Heart Failure - One Flew Into the Cuckoo's Nest

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]


III. PSYCHIATRY - January 5-February 13

One Flew Into the Cuckoo's Nest

Halfway through Christmas break I flash back to the bushy eyebrows of Dr. S - above his mask. I still feel like I want to burst into tears.

I am asked why I'm not leaving Boston for break and getting away. Being home, walking the streets, being outside is getting away. The menorah lights count off my days left.

Four-pointed star

The first day of the rotation I get the rundown. All the patients are manipulative - smiling then just attack you. Awfully skilled liars, I'm told. I bet we're better. Both feet on the floor, lean forward, eye contact, nod appropriately - we are instructed how to maximally look like we care.

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Surgery is over. But it's not. It did something to me. I can't relax. I get up with the same dread. Active expectancy of exploitation and harm, one of the Post-Traumatic Stress Disorder criteria. A Pavlovian response. And this despite the psych hours being good - nine to five with a laid back staff, human expectations. But I rush in my mind to get home - a universal focus. I selfishly hoard my time and then spending it slowly, worrying, overly protective. I want to have it, but then don't do anything with it. Sabotaging myself at every turn.

But I do feel safe enough to argue, my lifeblood. To assert Me. And that's all I need - given sleep - to hold on for another six weeks.

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My attending wears white socks, sweaters and untopbuttoned shirts. A bumper sticker on his wall proclaims "BACK YARDS NOT BACK WARDS for people with mental illness." And no white coat! "I have always wondered why psychiatrists wear white coats," writes the president of the People's Medical Society, "what's going to spill on their $800 suits other than some gourmet coffee?"[95]

He is none the less establishment, though. He proceeds to lay down the rules. "Patients want authority," he says. "Don't show emotion." Our, "eyes shouldn't water." Later, he says they shouldn't, "well up." Could he even say cry, tears? "Don't talk to any patients you aren't assigned to; they like to try to talk to new faces." "Don't give them anything. They'll ask for quarters for a soda or something - and no hugs. Only handshakes. They have to be taught that they can't go around hugging the world."

A few things, however, still bolster hope. For example, a quote in our syllabus: "One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient" - Francis Peabody, Journal of the American Medical Association, 1927.[96]

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On rounds this morning a patient is described as dangerous. Why? I ask. "He files [legal] complaints, creating mischief."

Today they discovered the prostitution ring on the unit. $5. She's HIV positive and the staff wonder if one of the patient's new flu symptoms are more than the flu.

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SHELL SHOCK

Veteran's Administration Post Traumatic Stress Disorder clinic - learning the disease from those who live it. One guy wishes he only had one leg so people could see how scarred he is. Why can't he get close to his wife? "Because when people get close to me they die." When was the other one in Vietnam? "Last night." "I am a 19 year old in a 45 year old body. I'm angry every day." "I did what I was trained to do; here I act like I did over there, an animal." And yet they had army shirts on. A flag in the corner says "Our Cause Was Just" over the map of Vietnam. Just?

Just 2 million murdered?

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Electroconvulsive therapy - shock treatment. Only her right foot seizes. They injected her with a paralytic agent to prevent full body convulsions. A tourniquet keeps the blood flow from her foot so they can monitor the seizures they induce with paddles pressed to temples. A single tear in the corner of her right eye.

For a flash from psychiatry's dark past, see Appendix 38.

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Steve Bergman: "I feel the same sense of outrage about psychiatry as I felt about medicine when I wrote House of God. Over the last two decades, I have found that the medical specialty supposed to be the most humane is in many ways the least."[97]

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Patients are doled cigarettes for good behavior

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An existential nursing order is written for a urine drug screen. Visualize the void.

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MINI-MORAL

Dr. F - brings us a patient with alcoholic AIDS dementia. "A wonderful, wonderful case," he exclaims. Last year, Dr. F - , the esteemed chairman of the Tufts psych department, role-modeled for us medicine's respect for human dignity. His was the first lecture of our psychopathology course. Three patients took the stage and poured out their hearts and minds to us. Dr. F - thanked them. As they were escorted out of the room he made sure to tell them explicitly to not worry - we would not be talking about them. Which, of course, is exactly what we proceeded to do.

