[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.