Authors: Sara Paretsky
She left the cases in the hall and went back down to the car. She was not an alcoholic, despite Becca’s ill-natured remarks. Just the shock of the man’s totally rude behavior made her want a drink to calm down. And now here was the driver demanding payment in a truly rude fashion. She would have to call her manager and tell him never to use this service again. Come to think of it, she needed her manager to give her an account number to charge the rental to. And her address book was in one of the cases still upstairs in the hall. It was all too complicated for words: Harry would have to pay for the car after all. Maybe for a place to spend the night as well. In the morning she would call New York and get them to wire her any new royalties that had come in on her recordings. Her manager ought to do something for her: she had made his career, after all. She gave the driver Harry’s MasterCard number and told him to collect her bags and take her to the Ritz.
Utilization management is God, and Hanaper is its prophet. This morning paramedics brought in a guy who wanted to launch himself from the sixteenth floor of the State of Illinois building onto the atrium below. He thought he was a chicken and could fly—a secretary grabbed him as he was teetering on the railing. A homeless man who often wanders through State of Illinois building, the medics say.
Hanaper, conducting rounds, was called to emergency room, dragging me along since it was my patient we were seeing when he was paged. The ambulance crew filled Hanaper in on what had happened, told the great doctor they thought the guy was schizophrenic.
H cut them off: “Does either of you have a license to practice medicine? I thought not. I’m the head of psychiatry here at Midwest and don’t need paramedics to make diagnoses for me.”
The homeless man was sitting on a gurney, twitching, muttering, rolling his eyes in panic. Hanaper walked up to him. While nurses and other patients looked on, he bellowed, “You know you’re not really a chicken, don’t you, my man?”
Poor devil, frightened at surroundings, people staring, white man in doctor’s gown shouting in his face, mumbled “no.” Hanaper turned to the paramedics, told them there was nothing wrong with the guy, to take him home.
Paramedics said, man homeless. They didn’t think he belonged on streets, couldn’t look after himself—survives by foraging for scraps in garbage cans. And Hanaper, bless him for consistency, said that proved he knew how to find food.
All this time I’d hovered in the background, part of the scenery like one of the gurneys. But at that point I tried protesting. The meek stammering protests of a resident worried about his job? Or just of Lily’s son, nervous of anyone in authority?
Either way it didn’t matter. H cut me off: “If you are willing to assume financial responsibility for this man, Dr. Tammuz, you may make all the diagnoses you want. If not, let’s get back to the patients we pay you to look after.”
And so on to the dreary round of trying to recommend hospitalizations that are too expensive and therefore unnecessary, or even worse, long-term outpatient psychotherapy. Even the hint of wanting to talk more to a patient brings out the Fear of Freud in Hanaper.
When I accepted this residency, thought of it as great opportunity to learn real psychotherapy on the job. Of course, Dr. Boten was still here then. Didn’t know that he and Hanaper were engaged in great battle over direction of psych dept—the outcome never in doubt as the utilization management team was backing Hanaper. Now Boten is gone, forced to leave, concentrating on private practice. The hospital grudgingly runs outpatient clinic on Weds, afternoons. Group therapies on Friday nights, but they love those—big moneymakers, treating alcoholism among rich overworked businessmen. No room for the kind of patient who needs more than Prozac or a shot of Haldol.
Hector, writing in an upper bunk in the on-call room at the hospital, using a tiny reading light to keep from rousing his sleeping colleagues, put his pen down in sour memory of the day’s frustrations. He and Hanaper had returned from the emergency room to
the ward, where Melissa Demetrios, the senior resident, was waiting with a new rotation of medical students. They had stopped outside the room of a woman Hector had admitted the previous afternoon. A worried daughter brought her in when she found her mother with her possessions piled around her in the middle of the living room, saying only that she was gathering strength for the journey.
Hector recited the bare facts, then added, “Her cat died last month and that seems to have upset her, maybe heightened an existing sense of anomie. I’ve ordered a general workup to make sure she’s not just suffering from a vitamin B deficiency or thyroid problems, but I would recommend talking to her several more times before—”
“Prozac, Tammuz. Have you ordered a trial dose for her?”
