The .Plan

Alcohol is such a terrible, terrible drug. It can eviscerate our families, deaden our souls, and reduce our brains to mush. Through the eyes of my patients and my patients’ families, I see so much of the damage it can do to our lives that when I read Philip Yancey’s latest column, for a brief instant I thought to myself, ‘how can he be so insensitive?’

Paul follows Jesus’ logic in the Sermon on the Mount: murder and adultery differ from hatred and lust only by a matter of degree. Indeed, the flagrantly evil person has a peculiar advantage of sorts: an inner gyroscope of conscience that registers a sense of being off course.

I once accepted a speaking engagement among Christians involved in Twelve Step programs such as Alcoholics Anonymous. As I talked with the attendees and pondered what to say, I finally decided on the ironic title, “Why I Wish I Was an Alcoholic.” It occurred to me that what recovering alcoholics confess every day—personal failure, and the daily need for grace and help from friends and a Higher Power—represent high hurdles for those of us who take pride in our independence and self-sufficiency…

Unless we accept the grim diagnosis, we will not seek a cure.
–Philip Yancey, “The benefits of brokenness”, Christianity Today, May 27, 2008

But then I realized that that is the gravity of the human condition. The blind spot is so deadly to our souls that an ironic title like “Why I Wish I Was an Alcoholic” could be an appropriate title for a talk given at an AA meeting.

It was a sobering realization.

On some days, the mental health care system is overused. I’m convinced of it. We overdiagnose, overmedicate, and overtreat.

Ms. Smith [*] is a 25 year-old woman with the signs and symptoms of schizophrenia. Unlike some of my patients with the diagnosis, she’s not wild-eyed, overweight, diabetic, and addicted to drugs. She more closely resembles the people in the pharmaceutical advertisements — slender, smiling, and ‘normal’-looking — except she’s Chinese and has plucked and tattooed eyebrows. Like many of my patients with the diagnosis, her family life is a mess. But in Ms. Smith’s case, her father is a sexual predator. As sad as it may sound, the hospital is probably the safest place for her.

Today I had to discharge her from the hospital because she was no longer sick enough to warrant continued hospitalization. Although we tried to find her somewhere else to stay, she insisted on going home. And there was no way we could compel her to accept an alternative disposition, because she refused to press charges against her father.

On these days — the worser days — the mental health care system is frightfully underused. I’m just as firmly convinced of it. Our patients reject our help, therapy takes too long to achieve lasting change, we miss diagnoses, and alcohol and methamphetamines pose barriers more powerful than any medication we can prescribe. And despite our best efforts, we often can’t protect the most vulnerable.

As I got into the elevator, I started up my iPod. Despite its hopeful message, the music seemed stale in light of the day’s events. Walking out of the building, I saw Ms. Smith and her father standing on the sidewalk, waiting for the bus. A cigarette dangled from his mouth. She stood there mutely, turned towards him as she stared woodenly down at the ground. While she cradled an open bag of Lay’s in her arms, he helped himself to a potato chip, dropping a few flecks of ash on the sleeve of her coat.

I wanted to punch him in the nose. But instead I leaned into the wind and walked by.

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[*] All names, dates, and other HIPAA non-compliant details have been confabulated.

A few months ago, Lori Gottlieb published an essay in the Atlantic Monthly (”Marry Him! The case for settling for Mr. Good Enough“) urging single women in their 30s to “settle” [*] rather than holding out for Mr. Right. She starts from the observation (which may or may not be true) that

every woman I know — no matter how successful and ambitious, how financially and emotionally secure — feels panic, occasionally coupled with desperation, if she hits 30 and finds herself unmarried.

and then proceeds with the exhortation:

Settle! That’s right. Don’t worry about passion or intense connection. Don’t nix a guy based on his annoying habit of yelling “Bravo!” in movie theaters. Overlook his halitosis or abysmal sense of aesthetics. Because if you want to have the infrastructure in place to have a family, settling is the way to go. Based on my observations, in fact, settling will probably make you happier in the long run, since many of those who marry with great expectations become more disillusioned with each passing year. (It’s hard to maintain that level of zing when the conversation morphs into discussions about who’s changing the diapers or balancing the checkbook.)

