William Houghton, MD

“Be yourself. Everyone else is already taken,” Oscar Wilde said. I thought he was joking. Then I retired from psychiatry in 2012 and was free to go out in public without calling myself a psychiatrist or wearing a badge of office.

The vast field of psychiatry is divided between the urge to work with a few individuals with intense focus and the ambition to minister to large populations, as in community mental health, psychopharmacology, DSM-5, neuroscience, genetics, etc. Which feels most noble or sells the best?

I practiced all kinds of psychiatry for more than 40 years, but since retiring with aching bones in 2012, I have had time to see better how society and politics work, the dominating power of money, and it has become clearer to me that each doctor must make a choice.

[Our weekly therapy group] gradually built trust, opened up, and each caught a glimpse of himself or herself in the mirror of the Other. I thought that  would last forever.

I worked in large city hospitals, clinics, and small offices in four states, always striving for the ideal of collaborative care. My last office was in Milwaukee, in a tall graceful cream-brick monument with “Historic Landmark Building, 1897” on the bronze plate out front. Inside, ten-foot ceilings had modern moldings and the front room had a fireplace with black iron grillwork.

I used the library with eight chairs in a circle, just right for the three or four groups of patients I met with weekly. We gradually built trust, each opened up, and often each caught a glimpse of himself or herself in the mirror of the Other. I thought that office would last forever.

Seven years out now with time to look back, I am elated not to dash off scripts, code, chase pre-auths, and straighten piles of papers on my desk, but I miss the faces of the many unique individuals I admired. One example is “Ray,” the 80-year-old engineer who showed me his chapter on boiler construction, mourned his wife of 55 years, and described his weekly games at the Waukesha Chess Club. Or “Mary,” the eccentric poet in a group, who wrote a piece about her hobby, “Skating as Fast as I Can.” Everyone held their breath. (DSM-5 was forgotten.) Each of us saw the fire of connection in the eyes of the Other.

I defiantly told my father I would “give medical school a trial” for one year, but after 3 days in Harkness Dorm, I knew I belonged.

I grew up in a well-off Milwaukee suburb and enjoyed a deep, clear, wild lake up north. Like Henry David Thoreau, I watched the birds, fish, and grasses there-I assumed I would carry on that religion forever. At school I yelled for all the attention I could get and tried to join the cool gangs. I thought I could 

, forgetting the painful quills of the other porcupines (crabby Schopenhauer’s crusty view of all society).

I can see now that I searched diligently for my “real self” and assumed it depended on which prestigious group I belonged to, my certification. As Willa Cather said, “This is happiness, to be dissolved in something truly great.”

My father was a surgeon with agile fingers and a talent for sketching. A practical man, he pushed me to go to medical school. I dragged my feet, applied to four places, and to my surprise was accepted by Yale. I defiantly told my father I would “give it a trial” for one year, but after 3 days in Harkness Dorm, I knew I belonged. There were no exams!

You had to write a thesis, but most of the faculty treated me as though I were an established researcher. My indulgent mentor, Dr Francis Black, helped me finish the thesis and publish a paper-seldom cited.

Walter Igersheimer, MD, was a shaping influence in my psychiatric residency. He was a German immigrant who looked old to me then (he was 50 in 1967).

I spent 3 hours at every dinner in endless bull sessions that flew me through multiple cultures, religions, hobbies, and nothing so dire that it didn’t end with a laugh. I married another Harkness gabber, Mary Alice, a rare woman who never failed to think of my needs, with hers being exactly equal. She was ready to fight for both.

Among others, Walter Igersheimer, MD, was a shaping influence in my psychiatric residency. He was a German immigrant who looked old to me then (he was 50 in 1967), and he ran a weekly group process session with seven of us residents. He told us he had a problem seeing, but he walked slowly down the streets of New Haven with no dog or cane. He sat in his chair at the head of the circle.

One day he didn’t arrive on time, and the wise-cracking member of our group, my friend Hugh MacIntosh, took his chair. Five minutes later, Walter Igersheimer walked slowly into the room. Everyone held his breath. Walter walked slowly to a chair at 7 o’clock and sat down quietly. We were stunned. After 3 minutes he asked, “What are people thinking?”

