Dr. Kapoor and I rode down in the elevator together and crossed the street. The sun was shining and the air was crisp with the coming spring. I felt my mood improving like the weather as we walked across the drive and away from Kings County Hospital altogether. He told me that both he and Dr. Singer had done their Ph.D.’s in research psychology, “so we have a lot of respect for psychologists.”
“Some of my best friends are psychologists,” I expected him to say next. How much psychiatric disdain was he trying to shore me up against?
Dr. Kapoor told me that his dissertation had examined how doctors talk to their patients about terminal diagnoses. He’d found that the doctors’ own anxiety about mortality affected their behavior. He asked about my dissertation and my background, and I told him. When we reached the elevator bank, he told me I should go up to the seventh floor to see a call that had come in that morning. I was delighted to be given so much independence so fast. Maybe some of his best friends really were psychologists. He gave me the patient’s name, Valerie, and her room number. She’d just had her appendix out, and the reason for the consult was “panic attack.” I should see her, determine what had happened, and then go down to his office on the fifth floor to report my findings. Reflexively, I began to review in my head what I knew about panic—the unconscious emotional states that engender it—but then stopped myself. I had before me only this beautifully uncomplicated task. A panic attack had specific parameters. I would determine whether this Valerie had one, not theorize about its underpinnings or help her place it within the broader context of her life. No wonder psychiatrists often seemed so self-satisfied. Dr. Kapoor said good-bye and headed for the staircase: he always climbed up, he told me, for the exercise.
I rode the elevator until the doors opened onto Downstate’s seventh floor. The floors were shiny and bright, the walls a pale shade of yellow. Doctors in white coats walked back and forth purposefully. Nurses in pastel scrubs worked behind the desk. I wished I had a uniform, some easily identifiable evidence of my role there. Everyone else who worked at the hospital seemed to have that much, from the security guards to the janitors. I felt so unfortified, wandering around in my street clothes. I found my patient’s room and went in. Valerie was maybe forty, light skinned and overweight. She was lying in bed, looking as if she was recovering from something. I introduced myself as a psychologist in training and told her I was with consultation-liaison psychiatry, that her doctors had called us to come see her. “I’m not crazy,” she said. My appearance by her bedside was obviously an insult.
“Psychologists aren’t just for crazy people,” I said. It was by now a well-worn line, delivered each Friday morning by Alisa and me, with utmost discomfort (it rendered such disrespect to the cuckoos) to our fluctuating group of cancer patients. “Your doctor was worried you’d had a panic attack,” I told the woman.
“A panic attack?” She looked confused.
“Did your heart start racing at some point? Maybe you thought you were going to die? Did your palms get sweaty?”
“No,” she said. Did I have the wrong person? Had Dr. Kapoor been confused?
“Do you think your doctor would have any reason to think you’d experienced something like that?”
She reflected. She was an easy talker once she got going. “I did get upset before my operation. I was in so much pain. I’d had it for weeks and figured it was gas. I waited for it to go away on its own. By the time I got here, it had been a month of hurting. So I’m laying there waiting to go into surgery, and they’d been promising me for hours that I’d get some medication. But it never happened. It hurt so badly, and I started to get worked up. I yelled at them. My blood pressure went up. Since I arrived, they’d been constantly prodding and poking me and hooking me up to IVs without any explanation or pain medication. It made me upset and a little nervous.”
“Do you get nervous often?” I wanted to be thorough.
“Once in a while,” she said.
“Tell me about the most recent time besides here.”
“About a year ago my son didn’t come home one night. He’s sixteen. I was worried.”
“When you worry, or even when nothing in particular is worrying you, do you ever have symptoms like the ones I asked you about—racing heart, sweaty palms, numbness in your hands maybe, or chest pains?”
“No,” she said. “That night I just felt scared about what had happened to my son. I went downstairs to a neighbor, and she helped calm me down. He came back in the morning. Teenagers.”
I did a mental status exam and asked about her history. She told me she’d been in the middle of a shoot-out once, twenty years earlier, at a party. “Someone pulled out a gun and started firing. I live in a rough neighborhood. Parties can get dangerous.” She hadn’t attended one since, but she assured me she still had an active social life. I told her it didn’t sound to me as if she’d had a panic attack, just a reaction to pain and the unfortunate difficulties of being in the hospital. That seemed reasonable, but was I missing something? Her surgeon, after all, had been concerned enough to call for the consult.
I reported back to Dr. Kapoor and asked him what he thought had happened. He guessed that the patient’s anger had upset the doctor, who’d responded by calling for psych. “The staff use CL in a lot of different ways. They don’t want to consider that poor treatment or just plain lack of information might be having an impact on a patient. They think that if she’s upset, she must have a diagnosable psychiatric problem. I’ll check in on Valerie later myself.”
The next day Dr. Kapoor told me that he agreed: Valerie had not had a panic attack. But as we sat in his office, another call about her came in. When he hung up, I looked at him questioningly.
