A History of the Present Illness

by Louise Aronson

  11I lost my temper just once, after receiving the suicide threat fax (see below), when I thought Mike was dead and that his death was caused, at least in part, by clerical error. On the other hand, it’s true that sometimes, when I got off work, knowing I’d had a productive day, I’d find myself standing at the intersection outside the SMCHC looking past the usual assortment of lost tourists; shivering, half-naked leather daddies; bedraggled, intoxicated homeless veterans; loft-living, gym-bound yuppies; and dilapidated working girls and boys, and I’d feel unsure which of the traffic lights was meant for me and also whether the latest designer antidepressants and colorful PET scan patterns mattered in a world where life was more pleasant for most patients off their meds than on, where schizophrenic diabetics with fungating foot sores didn’t qualify for emergency housing and teenagers in lipstick and high heels traded sucks for falafel and fucks for shelter of the most temporary and dubious sort.

  12No doubt you heard (or have heard about) the pager that went off repeatedly during the profound and moving Convocation of Fellows at the American Psychiatric Association meeting last year here in San Francisco, and I’ll admit now (for the first time) that the pager was indeed mine, but I offer my confession with the dual caveats that (1) I had brought it only because when Freddy “I know they’re wiretapping me even though I’m homeless and phoneless” Ramboteau gets it in his head to try for another dive off the Golden Gate Bridge, I’m the only one who can talk him off the outer railing and into the locked unit at San Francisco General and (2) I’d forgotten that I’d removed my suit coat (with the pager clipped to the right front pocket) and left it stacked against the wall with my three-ring binder and accumulating pile of free pharmaceutical company conference loot (which I take not for myself—I belong to the anti-freebie group No Free Lunch—but for our patients and their children who love the canvas carrying cases, the mega-grip Day-Glo medium-point pens, the logo-imprinted cerebrum/pill/heart-shaped bouncing rubber balls, and the colorful oversize striped shoelaces).

  13Mr. Quintanilla gave me a conch shell from the Philippines. Inside that one, he said, you can hear my country and maybe you remember me. He missed all his subsequent appointments. I checked the hospitals and obituaries for months but never found him. Basim Rashad brought me a rug as broad as my largest room and the bright red of the morphine he dropped on his only son’s tongue in the weeks after we stopped the antiretrovirals and Ahmed lost his ability to swallow. Bud Stanton’s wife, Myra, said if I could get him into Napa State, the inpatient psych hospital north of San Francisco, she’d take me to lunch. Anywhere in town, Myra said, price is no object. Each time I did a home visit, Fele Tafatolu’s sister gave me a palm-size present wrapped in burlap and tied with string. Fele thought water was poison, their shower stall a cell. The whole apartment reeked of urine and stool and open wounds. Inside the burlap was soap. Lavender and rose, chamomile and lilac and gardenia. For months before it was stripped and gutted, my Civic smelled like heaven.

  14Three weeks after Tina Ball died, I got the most incredible note from her daughter Daisy. Tina’s death certificate said cancer, but that was the least of it. She’d been schizophrenic, a horrible mother until Alzheimer’s gave her a second girlhood. Daisy said that last year and especially the months of her mother’s dying were the best of her life, and she couldn’t thank me enough for noticing the yellow tint in her mother’s skin and referring them to hospice. But Daisy’s note also said that since her mother’s psychiatric disease had burned itself out and clinic visits were a physical and logistic challenge, I should not have insisted on continuing weekly appointments right up to Tina’s admittedly painless blessing of an end, an accusation that shocked and surprised me and one that I wanted to (but did not) reply to by way of self-defense that I sincerely thought Daisy (if not Tina) benefited from the visits, that in my mind I had shifted to a sort of family systems approach that I believed would serve them both at that crucial juncture of their lives and that I could justify to our medical director only by billing for schizophrenia, since the clinic received some reimbursement for that diagnosis (albeit a small fraction of what is given for “medical” diagnoses), but no codes exist for finding oneself orphaned in adulthood, for grieving, or dying, or death.