“You would be upset,” someone said. A long pause>

“You would be upset,” someone said. A long pause

“You would blow up,” someone else said. Others thought of poor Walter falling down or stumbling over to choke Hugh, who sat there smiling but quiet. Walter had the hard-won immigrant wisdom not to judge too quickly but to be interested in how each of us saw it. It was irrefutably demonstrated to me that each of us saw these brief actions differently.

Politics is temporary teams but mostly solo kickboxing, with no loyalty expected.

Each streamed his own movie. These bedrock assumptions (or transferences) came up in my own two psychoanalyses, of course, and were repeated millions of times in my interactions with all sorts of people. Walter Igersheimer showed me how families, friends, workers, religions, and politics work together-or don’t.

When I first retired, I felt an obligation to join several political action groups and advocate for “Medicare for All,” better education, etc, but was repelled by the rallies, placards, fund-raising, and plotting to shame the opponents. Politics is temporary teams but mostly solo kickboxing, with no loyalty expected.

I learned “reflective structured dialogue” from the Boston group (not unlike good therapy) and “deep-canvassing”-knocking on doors and listening to what residents want without counterarguments. I got a kick out of the talking, as in Harkness Dorm, but could see these one-shot apostles are up against cheap e-mail, millions of dollars, masses of people, and the emotional forces that surge up in large groups, like the worship of demagogues. They forget that political leaders are human, dread a possible plot against them, and will use secrets, money, or force to control “the mob.”

I talk only with priests who listen carefully and speak the truth back.

From an early age I was drawn by the call to “love the sinner and the poor” by the Catholic Church (thereby nicely including myself in the deal) but stayed away from dull sermons and endless rosaries. With more time now, I went back to look at the huge worldwide salmon run of the Church and can see more clearly the huge egos of some of the clergy. Like all large corporations-eg, HMOs, insurance companies, and professional organizations-it is a fallible corruptible bunch.

Each of us must make up our own mind about the group we want: no rosaries for me and I talk only with priests who listen carefully and speak the truth back.

I am drawn to the sense of protection in large groups. I want to express my questions and doubts and be heard but fear taking off on my own.

In the words of Chuck Palahniuk, I admit: “Nothing of me is original. I am the combined effort of everyone I have ever known.”

E. E. Cummings is listed as a poet, but was he a psychiatrist too?

Or as Jimmy Breslin said: “There have been many Jimmy Breslins because of all the people I identified with so much, turning me into them, or them into me, that I can’t easily explain one Jimmy Breslin.” (He’s no fool.) It’s like scrambled eggs, but I always want to be the special French version.

“To be nobody but yourself, in a world which is doing its best, night and day, to make you into everybody else, means to fight the hardest of battles.” (E. E. Cummings is listed as a poet, but was he a psychiatrist too?) It is up to me to decide if I fly with the flock or walk on by myself.

The way I look at it now is that 8 to 12 members is the maximum number for any group of human beings in which each of the complex individuals can thrive, keep thinking, and be heard. That is when the one leader-or even better, several-can keep track of each member, too, without anyone melting down, or the tyrant of the day taking over and cracking down with rigid rules.

, talk honestly, be themselves, and take away a clearer idea of who they want to be. For these purposes, I have started some discussion groups (called “GrokMore Groups”), following the lead of David Bohm in 

, and hope that this helps with the isolation and division which many of my neighbors feel. I’m out of exclusive clubs and tribes with bold claims-I’d rather choose one ‘hood and tend a small garden.

Every individual must figure out who he or she is. “Be yourself. Everyone else is already taken.” Oscar hit the nail.

 is a retired psychiatrist. He resides in Milwaukee, WI.

The author reports no conflicts of interest concerning the subject matter of this article.

Articles

The world is a better place without a "tyrant of the day" taking over and cracking down with rigid rules. This and other life lessons after 40 years in psychiatry.

Label Me Not: Still Learning After All These Years

Dr Houghton is a retired psychiatrist. He resides in Milwaukee, Wisconsin.