“They want us to see her again,” he said.
“Anxiety?” I asked.
“Yes, but not hers,” he said matter-of-factly. “She’s crying. Doctors often call us when their patients cry.”
Dr. Kapoor let me absorb this and then continued, “And, of course, she has a psych history.” Another phrase I had come to know well, with its undertones of derisiveness.
“No,” I said, shaking my head. “I asked her about that specifically yesterday. She’s never talked to a therapist. She’s never so much as taken a sleeping pill.”
Dr. Kapoor’s face remained straight. I admired his unfailing placidity. He continued in an arch tone, with a smile on his face. “You saw her for fifteen minutes yesterday. Now she has a psych history.” He was still amused, though no longer befuddled, his expression said, by all of these doctors who were not psychiatrists. It was then that I first considered the gulf between psychiatry and the rest of medicine and realized that it might very well be as wide as the one between psychiatry and my own field.
One night a woman showed up in the ER saying she’d ingested antifreeze. She was high on cocaine and alcohol. The next morning at the meeting Dr. Singer speculated that maybe it hadn’t been a suicide attempt. Maybe she was just looking for a better buzz. He seemed excited by the novelty of this idea, and so I felt excited by it, too. “Do people use antifreeze to get high?” he asked. I guessed that he liked having students around: they would know what drugs the kids were into these days. But nobody would cop to knowing about the recreational pleasures of antifreeze. He made a note to call Poison Control to ask.
Dr. Cherkesov, whose intriguing tidbits, I was noticing, were often delivered like grand proclamations, said, “The combination of cocaine and alcohol is especially toxic! Impulse control becomes poor! As the coke wears off and alcohol stays in the system, painful emotional states become overwhelming! It’s a lethal combination!”
The resident Dr. Malou reported that there had been several calls from obstetrics the day before. “They rely on us too much,” she complained. Psychiatry residents did three months on CL. Dr. Malou was near the end of her tenure there and it showed. Dr. Singer explained that a young woman had come in a couple of years earlier on the verge of delivering an infant. She hadn’
t even known she was pregnant and insisted on leaving the hospital in order to go to her own doctor. CL wasn’t called. The woman left the hospital, delivering and then killing her baby.
“Ever since, they overuse consult,” he said apologetically.
Dr. Malou was on the pager, and so she and I left the meeting together. On CL, I was well below the psychiatry residents in the hierarchy. This was correct, I knew, because there was so much going on that was medical, completely unknown to me. But I resented it, too, pervasive as the psychiatry residents’ attitude of superiority to us psychologists was no matter the setting. Dr. Malou told me I could call her Amari, and my outlook on our relationship improved. She was my own age, with a brusque manner but a pretty smile, and being on a first-name basis felt much more natural to me, though the physicians rarely used first names even among themselves. Months of “Doctor” this and “Doctor” that had finally had the intended effect on me, and any other title had come to sound pedestrian, to the extent that I’d felt an immediate and startling disdain during the recent presidential primary debate when the candidates were addressed simply as Mrs. Clinton and Mr. Obama.
Amari and I made our way across the street. First on our list was an eighteen-year-old diabetic girl. She was in the hospital after letting her blood sugar get out of control, and not for the first time. Amari read the consult paperwork as we walked. She turned to me. “She has stomach pain. Her doctors want us to assess her because they think it’s psychosomatic, but that doesn’t make any sense. If she’s not controlling her insulin, of course she has a stomachache.” She shook her head and continued. “When they can’t figure out a cause for a symptom, they decide it’s psychosomatic, and then they call us.” She rolled her eyes again. CL was trying her patience.
“So if we suspect going in that the rationale for the consult is flawed, what do we do?” I asked.
“We have to go see her, and we can think about the case in other ways. Diabetes is easy enough to control for the average eighteen-year-old who’s been dealing with it for as long as she has. So why isn’t she taking her medicine? That will be our focus.”
The diabetic girl was effervescent, happy to have visitors. Amari introduced us and got down to business.
“Why aren’t you taking your insulin?” she asked.
It seemed like an obvious question, but apparently not one that her doctors had previously thought to ask. Hesitantly, the girl told us that she was Pentecostal and that the preacher at her congregation said in no uncertain terms that medicine was a no go. “I believe in healing,” said the girl. Amari took a deep breath.
“Are you familiar with the New Testament?” she asked. The girl nodded. Amari continued. “So you know that Jesus healed the blind with his touch. But it wasn’t the only way he did it. You’ve read that he mixed his saliva with sand and helped the blind man see that way? Jesus used medicine.”
“Huh,” said the girl. “That gives me something to think about.” She sounded as if she meant it.
“Nice story,” I said to Amari once we were in the hallway.
“What religion are you?” she inquired. It was a question rarely asked in my parts of the city, where a weak agnosticism was the polite thing to presume—if sometimes incorrectly. In East Flatbush, God was paramount, one more thing distancing me from the worlds inhabited by many of my patients. With a shrug I told her I was Jewish, because that is what I was, Jewish-with-a-shrug.