At the time, her essay generated a very negative visceral response from me. I dislike Gottlieb’s essay not because of her controversial exhortation — because, as I will explain further, I find some degree of truth to it — but because I think her starting point is a disordered set of fundamentals. Her idea of “settling” has to do with lots of incredibly trivial things. She shows appropriate restraint in that she recognizes that these are in fact fairly trivial matters, but she is at the same time demonstrating a self-centeredness that bodes ill for her future marital bliss (should she ever decide to ’settle’). The marriage she desires (whether the romantic ideal or the realistic consolation) and describes is all about her, her child, her stability, and ultimately, her happiness. The Aquinian, however quaint, notion of love being “to will the good of the other, for the sake of the other” is largely absent.

In some ways, Gottlieb is nibbling around the edges of the truism that our preferences are naturally disordered and that marriage is not just about romance. Stanley Hauerwas is fond of teaching “you always marry the wrong person“. If you are able to get past the deliberate, obstreperous, Hauerwasian provocation in this statement, then you can see that there is a lot of truth to it. After all, how does an unattached person, reared in a culture that accepts and promotes the efficiency of short-term commitments, develop any kind of concept of what it means to form a covenental bond that gives you the practice of monogamous fidelity over a lifetime? Rod Dreher — a fellow Louisiana School alum — commenting on the Gottlieb article at his Crunchy Con blog, elaborates on this theme, accurately [emphasis mine]:

Julie and I, married 10 years now, talked about this last night. We didn’t reach any hard and fast conclusions, but we agreed that married-with-children life is way more difficult than single people realize, and that the things that make for an exciting boyfriend or girlfriend don’t always make for a good partner in a lifelong marriage with children — but that’s something that’s very, very hard for single people to understand. You couldn’t possibly have explained it to me as a single man before I lived it (nor could you have explained the intense joys of childraising).

This is consistent with what my married friends tell me. The daily process of observing the Markan call to die to your self sounds like it is fairly difficult, and somehow I don’t see Gottlieb advocating this.

If I accept Gottlieb’s foundations, I can see how it would make sense to sign up for Internet dating sites such as match.com and eHarmony.com to assist with my search for a spouse. All I have to do is pick a set of characteristics that I believe will maximize my happiness, fill in the checkboxes, see who fits my profile of Prince Charming or Princess Lucinda, and then it’s off to the races. Even if I don’t know myself well enough to complete such a task — or if I am afraid of the miserable choices I seem to make — then I can go to eHarmony.com, fill out an exhaustive battery of questions, and see who fits my personality profile.

Leaving aside for the moment the question of whether one should participate in these ventures (for more on this point, please see Brother Warren’s takedown), there is plenty of research to suggest that they don’t even really work.

But what bothers me most about these approaches is that they assume a very self-centered, pre-specified, and fixed personality or set of preferences, and they ignore the importance of attachment and commitment.

An analogy from my own life might be instructive here. When I was thinking about applying to medical school, I had no idea what being a physician would be like. Working in hospice provided me with the opportunity to obtain a very brief glimpse at only two or three aspects of doctoring. Yet I made a decision to apply. When choosing among medical schools, my only sources of data were a series of one-day interviews and incredibly over-hyped data from the U.S. News and World Report. A priori I think it would have been a stretch to characterize any one of my potential medical school choices as the best one for me. In truth, because I was sufficiently lacking in direction, and because I’m fairly open to new experiences, I’m quite certain that any one on my shortlist would have been a reasonably good match for me and could have provided me with a nurturing environment, intellectually, spiritually, and socially. In the end, I decided to pick one, but I had no accurate idea about whether the medical school I chose would make me a “better” doctor than any of the other schools on my shortlist.

In retrospect, I now see that I incorporated a great deal of faulty data into my decisionmaking process. Nonetheless, things turned out okay — better than okay, in fact, and now I can say without a doubt that I picked the right medical school. But I don’t know that the school I chose was necessarily a priori the best choice. Whatever preferences I had as a college junior have been completely remade in the years since then, and most of my misconceptions have been corrected — so much so that I probably couldn’t even accurately describe what my preferences were in the first place. Key to this outcome, aside from living under the shadow of God, was the process of growing into the commitment I made to become a physician. Because I created and participated in a particular history, because of the ways in which I grew into my decision — the experiences I had were such that I cannot imagine what my life would now be like had I gone somewhere else. Given this particular history, I’m left to conclude that the school I chose was “The One”.

