by Samuel Shem
It was brilliant, as expected. But how did it help us now?
‘But that doesn’t help you now, ‘cause now you’ve invested, and now you’re trapped. So? So there are many different specialties you could choose. Most of them involve the same close contact you’ve had with patients all this year—touching, being tortured, killing yourself with night call. These are the “PC—Patient Care” specialties. PC specialties will not be considered here. The masochists may leave.’
No one left.
‘I myself am going into a PC specialty, Gastroenterology. I have my reasons. I am a very special case. Where I’m headed, GI is what’s best for me. A rare gift, eh? Right. But the NPC—No Patient Care—specialties number six and only six: Rays, Gas, Path, Derm, Ophthalmology, and Psychiatry.’
The Fat Man listed these six on the blackboard and told us he would list, with our suggestions, the advantages and disadvantages of each. ‘Game theory,’ he called it. This chart would ‘optimize’ our specialty choice.
‘First,’ said Fats, ‘is Rays. Advantages of Radiology?’
‘Money,’ said Chuck. ‘Big money.’
‘Exactly,’ said Fats, ‘a veritable fortoona. Other advantages?’
Aside from the assumed ‘No Patient Care,’ no one could think of any other advantages, and Fats asked for disadvantages.
‘Gomers,’ I said, ‘you do bowel runs on gomers.’
‘Narcolepsy,’ said Hooper, ‘you’re always in the dark.’
‘Gonads,’ said the Runt. ‘X rays can fry your sperm. Your first kid comes out with one eye, two teeth, and eight fingers to a hand.’
‘Terrific!’ said Fats, writing them down. ‘Men, we’re on our way!’
We proceeded to construct a table of the NPC Specialties:
SPECIALTY ADVANTAGES*1 DISADVANTAGES
RAYS Money (100K/annum) Gomers.
Dark offices, narcolepsy.
Damaged gonads; 8-fingered progeny.
Barium enemas and bowel runs.
GAS Money (100K/annum) Gomers.
Boredom punctured by panic.
Astronomical malpractice premiums.
Noxious gases, producing bizarre personalities.
Contempt, daily, of surgeons.
PATH No live bodies. Gomers (rare).
Low malpractice premiums. Dead bodies.
Smell of dead bodies and formalin-type picklers.
Basement office.
Contempt, daily, of all but other pathologists.
Depression.
DERM Money (100K/annum) Gomers.
Contagion.
Travel to sunny conventions. Naked skin—repulsion.
Naked skin—attraction.
OPHTHALMOLOGY Astronomical money (millions/annum) Gomers.
Astronomical malpractice premiums
Opportunity, daily, to torment GAS. Occasional patient care
Surgical internship required.
PSYCHIATRY NO COMERS! Hourly wage.
Never touch bodies except in sexsurrogate therapies Hard on lumbar spine.
Voyeurism, perversion eroticism, autoeroticism, polyeroticism. Multiple accusations from right-wingers. cf. ‘communist.’ ‘queer,’ ‘pervert.’
Easy on feet. Contempt, daily of other doctors except when they are in therapy.
Long lunch hours.
Cure—alleged*2 (many others . . .)
By the end of the Fat Man’s colloquium, the remarkable had happened: on paper, Psychiatry was the clear winner.
On the canoe trip, Psychiatry loomed even larger. Chuck had organized this final intern outing, and one bright, sweet-breezed summer day we signed out to the House residents, loaded the beer, and headed for the shore, into the foothills of the marshland to the tidal river, winding through the grasses to the sea. As we paddled lazily downriver, Berry and I found ourselves in a race with the two policemen for last. Gilheeny, a great red-feathered mallard in the bow, continued to curse his rudderman, Quick, as their listing canoe smacked first one bank and then the other. And yet what could have been better than drifting along, drinking cool beer, listening behind us for the deep carmine baritone of the redhead and the insistent tenor of his mate crooning ‘a lament from the Emerald Isle?’
We stopped on an island for a picnic. In a pine grove dappled with shadow, we found ourselves drawn to Berry. She listened to our discontent; she agreed that the year had been a horror:
‘It’s been inhuman,’ she said. ‘No wonder doctors are so distant in the face of the most poignant human dramas. The tragedy isn’t the crassness, but the lack of depth. Most people have some human reaction to their daily work, but doctors don’t. It’s an incredible paradox that being a doctor is so degrading and yet is so valued by society. In any community, the most respected group are doctors.’
