by Samuel Shem
‘You will be responsible for doing admission interviews, physical exams, and write-ups for every patient admitted between eight and five, Monday through Friday,’ Nash was saying. ‘Any patient arriving between five and eight is the DOC’s. You stay as long as it takes to finish your write-ups and orders. I leave at five sharp. Almost all admissions are scheduled. We have rare emergencies. Anything to add, Jennifer?’
Jennifer smiled. She was a willowy woman in a smart, dark dress. Her smile distorted the olive oval of her face, one side tardy and limited in its ascent. Jennifer said, ‘No.’
‘Volume,’ Nash said. ‘We make it on volume. I’ll show you the operation.’
Behind a bulletproof door as sturdy as a bank vault was the Admissions Unit. It was clean and bright and cheerful, with a Japanese leitmotif – rice paper screens; Toshiba TVs, VCRs, and computers placed as strategically as rocks in gravel gardens; and signs done in those letters with ballooning bottoms and slender tops that can be ‘seen’ by computers. Nash explained at length the physical layout. He said nothing about the patients.
‘What about the patients?’ I asked.
‘The patients?’ he asked.
‘The patients,’ I repeated.
‘The software?’ Jennifer asked.
‘Oh, the software,’ Nash said. ‘What about it?’
‘Will you be supervising me on them?’ He stared at me, uncomprehending. ‘Or will Jennifer?’ She stared at me, just as uncomprehending. ‘Su-per-vi-sing?’ I said deliberately, loudly, as if to someone who doesn’t speak your language. ‘So I can learn about patients?’ More incomprehension. ‘You know, learn?’
‘Learn?’ Nash repeated, and then went on, ‘Admissions Unit is short-term. Maximum stay seven days. After that it’s discharge back out, or transfer further in, to Inpatient Unit. You better start. So long.’
My first admission was a fireman named George who, several months before, had been the sole survivor when, as he was driving over a snowy pass, his car had crashed head-on with a drunken driver’s. His wife and three children – including a five-month-old baby – had been killed. An emaciated man with eyes sunken in horror, he was obsessed with its being his fault: ‘The baby gave out this happy squeal – she was in the car seat in the front, and I looked down at her for a second and heard my wife scream – “George, look out!” and then … glass everywhere, and flames. All dead. It was my fault. If only I hadn’t looked at her.’ He looked up at me, and I felt his pain and his isolation in it. Overwhelmed, he looked away.
‘That’s horrible,’ I said. ‘You poor guy.’
‘The irony is, my two older kids always called me a “bumblefuck.”’
‘What’s a bumblefuck?’
‘A slow, overly cautious driver. I haven’t been able to talk about it to anybody. All I see is glass. Glass everywhere. I’m feeling hopeless, Doc.’
‘You’ve been cutting yourself with glass?’
A look of horror and shame crossed his face. He nodded.
‘Tell me about it?’ He was reluctant. I understood – he felt trapped. But I also understood that my vision was larger than his and could hold his pain. His feeling trapped was normal, and, if opened up, was an energy for healing. I used the skills I’d learned from Malik to coax us along that tricky path of talking about the trauma and the time since. It was hard work. He’d open up, then shut down. But we were getting somewhere, until suddenly Nash Michaels burst in. He dragged me out into the hallway. Jennifer was waiting there.
‘You’ve been in there forty-three minutes,’ he said. ‘You can’t take that long. These days, no health care provider can. Length of stay is down; beds are empty; admissions are doubling every year, but the daily census is falling.’
‘But he’s in real trouble and—’
‘You have seven admissions to do today by five o’clock. Seven, and we’ll try to squeeze in two more, thanks to the run-up to Thanksgiving. The key to success in Toshiba is to always stay one step ahead of yourself. At least one.’
‘But he’s desperate. He needs to talk.’
‘Not now. Admit him. Talk to him on your own time, before eight or after five. You can’t open things up on admission – it does more harm than good. Including physical exam and write-up, you should take fourteen minutes for an admission.’
‘Fourteen minutes? That’s impossible.’
‘Dr Bozer did it. Best resident we ever had. C’mon. I’ll show you.’
‘But this guy is desperate – a cutter. I’m getting a really good history—’
‘For admission, you don’t need much history. The girls on the phones in preadmission get enough usually. The goal of Admission is to admit.’