Things happen slowly in psychiatry, but if you’re not in a hurry yourself, the patient opens a window and shows you the world.

This patient motors 50 miles to my office once a year, picks up his script of Prozac (20 mg), and drives back to the small town where he lives.

He is a short fellow, straight as an arrow, wears a tie, has the formal manner of a small-town businessman. He wrote tech manuals in a small engine company for 30 years until he retired. That was 5 years and a couple of jobs ago when he first started to see me.

I figured he comes this far because he wants the anonymity which is hard to find in a small town.

The half hour sessions once a year were rather stiff and formal at first. He talked of his work and barely touched on any social life. He found a job selling cars for the largest American franchise, a big dealer right off the freeway. He was very serious about the vehicle, telling me the dimensions, horsepower, gas mileage, the deals they were offering. The first year he was dedicated and enthusiastic for the job.

Naturally I asked myself: is this half-hour conversation a worthwhile form of psychotherapy, a medical necessity? But the fee was heavily discounted by the HMO, of course, and I am a slow learner, not highly goal-directed out of the starting blocks. Real insight-if it ever comes-makes a long slow dawning for me. And that might not be a bad principle for the whole field of psychiatry.

You unfold a story, and that’s the beginning of psychiatry.

The next year he was less enthusiastic about the job. He looked somewhat discouraged but not clinically depressed. Oh no, he still put his heart into talking up the product. This make of American car was just not selling as well as the imports.

Next year he cut back on auto sales and was looking for other work.

Next year he was building up hours as a teller in a bank, drawing a regular salary, and he was pleased to tell me the people there liked him very much.

One weekend, I happened to drive on other business through the town where he lived, one of those wind-swept conglomerations of buildings under a big sky, with at least 6 square blocks of downtown and a population of 5000. The streets spread out on the grid from there, all lined with tall trees, oak and elm, two blocks of Victorian mansions and then some ranches and bungalows, till the houses thinned out and the farms moved in. It was an old and successful Wisconsin town, and change came slow.

Next year my patient spoke of the bank job as a settled routine, quite satisfying, secure in his finances. With 10 minutes left, he said one thing he wondered about was that sometimes he did not get as sexually aroused. He could still "do it" and all the equipment worked; it just wasn't as ready and regular as before. Could it be the drug?

I asked the usual questions about morning erections, stress, and his physical health.

"It could be the medication," I said, "though you're using a low dose and it's been a while. I'm not sure it's that, but it would probably be a good idea to talk with a urologist."

I wondered if we were moving toward something psychiatric, but it was too early to tell.

Next year he entered with a quicker step and talked more rapidly.

He went to the urologist who checked him out. The doctor said he was fine.

"It's not the erection, I told him, it's the ejaculation. It doesn't 'spurt out' as well as it did in the past. The urologist said, 'Can you run as fast as you did at 16?' I had to admit I got the point."

Last summer, his whole family went out to Connecticut to visit a cousin. His parents went, and he carefully named 6 or 7 aunts and uncles. The nieces and nephews were swarming all over the place. It was obvious he enjoyed them immensely, and I realized I hadn't known much about his family before.

I could tell he was starting to unfold a story, and that’s the beginning of psychiatry.

Thanksgiving he went to visit his parents in Indiana, and his father was in a nursing home. He had a minor stroke, couldn't move his left arm, there were gaps in his memory, but he could still speak and have a good talk.

"I looked around that place and there were all these old people sitting and staring at the floor. They weren't looking at the TV and they weren't talking to each other. They were just staring at the floor."

"Then I came back to my job and home in Wisconsin," he went on. "You see, I usually get my meals at a diner near my house, 3 or 4 nights a week. Everybody knows me, calls me by name, and there's a good deal of joking and horsing around. There's a strip club nearby and the girls come in for dinner too. The girls are joking and the waitresses and cooks join in, too. After I saw that nursing home, I just didn't feel like it. For several days, I didn't care about food, no appetite at all. If an attractive woman came in, I hardly noticed. I didn't care about girls and I didn't care about the Green Bay Packers. It was like I stood outside everything and nothing was important. That lasted 3 or 4 days and then it all went back to normal. I could enjoy the diner again and my sexual feelings came back."