I twice raised my hand, demanding to know why he felt the need to blatantly lie to these patients in front of a hundred students. He was not interested in discussing the matter.

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In a show of rare insight, one of the psychiatrists reminds us that whether we go to the Harvard church or the Tufts church, it's all part of the same medical school religion. I'm beginning to like psychiatrists. They're opinionated - and with their own opinions.

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First overnight call of the year. Stethoscope around his neck hanging to his groin, the supervising resident comments on the "nice little red panties" of one of the patients. Listening to his dick.

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I learned a new word for doctors today. My psych text explains: "The narcissistic patient, in the extreme form, is egocentric, grandiose, entitled, shallow, exploitive, arrogant, and preoccupied with fame, wealth, and achievement and generally lacks empathy and consideration for the feelings of others."[98]

DOCTOROID

From an article by Fitzhugh Mullen, author of White Coat, Clenched Fist:

It is not easy to be a good doctor today. It is not easy to work within the profession and maintain one's sense of humanity, one's humility, and one's commitment to service....

The first battle will be against the forces of complacency, laziness, and fatigue and will have to be fought almost daily during one's career. The enemy will make it too easy for you to become insensitive, curt, greedy, prejudgmental, racist, rich, brusque, and thoughtless.... Imperceptibly, one will cease to be a doctor and become a 'doctoroid.'

A 'doctoroid' is a bright, young physician with good MCAT scores, good grades, excellent subspecialty electives, commendable National Board scores, Board certification in one of a number of specialties, and an essential inability to deal with people or communities. A 'doctoroid' sees its medical degree as a game of tennis - a hard won personal skill to be used primarily for self-gratification. A 'doctoroid' is well-to-do, dresses like a doctor, sounds like a doctor, and behaves like a doctor but it has no heart. Inside it is all bank accounts....[99]

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White walls and dark windows. In no other realm than psychiatry does the Third Year mantra "At least I'm not a patient" offer more perspective.

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A woman is weeping, demonized by voices and fears all day, every day, every year. From the journal Nature: "Schizophrenia is arguably the worst disease affecting mankind, even AIDS not excepted."[100] The interviewing doctor is the one with the flat affect, though, absently looking around the room as the patient describes her terror.

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One pill is worth a thousand words - Steffie Woolhandler[101]

Pseudonymous Samuel Shem, in his follow-up to The House of God, describes a psychiatric office visit:

The patients were treated with a courteous benevolence, like good dogs. It was astonishing to see how, being treated with total authoritarian objectivity, they responded with total submissive gratitude.... If patients wanted to talk diagnosis, he talked drugs. If they wanted to talk symptoms, he talked drugs. Stress? Drugs. Suffering? Drugs. Family Problems? Drugs. Job? Drugs.[102]

The only way psychiatrists listen to people's hearts these days is with a stethoscope.[103]

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In 1996, the World Health Organization estimated that nearly 5 percent of all elementary schoolchildren in the United States were on the amphetamine Ritalin. Educator John Holt testified before Congress that kids are given Ritalin so, "we can run our schools as we do, like maximum security prisons, for the comfort and the convenience of the teachers and administrators who work in them."[104]

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I got The Talk early this rotation, only a week inside. It seems (rather predictably at this point) that my greetings are "too friendly," my demeanor "too affectionate." I need to be "more remote."

And my neckties are too childish. As one of my favorite quotables, "No more muppets." It's the higher ups that always seem to have the problem. Class ties. The patients love them, the nurses. How intimidating can anyone with an Elmo tie be? But the attendings seem threatened, and over such cowardly silliness.

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A patient died yesterday and I saw grief among the staff for the first time in medical school. Melvin Konner, in his book Becoming a Doctor: A Journey of Initiation in Medical School, describes similar feelings; he was stunned when he actually heard a doctor use the word "tragic" to describe a patient.[105] The next morning in team meeting the psychoanalysis student is upset too. Because he killed himself, she says, "now I have to change everything in my paper to past tense."