She said, “I’m a Christian, and I believe in healing. I’ve had experiences with it. But these religious men who tell their congregants not to take their pills are criminal. When they’re sick, they rush right to the hospital and take whatever their doctors prescribe, but it’s not what they preach.”
Amari and I climbed a flight of stairs and emerged onto another high-gloss floor with pale yellow on the walls to see our second patient of the morning, a woman with MS. The brief reasoning scrawled on the consult paperwork was “crying.” When we got to the woman’s bedside, she explained that she’d gone temporarily blind on the subway, spending an hour just sitting in her seat, nervously waiting for her vision to return. Upsetting as this sounded to me, what had really done the woman in was that her husband—who despite their fifteen years together knew little about MS—did not believe her and was certain that her lost hour had been spent in the throes of passion with another man. This made more sense once she told us that she had five kids, the youngest of whom had a father who was not her spouse. Still, by the time we got there, her neurologist had already spoken to the wary man and assured him that his wife had indeed been struck temporarily sightless. Things seemed to be looking up.
“So how are you doing now?” I asked her. Amari had instructed that I should lead the consult.
“Wonderful,” she said. “My sister is planning a family reunion. My siblings stopped speaking when my mom died a few years ago, so it’s very exciting.”
It seemed an odd thing to say given the circumstances, but was it psychiatrically odd? Was she being tangential or just cooperative? I thought: Doesn’t she know why we’re here? But then I realized that I didn’t quite know why we were there. “Crying.” We established that she was employed, that she had deep attachments to her friends and family, and that she experienced only passing difficulty with her multiple sclerosis. Other than the tears, which were momentary and understandable, there seemed no reason to suspect she was any category of depressed, which was probably the diagnostic category most closely related in her doctor’s mind to “crying.” We wished her good luck and went to make a note about the consult in her chart.
As Amari was writing, the pager buzzed. She picked up a phone and called the CL office. Dr. Jonas, one of the attending psychiatrists I’d seen at the morning meetings, wanted us to meet her on the cardiac care unit to watch her assess for decisional capacity. Amari hung up and delivered another explanation in her weary tone. “One more reason doctors call us: when patients don’t want to take their advice. If someone doesn’t take their advice, they’re obviously crazy and in need of a psychiatric consult.” She rolled her eyes again. If her eyes were her abs, she would’ve had a rocking six-pack.
We dashed down the stairs. I loved all this running from place to place. It made me feel so unquestionably useful. Side by side we descended to the cardiac care unit. The space was big and airy with glass-walled rooms and doors that slid open automatically. Dr. Jonas met us at the front. She was in her sixties and stylishly dressed. She spoke brusquely and only to Amari, as if I were not there at all. “Seventy-eight-year-old male insisting on discharge against medical advice. He had a heart attack a few days ago, and his doctors want to insert a stent. He doesn’t want it.”
“So how do we establish whether or not he has capacity?” I asked into the air. Maybe I was not supposed to look at someone so resolutely not looking at me?
Dr. Jonas nodded toward Amari, who explained: “Generally, the patient has to show us that he understands the procedure, why it’s being recommended to him, and the potential risks and benefits. With this patient, since he’s saying no to a procedure rather than consenting to one, we want to make sure he knows the consequences of leaving the hospital without having it done, and we want to document that he knows.”
The two of them went together to the patient, and I followed along. From his bedside hung a bag swollen with urine, and it made my stomach turn. I had not gone into psychology to deal with bodily fluids. The man in the bed was a youthful seventy-eight. He was olive skinned and lively, with nails like a lady’s. Dr. Jonas greeted him and asked if he remembered talking to her yesterday. “Of course,” he replied, looking down his nose to show his disregard for the question. I’m not crazy.
His physician joined us by his bedside. She was young and Latina, with a bleached-blond streak in the front of her dark curly hair and two silver rings on each of her thumbs. Later Amari would tell me that she was in a band. While we listened in, the doctor explained the risks of the stent procedure: localized bleeding fr
om the catheter, kidney problems due to the dye, a bad reaction to anesthesia. “But none of these are likely because they didn’t happen with the last stent,” she emphasized. Apparently, they had a history. She continued with the benefits: the blockage in his artery could be cleared, reducing his risk of having another heart attack, which, she said, was almost inevitable without the stent. Her voice faltered on the last part. His refusal obviously pained her.
The patient cut in: “I’ve already told you I won’t do it! I’ve got something to take care of first, some business. I don’t want to talk more about it, because it upsets me. I’ll have the procedure in a month or two.” He folded his arms over his chest with a dramatic harrumph. Dr. Jonas asked him to explain the possible benefits of the procedure and the possible consequences of its refusal. He iterated both clearly. “I know I could drop dead without it. If that happens, it happens. We’ve all got a number. If you think you don’t, you’re nuts!”
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