A History of the Present Illness (28 page)

¹
After sixteen phone calls and hours of research; this isn't exactly a transparent process, is it??

²
Yes, this is the third time I've sent this proposed diagnosis because I have yet to receive even a standard-issue form letter by way of reply, and although I realize you're both at that post–traumatic stress disorder conference in the Caribbean, I checked online and know for a fact that your hotel has Internet access. The recent unjust and all-too-publicly exaggerated charges against me notwithstanding, I keep asking myself how an entire committee can simply ignore a well-articulated, life-and judgment-disrupting diagnosis? A diagnosis, I might add, that bears both accurately and acutely on the suffering of an undervalued and often unfairly penalized segment of the population, namely those almost invariably female and often also otherwise marginalized people who are and always have been disproportionately overrepresented in poorly remunerated and oftentimes dangerous jobs that require enormous emotional and temporal investments at equally enormous and not infrequently devastating personal costs. (Costs, I might add, that may explain why this majority segment of the population is represented on your committee only by Drs. Georgia Brown and Ethel Liu—there's a word for their role, the noun of which used to get a person onto ferries and buses.)

³
Noemi Kadish-Luna, B.S., M.D., M.A., M.P.A./H.S.A.(c)

⁴
I'm not sure
cluster
is the best word choice here, given that when the average American hears that word, she or he will likely have a mall-and/or holiday-based association to that increasingly ubiquitous and tooth-decay-inducing bite-size morsel, the pecan cluster, which, if you think about it, is what? Well, a cluster of
nuts
, of course, which I know is not the message you want to be sending, to say nothing of the other sort of cluster that might appear in people's (especially women's) minds when confronted with the image of a group of mostly middle-aged, mostly white, mostly male doctors sitting around a meeting room in some fancy hotel casually critiquing and summarily pathologizing people, many of whom are not middle-aged, not white, and not male, and most of whom are (for unclear reasons) not present while, between sips of Seattle's Best and bites of poached salmon with endive salad, the aforementioned middle-aged, mostly white males discuss nothing less than the very personhood of the un-and underrepresented absent majority. (Hint: it's a two-word phrase and the second word is
fuck
.)

⁵
Final digit dependent on number of new diagnoses accepted (see other potential Cluster B additions in footnotes 15 and 16 below). And in case you're wondering how one person comes up with so many apt solutions to the DSM's glaring (if publicly unacknowledged) deficiencies, the answer is simple: I don't just drop into the real world from my ivory tower for one or two half-day sessions a week; I actually live there.

⁶
I wish!!

⁷
I often find it helps to put a face to a diagnosis, so let me just mention here that for several years I practiced primary care psychiatry at the South of Market Community Health Center here in San Francisco, working fourteen-hour days while meth heads (active clients and a former employee, according to the police reports) broke into our on-site pharmacy, depleting our already inadequate supply of cold medicines and painkillers, and other criminals (guys who were probably also our clients) took apart my car, a maroon secondhand '86 Honda Civic with VOTE VEGAN / GIRLS RULE / DIVERSITY / NOT EVERY SPERM NEEDS A NAME / DOGS FIRST! stickers artfully arrayed on the back bumper. The Civic was all I could afford on what they were paying me at SMCHC and certainly wasn't much to look at even prior to its broad-daylight dismantlement, and yet its loss precipitated the single instance in which I wondered whether, rather than pursuing a life in the world of mental illness, I instead should have followed the leads of my friends who went into specialties like dermatology, pathology, radiology, and cosmetic surgery and who, since finishing training, have wed, slept late on weekends, traveled, and had children. Actually, to be perfectly accurate, while all the men have enjoyed these myriad fruits of their well-chosen professions, only some of the women have, and they were either those perfect ones who could do everything well, or the slimy types who gave up their careers without a single backward glance upon the first sign of their successful impregnation, as if doctoring had been for them nothing more than a loop in the holding pattern of their trajectory toward marriage and motherhood. (I can't resist digressing a bit here to comment on the irony that it was the members of what I think of as the M.D.-Mrs. contingent who criticized me most strenuously when that whole business between me and a certain postdoctoral pharmacy student—not under my direct supervision, not even from the medical center with which I have an affiliation—made the papers, even though easily two thirds of the published account was an obvious and blatant distortion of the facts conjured by the press to justify their lurid, bold-type headlines and sell this first-rate city's second-rate rag.)

⁸
I must admit here to not only the expected psychic
Sturm und Drang
but also to actual physical pain (occipital, primarily) when I learned I hadn't been invited to participate in the diagnostic revision process, particularly since (recent events notwithstanding) no current committee member has credentials remotely equal to my own.

⁹
You're so pretty
, Mike Reed, M.A., Pharm.D., said to me his first day at the SMCHC, as if looking at me were akin to gazing upon the idyllic (and perhaps imaginary) Hanging Gardens of Babylon or some other largely inaccessible and supremely exotic global trea sure and he felt fortunate beyond his (admittedly limited) powers of verbal expression to have the opportunity to gaze upon my corporeal self while clarifying one of my orders or less than optimally legible prescriptions. And the next week, just after my supervisor suggested (using his favorite deceptively quiet but devastatingly harsh voice) that I try a little harder to stay on schedule, Mike added,
You're so sexy
. And then,
I've never met anyone like you
. And also,
You know you're the smartest doctor I've ever met, don't you?

¹⁰
C'mon
, Mike said later that same day (and on several subsequent occasions in the weeks prior to our discovery, his firing, my suspension, etc.),
I really, really want you and there's no one in the med room
.

¹¹
I 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.

¹²
No 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).

¹³
Mr. 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.

¹⁴
Three 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.

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

¹⁶
Ditto 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???)

¹⁷
Contrary 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).

¹⁸
Anyone 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.