‘But even to admit, I’ve got to think about him, about his treatment.’
‘We do no real treatment on Toshiba. There’s not enough time.’
‘Well, then for diagnosis. I’ve got to give it some thought.’
‘Ah!’ he said, as if solving a challenging episode in charades. ‘That’s your problem.’
‘Diagnosis?’
‘Thought.’
‘What’s wrong with thought?’
‘Thought plays no part in diagnosis.’
‘You mean go more with my feeling?’
‘Feeling?’
‘Feeling. What the patient feels, and what he makes me feel, what I feel with him? Affect?’ He stared at me. ‘Go with the affect?’
‘No, not the affect. The decision. Don’t think, decide. As soon as I stopped thinking as a psychiatrist, everything went a helluva lot better.’
‘But isn’t thought essential in order to decide?’
‘Thought gets in the way of deciding. If you think, you leave room for doubt. If you doubt, you can’t decide. Like the college boards. If you put down your first impulse, the first shot out of the box, you usually got it right, right? If you thought, you doubted, and the other multiple-choice answers started to look better and better, so you got paralyzed, right?’
‘But this isn’t multiple choice; there are feelings involved here.’
‘Take your feelings to your therapist. We don’t do feelings here. Do you know how to make Decision?’ I said I did not. ‘Decision Tree.’
‘Algorithms,’ Jennifer said. ‘Technical name.’
‘You get raw data from the patient. You look in the back of this.’ He held up a well-worn copy of a small green book, the size of a child’s first reader, the kind with the animals with real wool the child can touch. ‘Quick Reference to the Diagnostic Criteria from DSM-IV. You look in the back.’ He looked in the back. Sure enough there were many treelike charts, where you start at one branch and you come to a fork and decide which of those to go to, and another fork and another until you find yourself out on a limb with a single leaf and no more forks, which is Diagnosis. ‘The computer will do it all for you – diagnosis, medication, date of discharge. Let’s go.’
‘Toshiba computer,’ Jennifer said proudly.
We went back into the room with poor George, who sat hunched over, staring at a wall. ‘Hi there!’ Nash said, loudly and cheerfully, and pumped his hand like a politician. ‘Mind if I ask you a few quick questions?’ Before George could answer, Nash was asking him a few quick questions.
It was astonishing. Starting with the Chief Complaint – ‘It’s my fault’ – Nash would ask a question – ‘You feel guilt?’ – and George would start to answer. Nash was interested only in yes or no answers. If George started to explain, he’d cut him off with another question. At first they seemed to be talking at cross purposes, but soon George got into the rhythm. Wanting to please his doctor – and perhaps feeling relieved that he didn’t have to confront the painful feelings that had brought him into Misery – he barked back, sprightly ‘Yes’ and ‘No,’ moving swiftly and neatly through Decision Tree in the back of DSM-IV until his doctor smiled, rose, pumped his hand again and said, ‘You have “Mood Disorder, Major Depression, Recurrent, with Melancholia, 296.33.” Your insurance wil
l cover seven days in Misery. We’ll start you on antidepressants. If we find you are suicidal or psychotic, we will rediagnose you and your insurance will cover more. Any questions?’ It looked like George had a lot of questions, but before he could start, Nash was saying, ‘Thank you very much Dr Basch will do your physical and have a pleasant stay in Misery,’ and was gone. Jennifer and I followed.
‘Four minutes.’ he said, back in the boardroom. ‘Have a nice day.’ He left.
Jennifer remained. I sensed in her face a kind of contempt for what we had just seen, and I asked, ‘It seemed incredibly cold, didn’t it?’
A pained look came across her face. I felt that I might just have an ally here. She walked silkily around the rosewood table to the thermostat.
‘It’s sixty-nine, precisely.’ She rushed out after Nash.
I was appalled. This technique was the classic ‘medical model’ I’d learned in the House of God. Starting with a live human being, you asked a lot of quick questions to funnel the human down into a diagnosis and a treatment. You cut off conversation, for talk meant less time for sleep. Malik had shown me that being a shrink was doing the opposite: turning the funnel upside down, opening things up in order to connect. It was delicate, meticulous, intuitive work, and I finally had a sense that I was learning how to do it, and now – Viv’s voice burst out of my beeper:
‘Number One’s ready for a physical, Cowboy, and Numbers Two, Three, Four, and Five are waiting, and Number Six is the Lady who Eats Metal Objects and she ate her hairdresser’s wedding ring and is on the way in too so don’t think, honeypot, decide.’