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I've been in school for 20 years straight now. Head down through high school to get into college and through college to get into medschool. Hello 1998.

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I need my own style of reality testing. A month, perhaps, to make sure I am and can still be the Me I've grown to respect.

In a letter entitled "Medical Education is Brutalizing," three psychotherapists urge medical students to "ask themselves difficult questions: about what is happening to them, their ideals, and their self-image."[106] What does happen to me when I'm in the hospital? Is it the white coat? I'm a different person. How could I do the things I did? Or the things I do?

Seven psychological principles, detailed in Appendices 39a-g, have helped me rationalize my inhumanity

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All time should be free (and of course is). "Is any man free except the one who can pass his life as he pleases?" - Persius. Charles Dickens: "I only ask to be free. The butterflies are free."

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Week 2 at the Post Traumatic Stress Disorder clinic. A vet asked if I wanted to be a doctor or a healer.

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I met someone with a soul today. A different Dr. S - , at the PTSD clinic - a conscientious objector. "I am an agitator for peace," he said. "The best treatment for PTSD is primary prevention, the end to all war, torture, and enslavement." Yeah, baby. He challenges my blame-the-victim attitude, my demonizing the soldiers as bearing the weight of atrocity. He tells me, "Never write off anyone's humanity."

Of course failing primary prevention he slips into secondary prevention, instructing the government how to best minimize trauma among its young men. Keeping the unit together helps prevent PTSD, he tells me. To me it sounds like a lot of apologist Nazi doctoring - well, if you're going to torture and murder (and die), do it safely now children. And he had the quaint idea that the U.S. military has historically served a defensive function. We have lots to teach each other.

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Another patient interview and the doctor wants to make a point. "What's your greatest disappointment in life," he asks the patient. Hospitalized for an attempted suicidal overdose, depression, the patient breaks down weeping. "This," the psychiatrist turns to us pointing to the patient, "is the limbic system*."

* The limbic system is a part of the brain thought to encompass the seat of the emotions.

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A patient complains of people putting things down her sink. Obviously delusional. The plumber came today to unstop the pipe clogged with everyone else's cigarette butts.

What if one got "normal" people admitted to mental institutions; would they be discovered? Appendix 40a.

THE WRONG FIXED FALSE BELIEFS

It struck me on the phone speaking to Dorothy from South Carolina. Her sister was one of my patients who was hospitalized four days ago for paranoid persecutory semi-religious delusions - fixed false beliefs. People in her apartment building were practicing voodoo against her. How did she know? I asked. "Chicken bones, they were throwing chicken bones on my porch." So she reacted with bizarre behavior - incense and candles to smoke away the spirits; salt sprinkled in the doorway. The police were called.

She denies that she's crazy. She doesn't think she needs the antipsychotic and becomes agitated when we won't let her leave. So "delusional" and "poor insight and judgment," I write in my note. The doctors don't want to let her go home for Thanksgiving, so I try to get family members to vouch for a day pass for her. "I know," her sister says, "all this talk about voodoo. I don't believe in that. I told her she should just read her Bible. The Bible says it's not true." I look around the walls of the Catholic hospital. There's communion Mondays, Wednesdays and Fridays, two prayer meetings a day.

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It is within my lifetime that the psychiatric profession formally classified homosexuality as a mental illness. In what critics describe as a, "thinly disguised effort to reintroduce the traditional 'homophobic bias' of psychiatry into the new nomenclature," the psychiatric disorder "homosexuality" was changed in 1973 to "Sexual Orientation Disturbance."

Since then it has been officially changed to "homodysphilia" then "dyshomo-philia" then "homosexual conflict disorder" to "ego-dystonic homosexuality."[107] In the American Psychiatric Association's listings in the DSM, homosexuality was sandwiched between exhibitionism and pedophilia.[108]

The DSM is the APA's Diagnostic and Statistical Manual, listing all the official psychiatric diagnoses. See Appendix 41.