‘You mean the whole thing’s a deception?’ asked the Runt.
‘An unconscious one, a terrific repression that makes doctors really believe that they are omnipotent healers. If you hear yourselves saying, “Well, this year wasn’t really that bad,” you’re repressing, to put the next group through it.’
‘Well, then, my clever woman,’ said Gilheeny, ‘why is it that these fine young men do this at all?’
‘Because it’s so hard to say no. If you’re programmed from age six to be a doctor, invest years in it, develop your repressive skills so that you can’t even recall how miserable you were during internship, you can’t stop. Can a star take himself out of a ballgame? No way.’
She was right. What could we say? We sat, still, absorbed, hushed, as the afternoon shadows inched on. Berry answered some questions about psychiatry, and as we awoke to what she was saying, she turned our picnic into a sort of group session. The theme was loss.
‘What all loss do you mean?’ asked Chuck.
‘What each of you has lost this year. I know it firsthand only from Roy, but I’ve heard about the MORs and RORs and . . . and Eddie’s break and . . .’ She paused, and then, her voice trembling, said, ‘And Potts. You lost Potts. If you felt that loss, you’d still be crying. You’re crippled by your guilt, the guilt of killing off the cherished parts of yourselves.’
In the darkening grove, silence hung somber as a shroud. I felt choked up. What had I killed off? Days like this one, my creativity, my ability to love. Gloom. Stasis. Doom. Finally, with the sun curdling down into the reddening hills, Gilheeny asked softly, ‘These men are wounded. Can anything still be done?’
‘Guilt’s a hot potato—whoever holds onto it gets burned. You’re all doing a slow burn. Give it up. Get mad. Give it back to the ones who infantalized you. Is there a House shrink to talk to?’
There was: Dr. Frank, the psychiatrist at the B-M Deli lunch on our first day in the House. He’d mentioned suicide, and the Fish had canned him. He’d stayed canned the whole year. Why? Returning to the canoes, we floated toward the sounds of oceans, each wondering what had been lost, how this Dr. Frank might help find it, and finally, as the lightning bugs began their dance, wondering how to take this rage and stick it to the ones who’d ripped off parts of each of us, these House Robber Barons, the House Bosses of Loss.
I was on call that night, and arrived from the canoe trip with blistered hands, my drunkenness beginning to hang, preoccupied with what Berry had said, and mad about being back inside the House. It was hot and humid, and my sweatiness brought back memories of the terrifying summer I’d spent as a new tern a year before. Everything had happened. An admission was awaiting me in the E.W. It was to turn out to be extraordinary in that it was to be redeeming. I was greeted in the E.W. by the Pearl, who wanted to warn me about this particular patient, but I wasn’t in the mood and I picked up the clipboard and read: ‘Nathan Zock, 63; bloody diarrhea;? benign polyp.’ No wonder the Pearl had wanted a word with me. Zock, of the MICU Zocks and of the Wing of Zock, which had shut out summer from my on-call room.
Irritated, I entered the room, the Pearl rolling in at my heels. I had never seen so much flesh. Six bovine Zocks,
overinflated flesh balloons, hovered around the stretcher, chomping, sucking, nibbling, snacking, smacking in a tribute to Freud’s oral stage of development. Gems glittering, the Pearl introduced me to Nate Zock’s fat kids, in an effort to herd them away from the stretcher on which Nate Zock allegedly lay. As they edged back, they dislodged a nasty-eyed chalk-voiced macaw of a woman with artificially black hair, who, hearing my name, said, ‘Well, young Dr. Kildare, it’s about time—’
‘Trixie,’ came an authoritative voice from the stretcher, ‘shut up!’
She did. There lay Nate, a rubbery-faced sixty, a bit boozeriddled, but with wealth in his manner and decisiveness in his mien. Even hassled by the herd, he was calm. The Pearl introduced me and left. Immediately I was besieged by the non-Nate Zocks. Everyone wanted feeding, about the diagnosis, prognosis, and the portending emergency: that Nate might not procure the best room in the House. To work on the latter problem, Trixie kept hinting in my ear the name Zock and ‘do you know who Nate is, have you head of the Wing of Zock, eh?’ After being sucked on for about three minutes, I’d had it and said loudly, ‘OK, everyone but Nate, get out of this room now!’ Shock. No one moved. To talk like that to Zocks?