“Not until I have a better sense of—”
“Prozac is the recommended treatment for compulsive collectors and hoarders.”
“She’s not really a hoarder, sir; she’s making these clay figurines, at least according to her daughter, or—”
“Writing on scraps of paper, isn’t she, collecting them around herself? Sounds like an obsessive-compulsive disorder. Obsessive-compulsives respond well to antidepressants. Twenty milligrams a day, you’ll find it effective.”
And as Hector stood stubbornly in the hall Hanaper said impatiently, “Have you written that down, Tammuz?”
“I think it’s premature, sir. What if her problem turns out to be—”
“When you’re responsible for this ward you can make that decision. I want her started on twenty milligrams of Prozac. Stat!”
It was typical of Hanaper to punctuate routine pronouncements with medical jargon. Tammuz sometimes wondered if the department head had forged or stolen the diplomas ostentatiously framed in his office, learning the little he knew about medicine from medical shows on TV.
When Tammuz had still not written down the order on the woman’s chart, Hanaper pulled him to one side for a confidential chat, making sure to speak loudly enough for the new students to overhear. “Dr. Tammuz. We have an obligation to cure people as fast as possible. Contrary to your emotional pleas, that obligation is not just to the institution, or our management team, but to the patients themselves. And, really, Tammuz, if you could choose between a pill that solved your problems in ten days, versus an analysis that might take a decade, wouldn’t you choose the pill? Oh, no, come to think of it, you wouldn’t.”
Hanaper gave the students a would-be hilarious account of Tammuz’s interest in—“infatuation with”—psychoanalysis, then swept the group into the new patient’s room, where he informed her with loud cheeriness that Dr. Tammuz would be giving her a pill that would make her feel good as new.
“Not that those big black eyes of his can’t help you, too, eh?” And Tammuz, hating himself, had written out the order.
The woman, from the middle of a nest of torn-up paper towels on which she was writing, said, “I don’t take pills. They’re against my religion,” and went back to rearranging the paper towels.
Tammuz had been unable to suppress a smile. Fortunately he was standing behind Hanaper. Melissa and the students stirred restively, not wanting any of the department head’s wrath deflected toward them.
“I thought her name was Herstein.” Hanaper whirled around to look at Tammuz. “Isn’t she Jewish?”
The resident Jew. “I don’t know, sir: you’d have to ask her.”
“How can pills be against your religion if you’re Jewish?” Hanaper asked one of the other students, not the patient, whom he typically discussed as if she weren’t present.
“It’s in the Mishnah,” Mrs. Herstein said unexpectedly from behind her barricade. “You think you’re an expert on life’s vexing problems, young man, but you would do well to study the Mishnah.”
Hanaper flustered to be called “young man,” promptly takes it out on us. Melissa gets chastised for sending a patient to long-term care without running it past review panel: insurance denied, now what do we do, family may bring malpractice suit if she commits suicide after discharge as Melissa thinks she’s in danger of doing.
A relief to go to afternoon clinic. At least people with anxiety disorders admit they have a problem.
At the end of his stint in the outpatient clinic, Hector tried to slide out of the hospital for a walk along the lakefront. He hoped that half an hour in the May sunlight would wake him up enough to get him through his looming on-call shift tonight. Melissa Demetrios intercepted him as he was heading to a back staircase.
“Dr. Stonds wants to take a look at our caseload,” she said. “Hanaper likes all the residents to be present—in case Stonds blows up we can take the blame.”
“Stonds?” After seven months at Midwest, Hector knew the neurosurgeon wielded enormous power in the hospital, but he didn’t understand why Stonds cared about psychiatry cases.
“Dr. Stonds cares about everything that affects the well-being of Midwest Hospital and its patients,” Melissa intoned, lowering her voice a register in an attempt to mimic Hanaper.
Hector laughed. “Yes—but does he look at all the admissions? When does he have time to scoop out brains?”