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La Maladie du Petit Papier
(The Illness of the Little Piece of Paper)

What of people who try to keep track of what they want to say to their doctor? From an article in the New England Journal of Medicine: "Traditional medical wisdom holds that patients who relate their complaints to their physicians from prepared lists are, ipso facto, emotionally ill." Osler named it neurasthenia - A patient with a written list of symptoms. DeGowin and DeGowin in their venerable textbook on diagnosis say that note writing is, "almost a sure sign of psychoneurosis."[109]

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ME AND MY EGO-ALIEN ORAL CANNIBALISTIC IMPULSES

"On Vegetarianism," a 1974 article in the Journal of the American Psychoan-alytic Association: "Vegetarianism must be related to depression and serve as a defense against oral cannibalistic wishes." The researchers studied a series of cases; they conclude, "our expectation of finding intense ego-alien oral cannibalistic impulses in vegetarians has been amply fulfilled."[110]

Couldn't possibly be for the 9.4 billion*.

* We made a new record in 1998. The USDA reports 9.4 billion animals killed for food in the U.S. alone. [111]

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One of the hospitals I rotate through handles the prison population. There's just something about women handcuffed to beds and black men in chains.

For psychiatry's spin on women, see Appendix 42; for psychiatry and slavery, Appendix 43.

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Another VA Friday. "When I first got to 'nam," he said, "I was panic-stricken in combat, but then I started really liking killing people. It got to the point I'd shoot a load off in my pants every time I killed someone or cut them up."

He describes the recurrent nightmare he has of one of the men he tortured, murdered and mutilated returning from the grave to ask him for his body parts back so he can get into heaven. The vet still carries with him a picture of that "gook's" family he took from the body.

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I still yearn to be with my "own" people. The ease, the security of communal isolation. I am growing further and further away from everybody else.

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Our course director. My attending calls him the best psychotherapist in the country. Every week we are afforded an audience with him. He is a master manipulator no-business-like-show-business betazoid telepath. He is who he wants you to think he is. He shows us his magic tricks: how to get on the patients' side, how to pretend, how to act. He does the same to us, swearing, dismissing his field as psychobabble. I am awed and spooked at the same time.

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Over for the day, I walk across frozen ground to the car, eyes narrowed against a smoke ridden headache, thuds of nausea in my throat. The days bleed away.

The course director quips, "If you're not depressed you're not doing it right."

Four-pointed star

EMPATHIC BLUNTING

Between 1970 and 1976 a natural experiment was set up. The American Board of Psychiatry removed, then reinstated, a medical internship requirement. Researchers then had two populations of residents, ones with and without an internship year. The residents were compared with each other in terms of clinical skill, with the expectation that those with the internship would be better psychotherapists. Surprising to some, the noninternship residents were found to be superior. A "disquieting possibility" was hypothesized that the internship with its, "traumatic components such as fatigue [and]... humiliation led to 'empathic blunting' as interns take on the 'authoritarian roles of doctor.'"[112]

Sigmund Freud in his book The Question of Lay Analysis:

The first consideration is that in his medical school a doctor receives a training which is more or less the opposite of what he would need as a preparation for psycho-analysis [Freud's method of psychotherapy].... Neurotics, indeed, are an undesired complication, an embarrassment as much to therapeutics as to jurisprudence and to military service. But they exist and are a particular concern of medicine. Medical education, however, does nothing, literally nothing, towards their understanding and treatment.... It would be tolerable if medical education merely failed to give doctors any orientation in the field of the neuroses. But it does more: it has given them a false and detrimental attitude.

More insight from Freud in Appendix 44.

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A class meeting, so good to see friends. Medical school gets lonelier and lonelier year by year.

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Ninth floor, rounds. It's so foggy you can't see the ground through the bars. A patient asks me if it's cold outside. Misty white light sifts through the windows.

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I learn about patients' "escape status." One patient, signed in on a voluntary, expressed her frustration as insight: mental institution as roach motel; you can check in....

"There should be no place called a hospital from which a person cannot walk out... - Thomas Szasz.

Described as the foremost critic of the entire field of psychiatry. Dr. Szasz - Appendix 45.

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Calling in sick and again the compassion. The resident demanded proof; do I have papers from a doctor?

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Under my dress shirt I wear one of the pacifist T-shirts I made in high school during the Gulf War. I am like superman, hiding my identity.