  15See proposal for new DSM diagnosis “Overachievement Disorder,” arriving under separate cover.

  16Ditto preceding footnote for “Good-Girl Syndrome.” (Surely this one has been recognized, at least by astute clinicians in urban and academic centers, since the dawn of feminism nearly a half century ago???)

  17Contrary to public reports (the source of which, I’m sure, was the clinic admin who never forgave me for losing my temper; see below), I had not been drinking on the day Mike and I were apprehended doing the two-step nasty in the med room, and while it’s true that I grew fond of a certain cost-friendly Australian varietal after his dismissal and my pre-suspension probation, I never drank before sundown and feel confident that I never imbibed enough at night that anyone would be able to tell the next day. That said, I believe I understand the source of people’s mistaken conclusions and hereby propose the following as an eminently reasonable alternative explication: I worked in a neighborhood where most people smelled of alcohol, weeks and months and years of it polluting their breath and seeping from their pores, and I commonly hugged such people (my patients) because it often seemed to me that I was the only person in their lives who did so and that it was just possible that my hugs were at times more helpful to them than all my talk and hard-won Medicaid-approved prescriptions. Of course, such details aren’t even relevant if, as the Review Board claimed, the issue was abuse of power (which it wasn’t), as if what transpired between Mike and myself was pedophilia or reverse rape(!) or something actually illegal and definitively pathological, when in reality, Mike came on to me, not the other way around, and I wrote his letter of recommendation weeks before we hooked up. Moreover, if Mike had the wherewithal to earn a doctorate, he was certainly also capable of (1) deciding the interrogatives (who, where, etc.) of his private/sex life and (2) obtaining a letter of recommendation without sleeping with the clinic psychiatrist. While I concede both my affliction with BBD and my poor judgment vis-à-vis Mike (yes, I saw the scars on his arms and belly), I must most adamantly object to the diagnoses given to me by the Review Board’s smug, obscenely well remunerated and therefore de facto biased and corrupt consulting psychiatrist (a man who has never worked in community health, who in fact has no continuity psychiatry practice of any kind, and who earned for each hour he spent on my case 8.7 times what I earned in an hour at the SMCHC).

  18Anyone will tell you that I was busy—panicked, if you must know—finishing my master’s thesis in transformative studies, “Cross-cultural Approaches to Individuation in Psychiatric Patients with Triple Diagnosis and a History of Geographic Fluidity,” and after my official reprimand, I had been barred by the Review Board from contact with Mike, so I hadn’t seen him for weeks or maybe even months by the time the whole fax thing happened (which of course they blame me for too), but let me assure you that Mike knew perfectly well that I always ran late, and stayed late, and didn’t get to my mailbox until evening, because I prioritized patients first, not paperwork, not even my own bodily needs like using the restroom or eating lunch or even my little interludes with him (he hated that . . .). And what of the admin who put the fax that said “Call me by 3 or I’ll kill myself” into my mailbox instead of into my hand?!? If that wasn’t just typical of the SMCHC and all such places where you work with no support or the sort of support that’s actually worse than no support, not that the referrals you make on behalf of your helpless and hapless patients go anywhere anyway, since the city and state and federal government keep cutting services, making it impossible for even the most professionally rigorous clinician to follow practice guidelines, and then those same august bodies turn around and give the clinic and its doctors a bad rating because those selfsame guidelines weren’t followed, which can and, as you
may know, in the case of the SMCHC did (two months after my return to work) lead to closure of a facility desperately needed by the neediest among us.

  19The newspaper listed “a car” among the objects I gave Mike during his two months at the SMCHC. The “car” to which they refer was the Civic, which, as I’ve already explained, had been gutted and so had no apparent value and didn’t run. Mike wanted it anyway; I have no idea why.

  20For a while, when the story broke, I set my alarm for four-thirty each morning and drove the thirty-two miles to my parents’ house in the Los Altos Hills to wait for the paper boy, then removed the Bay Area section from their San Francisco Chronicle, that section being the one detailing the so-called abuses at the SMCHC, including an unnamed (but otherwise obviously identifiable) psychiatrist’s on-site liaisons with a visiting “student.”