The analogy can be carried too far, but my fundamental point stands: that love is a creature of history and commitment. In his book The Four Loves, C.S. Lewis elaborates his taxonomy of basic human loves. Affection — in contrast to friendship, erotic love, and love of God (and clearly the borders between the four are hazy and not impermeable) — he describes as “warm comfortableness”, “responsible for nine-tenths of whatever solid and durable happiness there is in our natural lives”, a love that “can unite those who most emphatically , even comically, are not [made for each other]“. He continues:

In my experience it is Affection that creates this taste, teaching us first to notice, then to endure, then to smile at, then to enjoy, and finally to appreciate, the people who “happen to be there”. Made for us? Thank God, no. They are themselves, odder than you could have believed and worth far more than we guessed.

We don’t evaluate love in a vacuum. Though sometimes we contemplate it dizzily while fluttering home one evening — even when we are not so deeply entangled in it, we contemplate love in the context of history. It bothers me that we are being fashioned by the world into a people that defaults to thinking under consumeristic models of relationships. Doing so leads us to divorce characteristics of persons from the unfolding narrative of our lives together, and it — falsely, I think — makes sense to say things like, “I like her because she likes cats”, “I like him because he can lead me in the tango”, and so forth. My participation in an Internet dating site like match.com would only feed this deranged propensity by allowing me to specify all of the characteristics I want as well as those I am not willing to accept. But it seems to me that such characteristics cannot be contemplated abstractly, disembodied from the object of one’s love. Properly viewed from within the context of the intertwined lives we live in the Body of Christ, they simply cannot be bought and sold and traded off for one another.

I am not arguing that we should be rolling the dice, consulting magic 8-balls, and just picking spouses more or less at random and relying on commitment and fidelity to get us through the next 50 years. Marriage sounds difficult enough that we probably need every advantage we can get. For this reason, I do believe we should think carefully about what our dealbreakers are vs. what are our soft preferences that can be accommodated (perhaps with training) over time and eventually overcome. This sort of question extends naturally to guys who are widowers and women who have been widowed; alcoholism, drugs, and pornography; emotional baggage from prior relationships and/or sexual partners; infertility; and so forth. Thus, the “settling” I have in mind has very little to do with whether he appreciates Jane Austen or whether she likes beagles; it has to do with whether she and I can together have the love and commitment to sustain a marriage despite all of this stuff — or whether I am compelled to go chasing after the next shiny new make & model of car who has yet to accumulate such baggage (i.e., whose baggage accumulation process has simply been deferred to the future). But I don’t really think of this as “settling”.

In the end, I think Gottlieb is groping towards an adult concept of love, but she hasn’t quite made it all the way. She writes of “settling” as if it were an entirely negative concept, that we shouldn’t drop people we date from spousal consideration just because of minor differences that can likely be worked out in the long run. Realism does require this kind of understanding. We make the commitment to love despite trivial differences in compatibility because our feelings for the Other are deep and abiding. But Gottlieb isn’t writing about being realistic. She abandons the concept of love entirely and simply replaces it with a hard-nosed tolerance. Hers is a rather thin view of marriage. I’m a realistic idealist, and I’m not yet ready to give up on marriage and love. It should be about accepting the flaws in someone I have come to love — not simply dispensing with love for someone whom I grudgingly accept.

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[*] There is a technical rewording of Gottlieb’s recommendation, derived from my better cousins the mathematicians. This problem is known as the “Secretary Problem“, or the “Fussy Suitor Problem”: suppose I want to find the best match out of a group of N  women. Assuming that applicants who were previously interviewed cannot be recalled, then the decision rule that maximizes the probability that I locate the best match is: after the first N  / e women (where e  is approximately equal to 2.71), I should just pick the next woman in line who is better than the first N  / e women I dated previously. For example: suppose there are 100 women in my dating pool. I can’t date them all, and if I did then that would eliminate them as spousal possibilities. I should then just date 100 / 2.71 = 37 of them, and then stick with the next woman I date who is better than all of the previous 37. In the limit, i.e., if the eligible dating pool is N  =1,000,000, say, then the probability that this decision rule yields the best match converges to 1/e  = 36.8%.

