Two studies of patients who switched from Clozaril to generic clozapine are being evaluated by the U.S. Food and Drug Administration to determine whether the rating of the generic drug as bioequivalent (AB) to the brand-reference drug should be reconsidered and whether additional bioavailability assessment should be undertaken.
The patient, an overworked, middle-aged primary care physician, has more than once told me what led him to his choice of career. Misunderstood by his father, poised between the culture of the "old country" and that of the urban United States, he had found a unique comfort, as a boy, sitting in the big leather armchair of his own family's physician and chatting with him. This general feeling, more than anything scientific, was what he had hoped to provide for his own patients. We often commiserate about the social forces and bureaucratic systems that have conspired to keep us both from regularly and easily reaching this goal that we have in common.
My patient's commitments will not allow a wholesale changing of horses in midstream. His temperament might be better suited to the writing of poetry (which he used to love), but he will have to play out his medical career a good while longer. Yet, an incomplete response to psychotherapy and medication for his syndrome of anxious depression has convinced me that some concession to the needs of his own nature must be made, and I, in turn, have been trying to convince him of this.
While this is easy enough on an intellectual level, the psychophysiological mandate of the introspective poet is soon translated into the problem-solving idiom of the physician. Don't book appointments after 3 p.m. on Thursdays. Take a yoga class. Walk to work.
But Thursday afternoons fill up with dictations, paperwork, phone calls; yoga class conflicts with the kids' soccer games; he needs to take the car for hospital rounds. Both of us see what is happening, but it happens all the same.
One day, after another attempted cutback in work hours, he brings in a dream. A mute, "slapstick" version of himself is tied by the wrists ("poseyed," in medical slang) to a chair, but keeps getting loose and coming after him in a half-comical, half-menacing kind of way. My patient can't tell if the slapstick man wants to play or wants to hurt him. With difficulty, non-verbal persuasion and duct tape-that most universal of solutions-my patient gets his alter self back into the chair. But then the slapstick man gets loose again! And so on.
The truth of a person (definition postponed) is a wild creature. It cannot be domesticated or indefinitely restrained. Micromanagement of the office schedule and time at the gym will not keep the slapstick man chair-bound. This dream figure has gotten across to the doctor in a way that I could not, and we are now in agreement: Our job is to find out what this mute fellow really wants.
I underline the point with some imagery from just outside my window. In our coastal city there is the frequent summertime sight of sea kayaks on the roofs of cars. Whoever rents the parking spot below appears to install his or her kayak atop the Volvo in May and remove it in October, as if to be ever-ready for the spontaneous whim to throw the boat into the harbor and paddle away. But I monitor the spot: The Volvo-kayak is always there when I come in and still there when I leave. While I may hope otherwise, I suspect that the boat's primary function is to proclaim to the world that its owner has a soul (and perhaps to remind the owner as well).
We do this, all of us; we throw bones to the truth and try to keep it tied down. It wants to play freely in our lives, but its full implications threaten us. This is as true of cultures as it is of individuals. I think of the gospels layering Pauline theology over the words of Jesus, or later, of analytic institutes freeze-drying the insights of Freud and Jung. I think of the tired 12-bar blues played in bars coast to coast; buried beneath it, the tortured freestyle cries of Robert Johnson. We can't seem to bear the truth for very long. The weight of cultural accretions "takes down" the truth like a wrestler.
What do I mean here by truth, as an attribute of a person? Simply the expression of one's own essential being: whether actively, by doing or receptively, by seeing. But in either case, doing or seeing in the way that the individual uniquely does or sees. Some theologians place us here as the eyes with which God sees his creation, or the hands with which he furthers it. I haven't come up with a more scientifically correct way to put it. We may envy the conventionally religious, for whom the question "What was I put on this earth to do?" has an unequivocally clarifying effect. But whether we personally prefer to believe that some purpose already exists for each of us to find or that we only make one up for ourselves out of the raw materials of our lives, our task remains the same. Our beliefs are irrelevant to the psychological imperative embodied by the relentlessly approaching slapstick man.
In the physician's case, truth led, not to rest and relaxation, but to more work (as it often does). This work connected the introverted poet with a new and surprisingly outer-directed passion that would affect many lives. But the poet's eye remained and also found solace in a decidedly non-New Age pastime: tying flies under the tutelage of an older man who liked and appreciated him just as the doctor with the leather armchair had, many years before.
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