  21I decided to apply to the Master of Public Administration Program with emphasis on health services administration at USF after my temporary suspension and before my self-prescribed Prozac kicked in, on a day when I stopped by the SMCHC just to say hi and came upon Zbigniew (a.k.a. “Big Z”), whom one of the internists wanted to commit because Big Z had claimed in his peculiarly accented English (he’s from Minnesota, not Poland) that he’d not only seen but talked to Jesus that very morning and that Jesus had told him he’d find cigarettes behind the register and not in aisle 5. I had to explain to my well-meaning but medically myopic colleague that it wasn’t Jesus but Jésus who had spoken to Big Z—Jésus, whom I also sometimes asked for help, who pronounced his first name Hay-zeus and worked as an assistant manager at the pharmacy down the street—and that Big Z therefore was not hallucinating and so would not require a costly inpatient stay. Right then I realized that if a person designed a universally applicable language-and culture-sensitive medical personnel training program for docs like my internist colleague, that person would be making an important, ultimately cost-saving, and consequently bipartisanly popular contribution to the future of our tragically dysfunctional American health-care system and that a very smart first step toward such a contribution would be enrollment in an M.P.A./H.S.A. program.

  22!!

  23I have two much-younger brothers (my mother had a string of miscarriages until diagnosed with and treated for her “incompetent” cervix).

  24I must strenuously protest the comments in the press by certain well-known lights of the psychiatric establishment (including you, Dr. Saperstein) suggesting the high incidence of hero complexes in people willing or even eager to work under socioeconomically challenging conditions. While I did not use the best judgment in allowing Mike to seduce me, it seems to me even now, in retrospect, that I behaved as I did, not because I had found someone to fulfill an insatiable need for worship, but because occasionally a person needs a brief interlude of semiprivate vasculo-muscular and neuro-chemical bliss, an opportunity, if you will, for the evanescent release of the otherwise rigorously repressed but still wildly vital animal within in order to punctuate the daily horrors of her job and the uniformly dismal realities of her patients’ lives. It wasn’t, after all, as if I planned my encounters with Mike. They just came over me in that way cravings might justifiably overtake even the most disciplined among us after hearing from a person (who, no matter how derelict and odoriferous, is a fellow human being) about how a group of perfect strangers, well dressed and out for a night on the town, kicked him and urinated on him and set fire to his bedroll, his only possession, and how, as a result, he might have frozen to death were it not for the actions of a buddy of his, another person who, by all standards of conventional society, is a nobody. Fortunately, this nobody had earned only enough change from passersby that afternoon (while napping, hat in lap, outside the McDonald’s on Van Ness Avenue) to score a single pint and so was in the optimally functional zone between withdrawal and falling down drunk, and consequently not only spotted his beat-up, half-frozen friend but was cogitating sufficiently well to fetch the local cops, who got the friend to the emergency department at San Francisco General just in time. Imagine, if you will, hearing that story and then walking down a gray-carpeted, fluorescently lit hallway and seeing Mike’s lean, rectangular torso or his tightly sculpted runner’s thighs and wanting them for yourself, if only for a few minutes (which, I’ll be honest, was about all I ever got because, his later denials, protestations, confabulations, and retractions before the Review Board notwithstanding, Mike certainly seemed the eager little beaver in the heat of that and other similar moments, grunting and panting like those funny small dogs with the smashed-in faces), and then perhaps you can understand how, in the twilight zone of the SMCHC, I decided that maybe a quick fuck wasn’t such a bad idea.

  25Perhaps this should read “medical and/or personal”?

  26I know what you’re thinking: How did she, a well-trained professional—a psychiatrist, for God’s sake—not see that Mike was Borderline? The answer is simple: the usual way; I was charmed.