There are a few noteworthy observations to be made here. First, the secretary problem assumes away opportunity costs, when in reality the composition of the dating pool is not static — and the implications of this are asymmetric, gender-wise, as illustrated in the XKCD comic above. Second, the secretary problem assumes that every secretary applying for a job would accept the job if offered one. Third, because the composition of the dating pool is changing and because not every secretary would accept a job if offered one, by extension the pool of secretaries who would accept a position if offered one is also changing.

I.

Checking my office voice mail is quite possibly my least favorite activity. Walking into my office every morning and seeing that flashing red light indicator now reliably triggers in me an acute stress response every time I see it. It’s like opening up the now-proverbial box of chocolates. You never know what you’re going to get.

Message — received — at — 6:07 — PM.
“Dr. Smith [*], this is Bill Smith. Calling you about my daughter, Betty. Could you please give me a call back? My phone number is 333-3333. Thank you.”

II.

Sometimes the frequency of an event is so rare that the occurrence of that event provides very little information regarding the underlying data-generating process.

Take, for example, death in the 30 days following coronary artery bypass graft surgery. Policymakers interested in comparing the quality of care between hospitals might rank them according to their 30-day mortality rates, using logistic regression modeling to adjust these comparisons for a host of variables that might plausibly explain pre-surgical differences in propensities of death.

The problem with such an exercise, however, is that few hospitals undertake large volumes of CABG surgeries. And since the overall mortality rate is so low, the actual number of mortality events is small. Comparisons of risk-adjusted mortality rates, then, are plagued by extremely wide confidence intervals:

In the diagram above, the ‘best’ hospital, all the way on the right, clearly looks better than the ‘worst’ hospital, all the way to the left. But how does one differentiate among the mass of hospitals in the middle in terms of the quality of care they provide?

III.

Message — received — at — 7:01 — PM.
“Hi Dr. Smith, this is Bonnie. I don’t know what to do, I think we have to take my sister to the hospital, can you call me when you get this message? My cell phone is 222-2222.”

IV.

People die all the time in the hospital. In a busy academic medical center, where the acuity is particularly high, you become inured to the dying. Even when things go terrifyingly nuts, it still seems somewhat manageable. You just kind of tell yourself, ‘the antibiotics didn’t work’, ‘we did what we could’, and move on.

In the setting of a psychotherapeutic relationship — even in an acute, short-term setting like the psychiatric ward — the physician has no such comfortable retreat. When you make the judgment call that the acute phase of treatment is complete and your patient is ready to go home, and then she goes and commits suicide the very next day, you don’t get to question the antibiotics. You question yourself. Because the psychotherapist herself is the therapeutic tool.

But suicides happen so infrequently that you have no way of knowing whether you are the outlier all the way on the left side of the graph, or whether you are somewhere in the middle of the pack. There is just not enough information about the underlying data-generating process, and your insecurities all come bubbling up to the surface.

V.

Message — received — at — 11:15 — PM.
“Hi Dr. Smith, this is Bonnie. I’m calling from the ER now. Betty took all of the medicines you gave her, all at once. When we brought her home yesterday, everything seemed fine, I don’t know why she did it. The doctors are taking her to the ICU. Can you call me back tomorrow when you get in?”

Acuity on the inpatient ward has been high as of late.

In the span of two weeks, I

• surpassed my previous record of volume of serotonin- and dopamine-hammering agents prescribed to a single patient,
  
• received an invitation by an extremely attractive drug rep to do some consulting work for her employer (curiously, immediately after delivering a withering grand rounds talk that properly eviscerated said employer for questionable research ethics),
  
• admitted three acutely psychotic 18 and 19 year-old Chinese college students (all studying at the same local university, but without any social ties to one another),
  
• was invited to dinner by one of their fathers after a family meeting that included one of his apparently marriageable (and non-psychotic, and attractive) 27 year-old daughters,
  
• revealed my own religious background, for the first time, to two patients and one mother, and
  
• had two bouncebacks of patients with florid borderline personality disorder just when I thought I had gotten them out of my hair.