‘You wait a minute, young Dr. Kil—’
‘Trixie, shut up and get out!’ said Nate, and when Nate Zock talked, even other Zocks listened. The room cleared fast. As I began my exam, Nate went on: ‘They’re too fat. We tried, but nothing worked. You know, Dr. Pearlstein told me about you, Basch, he warned me, he said you’re a tough guy, that I shouldn’t try to cross you. Said you’re very good, but straightforward. I like that. Docs should be tough. When you’re rich as I am, people don’t treat you tough enough.’
I nodded, and continuing my exam, asked what his business was.
‘Nuts and bolts. Started with five hundred bucks in the depression, and now . . . millions. Nuts and bolts: not the best, but the most.’
I told Nate that as long as we didn’t do anything much to his bleeding gut, it would probably heal. As I finished, Trixie poked her head in, upset, saying that Nate would get only the second-best room in the House. Nate told her to scram, and said, ‘So what? I always get the best room: nobody visits you in the best room. So I’ll rough it for a night, so what? That’s what happened to those kids: all the time the best, and what happens? Fat. Too goddamn fat.’
789 had had a rough day. Caught in a maze of tests ordered by Olive O.’s Private, Little Otto, whose name still—still!—rang no bell in Stockholm, Sev was discouraged about making any headway with the humps. His first admission of the day had seen Sev and the radiology resident decide that the patient had a lesion on chest X ray, and when he presented the case to me, I dismayed him by quoting a House LAW: IF THE RADIOLOGY RESIDENT AND THE BMS BOTH SEE A LESION ON THE CHEST X RAY, THERE CAN BE NO LESION THERE. Despite Sev’s insistence, the lesion turned out to be the technician’s bracelet, and Sev was crushed. I tried to cheer him, but he’d have none of it, so I gave up. I’d try no more for anyone that night. ‘Sev,’ I said, hoisting myself down from the top bunk to the bottom, ‘I’m going to sleep. I want you to get your scrub suit and change into it now, so that you won’t come barging in here later, turn on the light, and wake me up.’ Through half-open eyes I saw the short bearded scholar strip down, bare his pimply and already flabby body to the neon, quickly and scurrilously slip on his morgue-gray scrub suit, and then pause. I asked what was the matter. After the thoughtful pause so characteristic of him, he said, ‘Dr. Basch, I’ve got several hours’ more work to do tonight, and you don’t. How come you’re always going to sleep, and I’m always staying awake?’
‘Simple. You’re a mathematician, right? Now, I get paid a fixed salary by the BMS no matter how many hours I’m awake. You pay a fixed tuition to the BMS, no matter how many hours you’re awake. Therefore, the more I sleep, the more I earn per waking hour, and the more you stay awake, the less you pay per waking hour. Got it?’
There was pause, and then Sev’s QED: ‘So you get paid for sleeping, and I pay to stay awake.’
‘You got it. Hit the light on the way out, eh, good buddy? Oh, and remember: Nate Zock is not a BMS case. If you talk to him—even say “Hi, Nate” or “Hi, Mr. Zock” to him—you die. Nighty-night.’
I heard the ataxic shuffle of the little polymath, I felt the puzzled look back at me, and then the lights went out, and I slept.
By the next morning, something had changed. A small epidemic had begun. Never in the House of God had there been anything like it. Starting as a murmur, a trickle, a loss seen fullface on a dusk-dappled island, the epidemic spread, and was soon many rivulets streaming around many islands, sounding louder and louder, an ululation of a river against a sea. Suddenly, urgently, five of us terns in the House had become infected with psychoanalytic thought. We had begun to BUFF ourselves for the possibility of TURFING ourselves into a residency in psychiatry on July the first.