  27In conclusion, I cannot resist pointing out what you as my fellow psychiatric professionals no doubt already know, namely that although personality disorders carry an ethically indefensible if sometimes well-earned historic burden of negative associations even in our own small psychiatric community, there are those among us who would benefit from receiving the sort of diagnosis that might be employed to explain our thoughts and behaviors not only to ourselves but to others, a diagnosis we might metaphorically hoist before us when we disappoint our families or lose a job or are subject to humiliating pseudo-public professional scrutiny, using it as protection in much the same way a soldier girds himself for combat with a bulletproof vest and helmet and grenade. Because, let’s face it, the tragic truth is that even now, in the twenty-first century, too many people fail to understand and appreciate the huge and significant difference between differentness (i.e., me) and true insanity (i.e., Freddy Ramboteau, Tina Ball, Big Z), how the former can make a person needy and might even periodically impair her decision-making capacity but may also be responsible for precisely those traits that make her a unique, even special human being, a person striving to make daily contributions, large and small, to the faltering social experiment we call life on behalf of those too ill to do so for themselves. In fact, it might behoove the committee to pause long enough to consider whether, in fact, the selfsame constellation of traits might account for not only the BBD “disordered” person’s character weaknesses and psychological vulnerabilities but also for those “gifted” and “good girl” aptitudes and interests that enable her both to excel in academic pursuits such as earning graduate degrees and developing new diagnostic categories and to feel a profound and sincere sympathy for those among her fellow humans who are too often ignored, written off, insulted, and abused by the sorts of people (including, I’m sorry to have to mention, certain media-hound-type members of the “Cluster B” revision subcommittee) who can look at the downtrodden and desperate and feel no sympathy or empathy, no bathos or pathos, and whose behavior leads some of us so-called crazies to wonder who among us really deserves the label of deeply and irredeemably psychologically deficient. Which brings me back to my relationship with Mike. I admit he was a manipulative, self-serving cutter, quick on the manly trigger and prone to dramatic exits both actual (he left a rainbow-colored trail of pills on the gray carpet the day the SMCHC fired him) and threatened (in addition to the fax, he twice left suicide notes on the handlebar of the bicycle I’ve used for transportation since the Civic’s demise, though last I heard he was alive and well and collecting disability while awaiting a trial date for his wrongful dismissal lawsuit). But unlike most of the other people in my life, Mike also seemed able to see the parts of me that are so often misunderstood, and he not only loved those parts but valued and treasured them, and as a result, for a time, so did I.

  A Note on the Author

  Louise Aronson has an M.F.A. in fiction from the Warren Wilson Program for Writers and an M.D. from Harvard Medical School. She won the Sonora Review prize and the New
Millennium Writings short fiction award, and she has received three Pushcart Prize nominations. Her fiction has appeared in Bellevue Literary Review, Northwest Review, Sonora Review, Seattle Review, Fourteen Hills, and The Literary Review, among other publications. She is the recipient of Ucross, Ragdale, and Hedgebrook residencies. She is an associate professor of medicine at the University of California, San Francisco, where she cares for diverse, frail older patients and directs the Northern California Geriatrics Education Center, UCSF Medical Humanities, and the UCSF Pathways to Discovery program. She is an associate editor of the JAMA Care of the Aging Patient series and director of public medical communication for the UCSF Program for the Aging Century.

  Copyright © 2013 by Louise Aronson

  All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission from the publisher except in the case of brief quotations embodied in critical articles or reviews.

  For information address Bloomsbury USA, 175 Fifth Avenue,

  New York, NY 10010.

  Published by Bloomsbury USA, New York

  Library of Congress Cataloging-in-Publication Data

  Aronson, Louise.

  A history of the present illness : stories / Louise Aronson. — 1st U.S. ed.

  p. cm.

  eISBN: 978-1-62040-008-1

  1. Medical fiction, American. 2. Physician and patient — Fiction

  3. San Francisco (Calif.)—Fiction. I. Title.

  PS3601.R67H57 2013

  813'.6—dc23

  2012018354

  First U.S. edition 2013

  Electronic edition published in January 2013

  www.bloomsbury.com