Each of these list items probably deserves its own entry. But the most draining activity by far has been being challenged to sit with a person whose “either-or” thinking leads her to cut or overdose when confronted with the slightest perturbation from her shaky equilibrium. Teaching rudimentary concepts of cognitive- and dialectical-behavioral therapy on the inpatient ward is a deeply frustrating task. But what you dislike most in other people are the characteristics that are most ingrained in your self, right? Lately I have been trying to take some of my own advice to heart. Instead of “either-or” language, I have been training — begging — myself to use the language of “both-and” in an attempt to appreciate the tensions inherent in everyday life.

For example:

Today, I both felt a little isolated while eating dinner by myself and was relieved to have the freedom to experiment with a new technique of stir-frying my string beans.

I felt both frustrated with the nonvolitional late nights of these past few weeks and appreciative of the opportunity to engage in deep self-reflection.

And so on.

“The first time I heard it, I was kind of surprised. It’s not like it was a thought of my own, it was more like a voice. It had an eternal quality to it.”

“What made you surprised to hear it?”

“Well, it happened when I was looking at an electrical socket. And it looked like there were two nails sticking out of it. And that’s when I knew I was supposed to blind myself.”

“Did you want to blind yourself?”

“Well, no, not really. But at the same time, I thought this might be an obedience thing. Every time I looked back at that electrical socket, I kept seeing those nails. Anyway, I went to sleep, but then I woke up again, and I just knew what I had to do. So I went to Walgreen’s, and I was looking for nails. I couldn’t find any, so I bought some needles instead.”

“Needles?”

“Yeah, well, I thought, ‘These are just needles, it’s not the same thing as nails, but it might do the trick’. But then when I was walking home, I saw this rusty nail on the sidewalk. And then the message came that I was supposed to use it. So I took it home.”

“Can you tell me more about what you were thinking at the time?”

“Well, I brought the nail home, and I didn’t really want to use it. I was thinking, ‘What if I get infected?’, or ‘What if I get lockjaw?’, and I didn’t really want to get lockjaw. But the voice was saying, ‘DO THIS AND TELL THEM THAT I AM THE LORD’. So I put the nail in a Mason jar, filled it with water, and then I stretched out my hands to bless it. Then I said, ‘For you and for Christ’, and I felt this energy go out from me. Then I drank the water and stuck the nail in my eye.”

“Did it hurt?”

“Actually, surprisingly, no, it didn’t.”

Ms. Smith [*] was dumped by her board & care at the ED tonight. After being asked by the ED attending to assess her suitability for psychiatric hospitalization, I made a difficult decision to not bring her into the hospital. It was a difficult decision because I think she would receive better care in the hospital than she is receiving at her board & care home, and the hospital social worker could find her a better place; but she clearly did not warrant psychiatric admission, and it would not have been a good use of the hospital social worker’s time and effort.

Then I woke up the board & care operator and spent 20 minutes yelling at her on the phone for dumping off their client in my ED.

Afterwards, I went to speak with Ms. Smith. She was sitting in the corner of her room, shoulder slumped over, looking at the ground, periodically wiping drool off of her lower lip with a napkin.

“I don’t want to go back,” she said. “They don’t want me.”

I crouched down, touched her knee, and said, “But you have to go back. Tonight, at least.”

It all came spilling out — the ways in which the stuttered course of her chronic mental illness had savaged her personal life. Dumped by a philandering husband many moons ago, dumped by a second husband because she could only cook Puerto Rican food, abandoned by her son, dumped at the board & care home by her daughter. And now dumped by her board & care.

“My son’s having a baby,” she said, “and I’m going to be a grandma.” “But he won’t let me see my grandson.” A trickle of tears ran down her cheek, mixing with a rivulet of drool that had accumulated at the corner of her mouth. It quivered under its own weight, then dripped down. She reached up with a napkin to wipe it away.

My pager went off.

She began rummaging around in her purse.