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Psychotherapy has been defined as, "an unidentified technique applied to unspecified problems with unpredictable outcomes."[113] E. Fuller Torrey, a psychiatrist, points out in his book The Death of Psychiatry, "Many psychiatrists have had, at least to some degree, the unsettling and bewildering feeling that what they have been doing has been largely worthless and that the premises on which they have based their professional lives were partly fraudulent."[114]

A classmate questioned the psychoanalytic student as to whether or not years of psychoanalysis actually makes a difference. "Well, if they're paying you...."

Psychotherapy has become a billion-dollar industry. Its usefulness questioned in Appendix 46a.

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A nurse remarked to me today in a matter-of-fact way, "Medical students are mere nothings."

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I let my fingernails grow to acknowledge distance from surgery. One of the residents used to be a surgeon. "There's no life. You have surgery. That's your life." Unconsciously, I open a stick of gum like sterile gloves.

I ran into one of the pediatric surgeons in the hospital today. I told him I was doing psych and that I liked it better than surgery since the patients were awake so you could talk to them. "Yes," was his reply, "but they talk back."

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From the Journal of Medical Education:

Studies over the past decade have repeatedly shown that doctors function poorly by certain indices of mental health.... The 'disease of being a doctor' takes root in a group which is as a whole excessively obedient, quite dependent, and given to passivity and feelings of self-doubt. Poor self-image and a sense of inferiority are common.[115]

Any man who goes to a psychiatrist should have his head examined.
- Sam Goldwyn

I wanted controversy? Dr. T - , a post traumatic stress disorder expert working at the VA. A Wilhelm Reich* disciple. He sits us down and tells us first of his theory of trauma. Why do victims keep revisiting their trauma in flashbacks and nightmares? "They liked it," he says. In the process of getting raped, he told us, women get sexually turned on. So they keep reliving it because it arouses them. Oh, by the way, same with getting arrested and thrown into a concentration camp. "It's sexy," he said.

* Reich died in a federal penitentiary - his books burned on order of a federal judge for advocating kooky cancer cures.

And his explanation for mental illness in general? Interrupting The Ballgame, his euphemism for walking in as a child on your parents having sex. He tells us all this switching in and out of an Elmer Fudd voice - literally. It gets harder and harder to tell the doctors from the patients every day.

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My evolution. First, I realized that the worry keeping me up at night was all just in my head. So I took a deep breath. Then I came to understand that my hospital bound hypervigilence, my fear that around every corner might lie some abusive confrontation was just a trick of the mind as well. I took another breath. Now I know that it's all self-imposed anxiety, even if the confrontation happens. I yearn to breathe free.

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"It is easier to get a heart transplant or cataract surgery than supper or a back rub." - Physician's comment on NPR[116]

An experience in psychiatry as a metaphor for all of medicine: there was a new face in Community Meeting this morning - big black guy. Seemed really nice. The meeting is held to reorient people every morning to the ward - the locked inpatient ward of Carney Hospital. And every morning the psychiatrist "group leader" asks if there are any questions. There almost never are; this morning there was.

This new face, his first day, asked, "Do you have to be crazy to be in here?"

The psychiatrist went into his best shrinky soft soothing voice, "Oh no. This is a place for people to come when they have a problem. If people have issues, they come here and we help them deal with them."

Later that day I saw the new guy in his coat being escorted out the door. What happened? "He was faking," an annoyed psychiatrist told me, "he's homeless and just faked it to come in and find a warm bed, food." Assured at the meeting that this place was to help people with their problems, he admitted that he had faked a mental illness. So we threw him back out on the streets.

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One essay on the Milgram experiments (Appendix 39f) concluded that "In most men, there is a latent Eichmann; most men can become - with surprisingly little external pressure - 'cogs' in a concentration camp apparatus...."[117] I can see how the entire profession could dissolve itself into the final solution.

Physicians played a prominent role in the Nazi vision. See Appendix 47a.