I did the physical on George the bumblefuck driver. When I asked him if the scars across his chest where he’d cut himself with glass were attempts at killing himself, he refused to open up to me again and said only:
‘Y’know, I really liked that guy, Doc Michaels. A real pro. Got straight to the point. Guy like you could learn a lot from him, y’know?’
When I went to do George’s write-up I found it already done, laser-printed and in the chart. Nash had given the computer the Yeses and Noes, and the computer had given back a terrific Admission Note, in the medical model that made poor George’s catastrophe look as bloodless and manageable as any medical illness – though he’d missed the glass-mutilation question suicide gesture, which I wrote in by hand.
‘I’m brain-damaged but I don’t think so.’ was the Chief Complaint of Number 2, a twenty-two-year-old woman whose heart-wrenching story included being hit over the head with a pipe after being raped in the parking lot of Misery Mall. I did what I thought was a terrific interview, but it took until noon and Nash was on my back to hurry up. As I escorted Number 2 through the lobby waiting room, I was accosted by Numbers 4 and 5 and their families – the ‘angle of the dangle’ man was Number 4 – as well as Number 6, The Lady Who Ate Metal Objects, who, when she recognized me, started screaming, ‘Your watch! Hey big boy, gimme your watch!’ Primo Jones was standing next to a man dressed as a woman holding two grapefruits for boobs. This was Number 5.
‘Thanksgiving’s comin’, Doc, and the turkeys are gatherin’, y’get me?’
I typed poor Hit Over the Head with a Pipe Number 2 into the Toshiba and it climbed Decision Tree out to the limb called ‘Organic Mental Disorders Arising in the Senium and Presenium 290.13.’ This seemed too cold, given what I’d felt with her, and too damning, labeling her forever as ‘brain-damaged’ when in fact her organic sequelae were minimal and she was reacting normally to a terrible trauma. I tapped in, for diagnosis, ‘Depression, appropriate.’ I listed no DSM code.
By the time I got to Number 3 it was way past lunchtime and I’d had no time for lunch. I was so overwhelmed with work that I decided I would try to do the Number 3 interview the Toshiba way – strictly multiple-choice medical model – but Number 3 was just about the saddest story in the world, an imploded fourteen-year-old boy who’d tried to hang himself in his mother’s walk-in closet.
Interviewing him and his parents – parents who seemed decent, concerned, caring, and mystified, and who’d done everything right as far as I could tell – I was drawn in, thinking of my own parents and of my too being a mystery to them. But at a particularly delicate point in the interview Viv paged me stat to the waiting room where Number 5, the Grapefruits Man, and Number 6, the Metal Lady, were rolling on the floor fighting. I told Primo to bring the Grapefruits Man into the other interview room and I’d be there in a minute.
When I went back to the boy who’d tried to hang himself, it was strange: he and his parents were still where I’d left them – opened up, ready to try to understand – but I was not. Frazzled and pressured, my mind elsewhere and my heart closed down, try as I might I could not get back to where I was, and things were going badly. Viv paged me that my patient Zoe was wondering why I hadn’t shown up for her appointment. I realized I’d completely forgotten it. I cut to the physical with the poor suicidal kid and locked him up in Toshiba and went to see the Man with the Grapefruits.
The Lady Who Ate Metal Objects, Number 6, took me until late afternoon. I was exhausted. There were at least four more patients to go. How was I going to make it through the day?
I shifted my mind-set, away from the hard, subtle work of being human with patients, to distance, diagnosis, and treatment. Don’t think, decide.
Sweet relief. Admitting Number 7, a gay man, hearing his plaintive question to me – ‘Do you know what it’s like when you’re a kid and every other boy is out playing baseball and you’re in the basement playing Cleopatra?’ – I smiled, ran the symptom checklist for depression, and hit 296.20, Major Depressive Disorder, Single Episode. With Number 8, a woman who kept saying, ‘This life is a test. It is only a test. If it were a real life you would have been given instructions on where to go and what to do’ – I cut things short, sealing her up in 295.40, Schizophreniform Disorder. And when Number 9, a Heiler Anorgasmic Dissociative, started screaming at me, ‘You fucking doctors don’t know what this fucking Prozac you give us does!’ – I hardly flinched as the future of psychiatry in my lap popped out ‘300.15 Dissociative Disorder.’
