minds.

(Sorry, 1, 2, & 517-- we peninsulars have to stick together, sometimes.)

A Change Of Calling

I told you(s) that I’m leaving Green Acres, but I haven’t had time to tell you where I’m going. It’s also taken me a while to say it with a straight face. I’m making a 180-degree professional turn and taking over a private practice in Tonytown, a lush suburb of the Smallish City. Or what passes for “lush”, anyway, in the Smallish State.

Truly, this new job couldn’t be more different from Green Acres without leaving the field of shrinking altogether. After six years of working with some of the Smallish State’s most dispossessed, most hopeless, most dangerous, most impoverished, most risky, most thankless, most shocking, most ill, and all-around most demanding individuals, I will now be working with some of the state’s most educated, most affluent, most intellectual, most ambitious, most accomplished, most connected, and all-around most demanding individuals. Okay, so the demanding part will probably not change—but everything else will.

I’ve already started, one day a week, at my new office. Unlike the vast majority of my Green Acres patients, most of my new patients have actual jobs, are staying home with young kids, or are in school. There are PhD candidates, artists, writers, attorneys, midwives, master carpenters, musicians, several therapists, and even another psychiatrist. After a dozen or so intake appointments, I’ve not had one single death threat, not been spit on, and had nothing thrown at or even near me. Believe it or not, several people actually thanked me, even though I couldn’t see that I’d done much of anything for them yet.

It would be easy to argue that these folks don’t really need my help. It would be easy to argue that I won’t be doing a great service for the world the way I have been in the public sector at Green Acres. It would be easy to label my new gig as “cosmetic psychiatry”. These, indeed, have been my fears and misgivings going in.

After much reflection, though, I’ve decided that it’s not so clear-cut. The truth about Green Acres is that my people there rarely get much saner, or stay any saner very long. Even when I can help them get saner, they often don’t want to be so, and to many of them the process of getting saner seems far more loathsome than insanity itself. Largely, my job has been to coax, cajole, convince, bargain, and, if necessary, strong-arm people into sanity—not to make them happier, necessarily, but to make society safer from their rages, or prevent society from having to feel guilt when they suicide. After discharge, a substantial proportion of patients decline, resist, or avoid further treatment, relapse, and are involuntarily readmitted (the Smallish State has, until recently, been highly protective of patients’ rights to refuse all treatment once they are out of the hospital.) In the past year, this situation and pattern has lead to disastrous results for a few of my patients. Admittedly I am taking a somewhat bleak and cyncial view of my role at Green Acres—but six years there will do that to a person.

In contrast, my new clientele, while overall less ill, are highly motivated to get better. They are so motivated that they will call me repeatedly for an appointment, rearrange their schedules to see me, and, in some cases, pay out of their own pockets. A lot of these people, I think, are going to get a lot better. And these are people who, when they get a lot better, will have considerable positive impact on the world. One person I’ve already met was significantly impaired by bipolar disorder as a young woman, but, with treatment, has carried on a prolific career, producing research results which have become household knowledge. Tens of thousands of people should thank the anonymous psychiatrist who helped this person get on lithium (it wasn't me, but I'm hoping I might be the first one to help the next person like her.)

Looked at another way, these are people whose talents are sorely missed by society when they become even moderately disabled by mental health issues. Working at Green Acres has felt somewhat like coaching a Special Olympics team; my new job feels more like coaching the Major Metropolitan Area's major-league baseball team. Who’s to say which is more important? More rewarding? Which job offer would you accept? (Before you assume that the major leagues pay more than the Special Olympics, let me disabuse you: my income in private practice will be considerably lower than my salary at Green Acres.)

And the final simple truth is that I desperately need a change from the work I’ve been doing. It has felt like an episode of Survivor, lately. In the past decade or so, no other Green Acres ward shrink has lasted more than three or four years; two or three years is about the burn-out average. There’s a reason for this pattern; it’s time for me to recognize I’m not immune to it, and that no number of blue-water ocean voyages will provide the antidote. Off I go into a new adventure—wish me luck.

Uneasy

Full moon again tonight... it's drizzly, chilly, and dark. I'm holding the Green Acres pager, for the last time. All is suspiciously, suspiciously quiet. Why? What am I missing? This is not normal. Nurses chuckle and joke in the chart room. An aide fills in a crossword puzzle, eyes only casually and intermittently on the video monitors below the desk. A cloud moves from the moon. A cold white beam passes along a sleeping face. An eye glints open and darts left and right. A jaw tenses, slackens, tenses. Fingers twitch. A mind starts to race. What will happen tonight?