Together we five began to study Mourning and Melancholia. We sought out Dr. Frank, who at first was delighted with Eddie’s interest in a psych residency at the House, but who, when four more of us followed suit, ran to the Leggo with the news. We ordered psych consults on our patients, and we attended psych rounds, our dirty whites conspicuous amidst the psychiatric fashion show, our rudimentary questions on anger, loss, and show, our rudimentary questions on anger, loss, loss, and guilt demonstrating our ignorance. At a case conference on an obscure autoimmune disease, Hooper startled us by letting fly a psychoanalytic interpretation based on Freud’s ‘Death Wish.’ Eddie, still racing Hooper down the stretch for the alleged Black Crow, was delighted to find Freud so tight into anal sadism, and developed a facial tic. Chuck grooved on the passive-aggressive personality, and discovering his pathological closeness to his momma while his poppa was reading cowboy novels at work, came out with, ‘Man, it’s amazin’ I ain’t queer, ‘cause everythin’ in my upbringin’ points right to me bein’ a fag.’ The Runt, of course, plunged deepest into the one whom Fats had tagged ‘that red-hot from Vienna’; obsessing about what the hell he’d been letting Angel do to his face, he’d look dazed and say, ‘Holy cow, is there ever something wrong with me!’ I kept on self-analyzing in my top bunk, finding and stashing these pieces of myself.
The day came for our ‘future-plan-Leggo-chats.’ The Leggo had heard of the epidemic and had discounted it. He harbored no doubts about our future plans: the House residency year. With July less than a month away and a year full of residency on-call night slots to fill, the Leggo was a little surprised to hear the Runt, Hooper, and Eddie, one after the other, say: ‘Well, sir, I’m thinking of starting my residency in psychiatry.’
‘Psychiatry?’
‘Yes, sir, on July the first.’
‘But you can’t. You’ve agreed to stay in medicine for your residency year. I’m counting on you, on all of you boys, to stay.’
‘Yeah, but you see, I feel kind of urgent about this. Lotta things to work through, and some things, sir, well, they just can’t wait.’
‘But your contract says—’
‘There is no contract, remember?’
The Leggo didn’t remember that the House had refused to write us a contract—the only way it could legally treat us like shit—and he said, ‘There isn’t?’
‘No. You said we didn’t need one.’
‘I said that? Hmmm . . .’ said the Leggo, drifting out the window. ‘Why, no one doesn’t need a contract. No one doesn’t, at all.’
When Chuck mentioned psych, the Leggo burst out with ‘WHAT!? YOU TOO?’
‘No foolin’, Chief. What this country needs is a high-class black shrink, right?’
‘Yes, but . . . but you’ve done so well so far in medicine. Up from the poverty of the rural South, your father a janitor, to Ober—’
‘Ezactly, man, ezactly. And get this: today I was in my Clinic, and this chick got mad at me and threw this textbook across the table and hit me in the ear, and instead of smackin’ her up side of her haid, I
go: “Hmmm, gurl, you mus’ be angry, huh?” So right then I knew I was gonna think about shrinkin’. I’m talkin’ to Dr. Frank again tomorra about goin’ under analysis myseff.’
‘But you can’t start this July, I need boys like you.’
‘“Boys”? Did you say “boy”?’
‘Well I . . . What I meant was—’
‘Want me to send in Roy now?’
‘Basch? Hmmm. You wouldn’t know his future plans, would you?’
‘Yup.’
‘Psychiatry?’
‘Really.’
‘Yes, well, no, you don’t have to bother to send Roy in.’
And so he didn’t call me then. Despite Berry’s formulation that the Leggo couldn’t help it, that he too had been damaged by the system, I was too angry not to see him as Nixonesque, getting squeezed by us as Nixon was getting squeezed by Sirica and the Supreme Court for the tapes. Couldn’t it have been the Leggo himself, standing with St. Clair on the bow of the yacht Sequoia at Mount Vernon, listening to the ceremony of ship’s bells and the National Anthem, who, when it was over, drunkenly spilled out: ‘They pay you nickels and dimes, but this is what makes it worth it’? Berry was right—it was pathetic. But these pathetic men were powerful men, and soon the Leggo began to pressure us to stay. Through the Fish, at first by insinuation and then by clear threat, the Leggo made it known that to leave in July ‘would seriously—very seriously—jeopardize one’s future plans and career.’ We didn’t budge. The Leggo got more vicious. Vulnerable and powerless, we got madder. As July came closer, all his retaliations having failed, the Leggo began to panic.
None of us knew what he would do.