With the burden of trying to help lifted, I cruised, filling in the blanks of the medical model, doing the physicals, tapping into the toy Toshiba, hitting ‘print.’ snapping the Admission Note into the three-ring binder.
Number 10 was a 44 y.o. rural rabbi of the Reform movement with a Chief Complaint of ‘I’m gayogenic and I’m abusing suckinols.’
‘Gayogenic?’
‘I turn women gay. A year ago my wife left me for a woman, a few months ago my female cantor left the temple for a woman, and just after Succoth the head of my temple’s Haddassah made aliyah to Israel with my cousin’s wife. My faith in God is shaken. How could God do this to me?’
‘Good question and shalom,’ I said, locking him up. I sat with my cute little Toshiba Satellite Pro, with 90MHz modular Quad-Speed CD-ROM and 810-million-byte hard drive, watching admiringly as it did 305.41, Barbiturate Abuse (Seconal) in living color, and thinking, Hey this is almost fun.
‘Fun, eh kid?’ said a familiar voice.
‘Malik?’ He was in a blue and white sweatshirt emblazoned with a line of Hebrew, translated as ‘It’s Better in Israel,’ and twirling a basketball in his hands. With him was Henry Solini, in baggy gym shorts, red, green, and black Marley T-shirt, and rainbow-colored wool Rasta cap.
‘Let’s play some hoop! Malik shouted. He was eating a carrot.
‘When’d you get back?’
‘Yesterday. We do Thanksgiving in Chicago. My family. I need Chicago, after a month in the Promised Land with Bronia. I got the gym for an hour.’
‘Don’t have time.’
‘C’mon c’mon – you can’t make any real contact with these patients, there’s no time, right? Don’t get involved. C’mon out ’n’ play with Henry ’n’ me.’
His words went against everything he had taught me so far.
‘I know what you’re trying to do, Malik. It won
’t work.’
‘Yeah, these suckers are doomed! So feed some shrink bullshit into that bullshit computer and we’ll choose up sides. This weather makes me want to shake and bake!’ He wiggled his hips, dribbling the ball, and I sensed the ‘hoop fever,’ so familiar to me – a hum of vitality in my body and head every November, my pulse quickening, happiness sparking in my palm with each tap tap tap of the ball on the pavement on my walk down to the gym. ‘Over to Jordan!’ he cried, throwing it to me.
I had played basketball in Columbia, in fact had been co-captain with the immortal George Konopski of the Columbia High School Fish Hawks. Basketball had been my one-way ticket out of the foreign country of my family, my ticket into the life of buddies and bodies and girls. In one smooth motion I caught the ball in one hand and spun it easily up onto my index finger, then ‘walked’ it down each finger in turn, keeping it spinning, until, spinning it on my pinkie, I popped it back to him. Years to learn this.
‘Hey hey hey!’ he said. ‘You play hoop!’
‘Saved my life.’
‘Me too!’ Malik said. ‘Come on.’
‘Me three!’ Solini said.
‘You too?’ I asked, startled, given his minuscule size.
‘Point guard, Mandan Braves. Unbeaten, my senior year, till we played the Fort Yates Warriors, in their gym down on Standing Rock Reservation. Everett Chasinghawk, their point guard, stole me silly. Same dude that stole my wife last year. We were doing OK till they got out their war drums for their fight song, “On the Warpath” – we crumpled.’
‘C’mon, Roy,’ Malik said, like a little kid dying to play, ‘c’mon!’
‘Can’t. I’m way behind.’ Shaking their heads, they started to leave. ‘Hey wait a second, Malik. What do you mean they’re doomed?’
‘Once they come into the Misery system, they gotta hope they run into guys like us, who are out of it, to help ’em out of it. Tell you what. Gimme the name age sex address occupation religion and Chief Complaint of each of your admissions. I’ll give you back the DSM diagnosis.’
I did.