“I know it’s here–”

More rummaging. A few rubber bands. Several wadded up pieces of tissue. A folded receipt for chicken Caesar salad at the Smith [*] Cafe on Smith [*] Blvd. A cheap pleather pocketbook.

“–I think I left it at home. My rosary. This is for you.”

She pressed a crumpled piece of paper into the palm of my hand: a cheap pamphlet, yellowed with age, describing the medal of Mary in the glory of her Immaculate Conception. I glanced at the text: Her feet crush the serpent, to proclaim that Satan and all his followers are helpless before her. It shows her as intercessor, the ray of light from her hands symbolizing the gifts coming through her intercession to all who ask for them…

“I hope I see you again.”

“But not in the hospital, Ms. Smith.”

“Come to Ocean Beach sometime. I like it there. Much better than the zoo.”

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[*] All names, dates, and other HIPAA non-compliant details have been confabulated.

These days are characterized by very little reserve. But whenever I find myself in such a state, I find that talking to my inpatients easily snaps me back to the reality of my embarrassingly blessed life.

“I woke up, put my hand on a broken pipe, got up and stepped barefoot right onto a used syringe, knocked over an empty bottle, climbed over my roommate and nearly slipped in a puddle of nasty-a** vomit. Then I realized that I’m nothing but a piece of sh*t, and I’m never going to have a normal life like everybody else. Wouldn’t you have wanted to kill yourself right then, too?”

Earlier in the morning, Mr. Smith [*] had kicked me out of his room with a loud string of nasty racial and non-racial epithets. At the time, he was not particularly inclined to speak with me about his drug problem.

After lunch, I sauntered on down to his room to see if he might be more amenable to a conversation on a full belly. When I walked into the room, he glowered at me.

“Hi, Mr. Smith.”

He remained silent. Bread crumbs dotted his scraggly, disheveled, unkempt beard. There was a rivulet of coffee dribbling down his chin — or was that milk mixed with the foulness of his lunch? An unappetizing hospital lunch plate sat on the tray in front of him. His left arm, wasted from years of neglect, withered and contractured by an old stroke, lay uselessly at his side. In his right hand, he clutched a half-eaten sandwich as a six year-old would, with mayonnaise squoze between his fingers, bread mashed and pinched.

“Mr. Smith?”

I stood there unexpectantly, my eyes occasionally drifting towards the mayonnaise. At the head of the bed, a large sign: ASPIRATION PRECAUTIONS / HOBUP 45.

Come to think of it, Mr. Smith looked a little ashen. His chest was heaving, but for that much effort I couldn’t hear him breathing.

“Mr. SMITH?”

He wasn’t breathing. And he wasn’t grey, he was blue. My pulse jumped from 60 to about 120 in the next three seconds.

“Are you choking, Mr. Smith?” His pulse was thankfully present. I tried to peer into his mouth, but all I could see was sandwich. His breath was foul. The fingertips of my left hand were coated with sandwich, mayonnaise, and coffee — or milk.

“Nurse, I need a little help in here,” I called into the hallway. Circling around him to the other side of the bed, I leaned over the bed and attempted to put my arms around all 350# of him. Fist above belly button. Thumb inward. Squeeze-pull. The back of his hospital gown was moist and warm, and I turned to the side to get a better grip. My cheek became unpleasantly moist. Squeeze-pull. I tried harder. Squeeze-pull.

Two nurses came in. “Doctor?”

I said — as softly as I could, in order to mask the shrillness of my voice and elevation of my own pulse — “Mr. Smith is choking. I can’t dislodge the food. Can one of you please go call a code?”

My back was beginning to feel uncomfortable. I put a knee up on the bed to get a better grip. It landed squarely in the middle of a yellow stain on the incontinence pad. Squeeze-pull. Squeeze-pull. My knee was wet.

One of the nurses ran into the hallway. The other — a rather youngish one — stayed, and she immediately tried to do chest compressions while I tried to continue with squeeze-pull. squeeze pull. I swatted her away, saying “wait, no no no, STOP! He has a pulse!”

Squeeze-pull.

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[*] All names, dates, and other HIPAA non-compliant details have been confabulated.