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Not even a collapsing world looks dark to a man who is about to make his fortune.
- E. B. White

From a letter in JAMA:

It is not intimidation by a totalitarian political force that grips U.S. physicians but, like German physicians in the 1930s, fear of loss of income. This fear is currently used by powerful corporations to manipulate U.S. physicians into overlooking, and even abandoning, patient confidentiality and sustaining collegiality, respect for patient's dignity, and adherence to our ethical beliefs, all in return for fancied security of income.[118]

How radical is it, the separation of medicine and money? In therapy I have uncomfortable discussions about payment plans and how much per session. Then it's business, thoughts of time wasted, getting one's money's worth - more stress. The course director impressed the importance of billing this week, "Money has to be involved, otherwise the patient might question why you're doing it. Might think you get some kind of personal gratification." God forbid. And the implication, I guess, that having them think you're just greedy is better.

But the physician is above all this. The artificial distance - third party payers, paying at the desk - obscures the reality. Imagine handing the doctor the $40 to look into your kid's ear. What if you only had $25? Would he take personal checks? Would she? American Express? Your child is suffering. Would it be cash up front? Half down, half later? Is it objective loving support or all pretense? Medicine as distant to healing as prostitution to love.

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The rotation was not horrible enough to distract me from the emptiness in my life. But outside, I can smell Spring. Eighteen weeks to go.

 


 

[95] Inlander, CB. This Won't Hurt (And Other Lies My Doctor Tells Me) Allentown: People's Medical Society, 1998.

[96] Peabody, P. Journal of the American Medical Association 88(1927):882.

[97] Knox, RA. "Inflicting Misery." Boston Globe 31 March 1997:C1.

[98] Stoudemire, A. Clinical Psychiatry for Medical Students. Philadelphia:JB Lippincott Co., 1994:185.

[99] Mullan, F. "Medicine's Star Wars: Will Doctoring Survive the Computer." New Physician:22-24.

[100] "Where Next With Psychiatric Illness?" Nature 336(1988):95-96.

[101] Wollhander, S and D Himmelstein. "For Patients, Not Profits." Nation 22 December 1997.

[102] "Mount Misery." British Medical Journal 318(1999):743.

[103] Breggin, PR. Toxic Psychiatry Why Therapy, Empathy & Love Must Replace the Drugs, Electroshock Therapy & Biochemical Theories of the "New Psychiatry New York: Saint Martin's Press, Incorporated, 1994.

[104] Breggin, PR. The War Against Children How the Drugs, Programs, & Theories of the Psychiatric Establishment Are Threatening America's Children with a Medical "Care" for Violence Bethesda: Lake House Books, 1994.

[105] Konner, M. Becoming a Doctor: A Journey of Initiation in Medical School New York, Viking, 1987.

[106] Haigh, R, J Appleford and A Bond. Letter. British Medical Journal 310(1995):527.

[107] Spitzer, RL. "The Diagnostic Status of Homosexuality in DSM-III." American Journal of Psychiatry 138(1981):210-215.

[108] Bayer, R and RL Spitzer. "Edited Correspondence on the Status of Homosexuality in DSM-III." Journal of the History of Behavioral Science 8(1982):32-52.

[109] Burnum, JF. "La Maladie Du Petit Papier." New England Journal of Medicine 313(1985):690-691.

[110] Friedman, S. "On Vegetarianism." Journal of the American Psychoanalytic Association 23(1974):396-406.

[111] "A Not-So-Healthy Appetite." Good Medicine 8(1999):23.

[112] Lindy, JD, BL Green and M Patrick. "The Internship: Some Disquieting Findings." American Journal of Psychiatry 137(1980):76-79.

[113] Albee, GW. "The Futility of Psychotherapy." Journal of Mind and Behavior 11(1990):369-384.

[114] Torrey, EF. The Death of Psychiatry, Chilton BookCo., 1974:199.

[115] Povar, GL and M Belz. "Helping Ourselves." Journal of Medical Education 55(1980):632-634.

[116] National Public Radio 11/11/95.

[117] Patten, SC. "Milgram's Shocking Experiments." Philosopy 52(1977):425-439.

[118] Crawshaw, R. Letter. Journal of the American Medical Association 277(1997):710.

 


 

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