“I can’t believe this is the first time we’ve been summoned to the master’s office since you’ve been here.” Melissa looked around to make sure they weren’t in anyone’s radar range. “Stonds’s grandfather—the original Dr. Stonds—was one of the founders of this hospital, back in the 1890s, so the family has always had a lot of clout here. When Abraham—
our
Dr. Stonds—was a neurosurgery resident, neurology and psychiatry were one department, and they learned how to treat ‘diseases of the nerves.’ That’s still how Abraham thinks of mental illness. Somehow he persuaded the hospital to let him review all the neurology and psychiatry cases.”
“Oh, a kind
of droit du seigneur,”
Hector said. “It fits in with the medieval atmosphere this whole hospital exudes.”
“Droit du seigneur?”
Melissa echoed. “Oh, you mean like barons getting to sleep with the peasants’ daughters. I suppose. And he certainly likes to act like a grand seigneur. He lives in baronial splendor on the Gold Coast, in a huge apartment on one of those quiet streets near the Cardinal’s palace. You’ll get invited there for dinner in the summer—he always has new residents in at the end of their first year. His older granddaughter is incredibly gorgeous, by the way, so if you could get her to fall in love with you, you’d never have to grovel to Hanaper again.”
Hector snorted. “Yeah, but then I’d have to grovel to Stonds, which would probably be worse. Or the granddaughter, if she’s anything like him. Is she a doctor?”
Melissa shook her head. “Nope. A lawyer. So the good news is that the Stonds empire will die out with the old man. The bad news is, even if he is seventy-seven everyone says he’s still really sharp in the OR, And he shows no sign of wanting to step away from his fiefdom.”
Melissa’s beeper sounded. She read the number on the display. “Hanaper. Time to grovel. Hector, I know you really believe in psychotherapy, but try not to mention it this afternoon—it will make your residency so much easier.”
Followed Melissa down the hall to join Hanaper and the other two psych residents on our procession to the surgery wing. Don’t mention psychotherapy in discussing psychiatry patients—I’d laugh if it didn’t make me cry. Or the other way around!
Watching Hanaper bow and scrape to Stonds is almost worse than watching him send a psychotic homeless man back onto the streets. Like all bullies he’s obsequious to those with greater authority.
As the new kid on the block I had the privilege of having my work dissected by the Great White Chief. Hanaper brought up what he refers to as my “devotion to outmoded methods,” so Melissa’s advice was all
for nought as I had to explain my belief in nonchemical therapies. Stonds is too full of his own greatness to share Hanaper’s cheap sarcasm over the talking cure, but he rumbles good advice at me.
“In my day, young man, people were infatuated with Freud. They thought analysis would solve any and all psychiatric problems. But just look at the state modern society is in. A direct result of the permissiveness encouraged by letting people find excuses for their problems, ducking personal responsibility. Pharmacology is making important strides with some of these more intractable cases. The important thing is getting people up and working again.”
I said the only thing possible under the circumstances: “Yes, sir.”
Then Hanaper, as a parting joke, brought up my new patient’s comment about the Mishnah. I thought Stonds was going to explode all over us. “These neurotic women who like to sit around reading ancient texts and pretending they know something about life. I don’t want to hear any more about it, Hanaper. Get her out of the hospital. I’m sure someone who’s really ill could use that bed.”
The Great White Chief got up to leave. On his way out said, Oh, Hanaper, by the way, I want you to see someone for me. Hanaper tugs at his forelock: your wish is my command, O King.
Luisa Montcrief, the GWC says. A diva whose family is concerned about her. The Minsky family—they gave three hundred thousand to the cancer research pavilion after old Mrs. Minsky died here of a glioblastoma. We owe them some attention. I told poor Harry Minsky his sister could stop by your office at eleven on Friday.
Naturally Hanaper scrambles to rearrange his schedule, which means we all have to rearrange ours as well since H wants us to sit in, see how you really conduct a patient interview. But putting off our own patients is unimportant. After all, at the name of Stonds, every head must bow, every tongue confess him king of glory.
M
AYBE EVERY TONGUE
in the hospital paid liphomage to Dr. Stonds, but it was a different story in his fifteen-room apartment on Graham Street. Well, yes, Mrs. Ephers, the doctor’s housekeeper (his shadow, his executioner, young Mara muttered), certainly declared the doctor’s glory. Mrs. Ephers had spent her adult life not exactly worshiping so much as building a temple around him, with herself as its high priestess.