Monday, December 08, 2003

On Quitting

Anticipating a long wait, I brought a book to my last xray and doctor appointments. As I had to walk a quarter mile from the Brigham to the doctor's office carrying a hefty packet of CTs and MRIs, my criteria was that the book be small enough to fit in my coat pocket. I grabbed a ancient paperback edition of Bruno Schulz' The Street of Crocodiles from my bookshelf, one I had bought in Chicago 25 years ago.

Later, when I opened it in the waiting room, a piece of yellowed paper fell out -- a bus ticket receipt: Trombly Motor Coach, Boston to Andover, 9 06 78. I stared at it in wonder. It didn't take me long to figure out where I'd been and where I was going on that day.

Today, looking at the receipt, I note the slogan: "Where you go is your business. How you go is our business." There's a slightly disreputable, complicit ring to that slogan, as if the company were perfectly content to ferry murderers to their victims or safecrackers to the bank vault -- as long as they were kept blissfully ignorant. Don't ask, don't tell.

So what was my business on September 6, 1978 ?

It was disreputable.

I was escaping. On the lam.

I've noticed that, twice, someone has found my blog via a google search on "quitting residency." I felt a pang of absolute empathy for what I imagine to be a miserably unhappy resident or intern, contemplating the unthinkable. Mon semblable, mon frere. Or ma soeur, as the case may be.

I began a residency in psychiatry in Chicago in 1978. It was a disastrously wrongheaded, ill-thought-out, neurotically fucked-up move on my part. Totally gonzo. Off the charts. If I had set out to make a bad choice -- medical school -- worse, I could not have picked a better method. I wasn't crazy about medicine. I'd hated internship. Psychiatry seemed a lot like poetry and literature. So I'd seek asylum there. I'd forgotten about one small thing: psych patients.

I could not have been more unhappy. I was, to start with, extremely homesick. This was compounded by the fact that, instead of beginning at the University with my fellow residents, I was sent across town -- to the old slaughterhouse district, I swear -- to a grim joint called ISPI, a heavily research-oriented state hospital, the Illinois State Psychiatric Institution. So I had no chance to bond with my fellow residents -- a task that, even under the best of circumstances for this shy recluse, would have been difficult.

There was a relationship, too. There's always a relationship. It came apart and came together several times over the two months I was in Chicago. The fella back home came to the windy city several times. I sent him away and resummoned him several times. And eventually married him, had a child with him, and divorced him but that's another story.

Last, and worst, there was night call. Which meant being the first doctor summoned to the ER when a psych emergency arrived. I felt utterly unsupported and unprepared. I didn't know the staff on the psych ward where I'd be admitting patients. I barely knew where the ward itself was. I'd done a year of internship, and could handle post op fevers and congestive heart failure, but psych was a whole new gig.

Like any new resident, I was green. Probably greener than most. Virtually clueless. I vividly remember consulting the neurology service one night on a patient who was probably catatonic. The resident who responded was peremptory, scornful and abusive. This was not, he lectured, a neurological case. It was clearly psychiatric. How stupid could I possibly be ? I can still feel the sting of it to this day. A teaching hospital at its best.

The other ER patient I vividly remember was more colorful. Literally. She wore a purple feather boa, honest, and shiny silver stockings. She clung to the arm of the (male) ER resident, fawning crazily and seductively over him, and glared at me with undisguised hatred and hostility. (My over-fed mind whirred: Borderline personality disorder. Often histrionic. Engages in splitting of the world into good and bad. Lack of fusion of the internalized imagos of good and bad mothers. Often characterized by self-mutilation and suicide gestures.) OK, fine. But now what ?

Fortunately for me, while I was spinning my Freudian psychodynamic wheels, she eloped from the ER. I prayed she would not return. Great case, eh ?

There was another sharp-tongued, young, long-term patient on the ISPI chronic ward, who also instantly had me pegged (my deer in the headlights demeanour was not subtle) as an easy mark. I remember her acid ridicule of my "little flat shoes." Foreshadowing by several decades the Hannibal Lecter/ Jodie Foster interaction in Silence of the Lambs.

I was no Jodie. In fact, Henry, a tactless colleague at ISPI, went out of his way to tell me I reminded him of Sylvester Stallone's girlfriend in the Rocky movie: the girlfriend before she became glamorous. The painfully shy, bespectacled woman in a wool hat and a dowdy coat. And that maybe I should take dancing lessons. Or something. Thanks a bunch, Henry.

Yes, night call was sheer terror. I'd begin dreading it days in advance. On call I would sit, hyperventilating, praying my pager would not go off, in an office I apparantly shared with Dr S.. There was no evidence of me in that office. It was full of her tasteful objets d'art and memorabilia. I felt like a trespasser.

Dr. S. had once been a classmate of that hyphenated chick, Dr Kubler-Ross: there was a framed photo of them together amidst Dr S's tasteful baubles. I was so so paralyzed by fear, that I spent one on-call night curled in fetal position on Dr S's sisal carpet attempting to sleep.

All that summer I was reading esoteric books on existential analysis, psychoanalysis and phenomenology -- books mostly over my head, and of no use whatsoever in the midnight emergency room. I reread Camus' The Plague. Read lots of Binswanger. Merleau-Ponty. Simone Weil. Neruda. Harry Stack Sullivan. Sigmund Freud. Anna Freud. And, of course, Bruno Schulz.

None of this prepared me to assess and/or treat psychosis in the ER. None of it helped me understand my own distress.

So, one afternoon in mid August, after days of agonized hand-wringing and vacillation, I left. Eloped as abruptly and completely and illicitly as my feather-boa'ed ER patient had from the ER. I can still recall the sense of absolute freedom and relief I felt as I took a train, then a bus back to Massachusetts. I left, telling no one, not even the director of the program, until I'd arrived home.

He persuaded me to return. Chastened, I did. They made some "helpful" changes. Nothing helped. So, on September 6, I once again fled back east, by plane, then by the infamous Trombley "where you go is your business" Motor Coach.

This time the director had no problem accepting my resignation.

Quitting a residency is a Very Bad Thing. It leaves the remaining residents, already overworked, with all the more nights of call and patients to cover. Sometimes new residents can be recruited, sometimes not. It's a huge blot on one's resume. It's a very harmful and destructive act, and I did it in the worst possible way.

The feeling of exhiliaration and relief I felt was indescribable. It was a moment of Pure Bartleby, my first and most breathtaking. There have been other, lesser ones. But this was the spectacular refusal.

Sixteen years later, when I was finally finishing training in internal medicine, two residents left our program. One simply never returned from a west coast rotation, another was asked to leave. We all had extra call, and extra patients.

Yes, Virginia, there is a karma clause.

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