"Very interesting," said I, drawing on years of clinical experience (and the back-swing is getting easier now), "What do you think was happening?"

"I was scared," he said, "I was scared I'd wind up in that nursing home. Scared the hell out of me."

"You bet," I said, "You were face to face with the Grim Reaper, something we'd all like to forget."

In the 5 minutes left, I mentioned as casually as I could estate planning (if that's your thing), the comfort of religion (ditto), the 

 option, and what St. Francis said if he knew he was dying next morning: he'd tend his garden and feed the animals. Also, Montaigne's: "I want death to find me planting the cabbages."

I thought that fit the location and his thinking pattern. Some crops take years to reach their peak.

Rising to go, he said it was good to talk with someone who knew the territory-he'd see me again next year. He gave me a long look and a quick solid hug like the players do.

In psychiatry, things happen slowly-but if you’re not in a hurry yourself, the patient opens a window and shows you the world.

The Weather Report at 10 PM

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.

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. 

“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.

“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.

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.  

There’s no procedure code for a visit like this. But I can’t fault my psychiatrist wife for crossing a boundary and getting too personal.

A True Believer

[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.

, 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, 

,” (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, 

 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 

 Any resemblance to any person or entity, past or present, is purely coincidental. The characters and scenarios are 

 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.”]

"I don’t want to climb any more cliffs. I’m looking for a slow job in a small town on the prairie," says the author in this work of fiction.

Between a Rock and a Hard Place

I walk my 70-lb golden retriever, Huck, every day at 6 am and 6 pm. Late nights, not till 8 pm. I try to hold him on a 30-ft spring-loaded retractable leash.

Huck is fired up, rarin’ to go, nearly yanking me off my feet. He is eager to roam for as long as I can keep up, and he shows me the way to go home-I mean truly home-in more than one sense of the term.

As a card-carrying shrink, I work all day in a hushed office and discipline myself to listen, be reasonable, circumspect, and consider all the facts. I pay attention to as many of the rules of business and society as I can remember, and fill out my treatment plans with solid good sense. Catalog, classify, check the algorithm-that’s me. Compassion fatigue and hard-headed science do take their toll. For 10 hours, the lines of text race by and I forget all sense of smell, touch, the heft of bodies. Impulse, play, and intuition-all go hungry.

Huck knows nothing of that and will never learn. He tugs and humps from tree to tree, ecstatic over each new scent. Every tree he comes to he circles intently, on a search, and buries his nose in the crotch, a crevice of snow or dirt. How sensitively his nostrils quiver, alert to wisps of odor I know nothing of! He follows a trail of scent as solid as a rope and races to gulp it down. Watching him for a minute, my attention quickly shifts to a different realm.

I pull to move on. He hunches his shoulders, digs in, anchors, won’t go the way I pull him. Histrionic type, but not a disorder.

“That’s it, that’s it! That’s the mother lode!” his whole body shouts. His posture shouts it, without a word, a whole new language to me-I who am lost in words all day.

He is a scholar of hieroglyphics, deep in his text, finger locked on the Rosetta Stone. Smell that reference! Check that date! Catch the allusion! He points a delicate paw in demonstration. Then he carefully pivots, raises his hind leg at a thoughtful angle, and adds a footnote. His satisfaction in this job is no less than mine in signing off at the bottom of a long report.

There is the way he puts his head down, close to the ground and stretching forward, haunches rolling, putting power into each step, which can only be called “tractoring”-any other term is too feeble. He tractors down the sidewalk, stick-figure Houghton with his big brainy head dangling behind.

His most brilliant feat, of course, is his shifting instantly from goal to goal. Only the most dazzling conversationalist can jump so easily from one topic to another. (Brainy Houghton gets stuck for decades on one complex formulation.) Attention deficit disorder? No, attention maximus.

Once he picked up a dead squirrel. I tried to take it out of his mouth and he snarled and snapped at me. With a trick of distraction, I got him to drop it, and 10 seconds later he forgot the whole thing. I was frightened by his anger as it flashed by, but he immediately tore off on another scent, and his brief anger only made him seem more human. My battles with people should come and go so quickly! Huck flares up but lets bygones be bygones in seconds. Short memory has its advantages.

And what do I gain from these daily walks with Huck, my chance to connect with another race and culture? He is an important part of my expanding view of the world, a neighborly form of consciousness-raising-a “mind-altering dog,” safe and perfectly legal.

When I wake in the morning, I search my memory for night thoughts and listen to my body for several minutes. My back may ache or my stomach feel bloated. These are the ways, on first awakening, I am as close to my body as Huck is to his, and as I am to him on our walks. From this perspective, it is clear my body is another Huck I take out on a leash, follow around, put in the kennel and forget for the day. My soul may be lofty-I keep hoping-but I dwell in this mortal coil. My urges to sniff, tractor, lust, and snatch are no less than his.

We both have the brilliant everlasting dumb luck to be fueled with oxytocin, the urge to eat and to bond. St Francis called his body “brother ass.” I call mine “brother dog.”

Brother Dog

We could take you to court for those coding errors!” the medical director of ICIC (the Iron Curtain Insurance Company) shouted at me.

I run a tiny outpatient psychiatry office and this kind of phone inquisition by an insurance company representative is becoming a large part of the job. My notes had too much history for him, too little homework for the patient, and did not push medication sufficiently. I aim to combine both pharmacology and empathy, as needed-no small feat. He wanted the forms and a quicker cure. The patient and I had gone for an outside review and the medical director was angry at me for not falling into line. I didn’t think his threat would hold up, or that he would bother to do it, but I heard how angry he was. I felt a shiver and was briefly tempted to drop the patient. “If I told other companies, no one would want to deal with you!” threatened the ICIC director.

These reviews and legalistic wrangles are becoming an oft-repeated hassle in the commercial medicine of 21st-century America. The Affordable Health Care Act of 2010 has put a huge frosted cake on the table-50 million new patients. The corporate interests (insurance, pharmaceutical companies, HMOs, clinics, and doctors) are angling to grab the best pieces by ads showing resorts with beautiful people (actually hospitals)-and trying to find a way to dump the tough cases. Companies dole out benefits with tight fists. PBMs (pharmacy benefit managers) subcontract with insurance companies and may cut off the supply of medication a patient has used for years. It is up to the doctor to preauthorize or appeal-or deal with a distressed patient. Insurance often pushes pills rather than talk therapy, believing drugs are less expensive (although there is a fair amount of evidence to the contrary).

To make ends meet, many doctors, especially in primary care and psychiatry, are forced to comply. They may spend 30% or more of their time doing paperwork and talking with the likes of the medical director from the Iron Curtain company. It looks bad for the preservation of privacy, patient choice, and personal trust in the doctor-patient relationship. I am not optimistic, but here is my theory, based on mammalian evolution, of one force that may work against the corporate takeover of medicine.

The structure of society-people who stay local, those who concentrate on personal relations, businesses small and large, government-mirrors the way all humans grow up. We learn first to control, then to share, love, be open, or the reverse, keeping secret and not sharing. Some stay home and count their money. Others give dinner parties or go to a church or pub.

The earliest form of human development is face time-that period when you are in someone’s presence, in the same room, and directing your thoughts to him or her. (Watch an infant scan faces, work the room.) The other person expresses himself to you in real time, and you volley back. That’s the only kind of signaling that provides human meaning and and helps us work together. Anything else is more or less unreal. Basically, I am counting on our simian reflexes to work against business, in the long run. We’re more ape than computer.

Of course, thinking about some other individual is hard work and can cause pain or boredom. Most of us don’t do it very well. It hurts the brain to stop and listen. You can be with someone but mainly space out, dream of something else. (You might even dream of starting a large company and making millions.)

How are corporations born? If it is hard to deal with someone one-to-one, it is even harder with a group of people. Remember the first day of kindergarten, when you walked in by yourself, unprotected? Even worse is high school-any one of those faces could go after you, put you down, and who could you count on? You needed a “gang” to stand by you and make you feel safe. You picked up some knowledge and coolness and a band of allies, developed a social persona (or mask), and then it started all over again, as you moved on to college and corporate life.

The grown-up world isn’t that much different, actually, except that we’ve made a thicket of laws, hired attorneys, and invented a number of tools that keep us away from face time. That is when the value of collecting information about others, building a company, and taking power comes into its own.

Information can be gathered in printed texts, detailed contracts, e-mails, corporate structure, electronic health records (the big hope for handling millions of patients), and people who function as automatons (they take no responsibility themselves but simply follow the procedure laid down by their manager). Of course, it is the same thing in industry and banking, but do you want to put your body on an assembly line?

The medical director at ICIC is a decent fellow doing his job; he means no harm, he simply reviews the treatment of patients by a formula, and nudges me as his boss directs him. He is the mouthpiece for a company policy, and whoever decides that remains invisible.

The corporate interests favor the efficient processing of information to handle large numbers of people, and as the pioneer of information theory, Claude Shannon,

 said, “Information is numbers without meaning.” More information equals more money (and less meaning).

It used to be you went to your family doctor and had your face time, and it was a safe enough encounter, even if you took your skivvies down. Now you see an assistant first, he or she asks about your symptoms and tells you what will happen, and you see the doctor for 10 minutes. The doctor orders tests and the assistant calls with the results. A modern doctor is programmed to place the emphasis on tests, not your story, and the diagnosis must be arrived at quickly, to put it on the insurance form for reimbursement. The doctor can’t waste time considering too many diagnoses and is not supposed to spend much of his limited time explaining (which is a “cognitive service” and poorly reimbursed). (Cognitive service is pretty much like face time, and what some psychiatrists like me still do.)

The business schools have persuaded many parts of our society that the most efficient way to make a product, provide a service, and make a profit, is by using their business methods. Unfortunately, increasing numbers of hospitals, clinics, and doctors have signed on.

The patient under review and I went to the office of the Commissioner of Insurance and appealed both in and out of the ICIC. They all said the company was acting within its legal power. (Human meaning doesn’t matter.)

Once I saw the tsunami coming, I was scared but saw I could accept it out of necessity. To the lords of information, a psychiatrist is regarded as a kind of nanny to the unruly and the underprivileged. We are a small number and not much trouble. Still, I count that ancient, low-tech, and meaning-making method of face time as too valuable to throw out. I will keep looking for it in my doctors and will try to give it to my patients

I tell all my patients, both within the ICIC and those who are under another company, “She’s not your mother.” If patients want to appeal (protest), I’m game. They know where I’m coming from.

 Shannon CE. A mathematical theory of communication. 

 Insurance often pushes pills rather than talk therapy, believing drugs are less expensive (although there is a fair amount of evidence to the contrary).

Hippocrates Under Contract

The Patient Protection and Affordable Care Act of 2010 has expanded the market for insurance by 50 million patients. The goal is lofty and just, but if the cost pains you, you can take it to Congress or to court and dispute it. Private insurance companies will have the honor, the challenge, and the bonanza of treating the newly insured. Doctors scheduled into briefer, more time-efficient slots will have fewer minutes to talk with patients and consultants. Corporations of all kinds (eg, insurance, hospitals, software companies) are hoping to make a killing. We hope the killing won’t be the death of respectable medicine-and of our quaint, old, low-tech specialty, psychiatry.

 Digital technology is a valuable tool, but if it dazzles us with its speed and control, there is the risk that we may forget the old way of connecting. 

Author | William Houghton, MD

Articles

Label Me Not: Still Learning After All These Years

The Weather Report at 10 PM

A True Believer

Between a Rock and a Hard Place

Brother Dog

Hippocrates Under Contract

The “Bar-Coding” of Patients With Electronic Health Records

Face Time, Real Time

How Can a Psychiatrist Make a Fair Agreement With a Patient?

Neglect of Privacy and Continuity Under Managed Care