LUSTER
He spoke in an improvised rhythm, starting out fast, flying up the register, skittering from bright thought to bright thought. I struggled to follow his lines, so I asked him to slow up, to talk along with me, so that I could appreciate the forces at work in his mind. Now he repeated words, using his sculpted lips and tapered hands, to tell me about the voices, voices, voices. “They come at night, night, night and tell me to die, die, die. All right, all right, all right. Tip-tap, tip-tap, tip-tap.” He moved his feet in time with his voice and then accelerated his speech again. As he ascended into the crazed rhythm of clang associations, he shone like the saxophone he played with those hands and those lips.
I could have listened to Gregorio all day.
Unlike many of the people I meet on the psychiatric ward, Gregorio shone. I mean his pants were clean, his shirt creased, and his hair newly cut—strange enough on our ward—but also that he seemed to emit a warm light. He was the kind of man that women would want to sit next to on the bus. Most of the people I meet on the ward are the kind whom you would avoid whether on a bus or in a bar, even if it meant having to stand. They are usually poor and imperiled by their illness. They take orders from unseen forces, tune into stations in their heads that no one else can hear, and frighten people in bars and on buses. Sometimes, they frighten me.
On paper, Gregorio sounded like one of those people. He had been hospitalized because voices were telling him to kill himself, a common refrain on the ward. Like many of the young men I meet, Gregorio had begun life sweetly enough, with an occasional sour melody that was at first an interruption, but that eventually became an incessant refrain. He was raised by a single mother. He enlisted in the army to pay for a bachelor’s degree in music but left the service because he disliked violence. He toured as a saxophonist and then began an MBA to figure out how to turn gigs into a career. But the voices intervened.
He had been kicked off his last tour, hospitalized in a distant city, and then discharged to the Greyhound station. He was sent back home to live in his mother’s basement. After six months of that—doing okay, playing along—he suffered more loss, the murder of a brother, the suicide of a girlfriend: the dissonant chords of being black, poor, and mentally ill in a society that stigmatized all three.
So his mother cared for him—her favorite son, her youngest, her only living child—but she brought him to the hospital when the voices persisted, hoping to shelter him more safely there. She knew what the voices meant. Schizophrenia ran through the family. It had taken her father, her oldest son, and now Gregorio. Schizophrenia, with its fainter hammers to the head, had become her family’s full music.
At the Psychiatric Emergency Department, it is never night, but never dawn either. The lights are fluorescent, the windows are bricked-in, and the clocks face the staff. All you see are the nurses. They sit behind security glass, reinforced with a lattice of steel mesh. Sometimes a nurse comes out from behind the glass. She asks questions. Checks your temperature. Draws blood. Collects urine. Food comes. Time slips. The physician sees you. You try to explain inner voices and outer voices to him. He tells you that you will be hospitalized.
When there is a bed, you come upstairs to the ward. We have windows. We have sunlight. We have a clock you can see. The day’s schedule is clearly posted.
On the schedule, it says physicians make rounds in the morning between 7 and 11. I make those rounds to see patients who, like Gregorio, are hospitalized against their will because someone decided they are mentally ill and a danger to themselves or others. These are potent phrases, but also euphemisms. What do we mean by mental illness, by danger?
Mental illness is a social construct, a divine curse, a neurobiological illness.
Danger is a schoolyard slur, a drunken threat, a determined act.
My job is to define these vague terms for each patient, to sift out the mentally ill from the malingerers, the truly damaged from the ordinary wounded, and the imminently dangerous from those who will explode only under particular pressures. To do so, I ask a lot of questions, but I often forget that these questions, while informative, can be more intrusive than illuminating. Gregorio is a reminder of the difference.
I learned much from Eleanor, but she was the last patient I saw in psychotherapy. The notebooks in which I transcribed our encounters now sit inside my desk in the back hallway of a locked psychiatric unit. I practice in one of Basil’s hospitals rather than one of Freud’s clinics.
When I finished residency, I wanted to work at Denver Health because it allowed me to be a kind of servant in my home state. I had gone away for training, but I wanted my children to know their grandparents, aunts, and uncles, and to grow up alongside their cousins. One of the great privileges of being a physician—and there are many—is that I could choose where to work. I am privileged to work here, a place where I can be a physician to indigent ill people like Gregorio.
Working here, I often move among roles. When I fit Gregorio’s experiences into a diagnostic criteria set, I act as an author of Gregorio, the patient. When I select a treatment for him after reviewing the available scientific evidence, I am an epidemiologist. When I follow standardized checklists to ensure he receives evidence-based care, I am a technician. When I help him achieve a level of health he could not achieve on his own, I am a coach. When I teach him about his illness and its treatments, I am a teacher. When I ask about the people and places in his life and how they affect his health, I am a gardener. When I return at the day’s end to sit with and listen to him, I am a servant. When I tell other people about the many ways we fail Gregorio, I am a witness. When I help him with all his medical needs without taking full responsibility for his successes or failures, I am like a ship’s captain. Throughout, I am privileged to attend to Gregorio.
In these roles, I see Gregorio in different ways. At times, he is a source of income. I am no doctor without silver, but a salaried employee of Denver Health. Being a salaried employee frees me from many incentives to overtest and overtreat patients, but it also means I cannot operate a private practice on the side, as physicians in a previous generation did, the kind of private practice where I could see patients like Eleanor. I miss that lost opportunity, but the salary is regular and allows me to keep pace with my student loans and to support my family.
At other times, I see Gregorio as a collection of parts. I am fascinated by neuroscience, by the circuits and neurotransmitters that are operating within Gregorio’s brain when we sit together. I am amazed by remarkable pathologies and frightening derangements. I find myself swapping stories with colleagues, then feeling embarrassed because my own health, in comparison, is good. It is much easier to be a physician than a patient.
But someday I will, of course, be the patient. That time comes for us all. I worry about what kind of physicians I will encounter. Every few months, a new version of healthcare reform whips through the hospital, as constantly changing as the weather. Some people argue that paying physicians for performance and outcomes is real reform. Performance and outcomes are important, but they are no more than a standardized and scaled version of the view of patients as parts and money. I suspect that real reform will come only when we change what physicians and other practitioners see in the people they meet as patients, and when we allow patients to see us in return.
I want to tell you what Gregorio saw in me.
I met Gregorio for the first time the morning after his mother brought him to the hospital. Whereas I had slept at home in my own bed, he had slept on a molded polymer bed bolted to the floor of the Psychiatric Emergency Department. After telling her son’s story in the Emergency Department, his mother had gone home, where she could sleep, for the first time in months, without checking on him every half-hour. In her absence, Gregorio became upset. The psychiatric emergency nurses tried to reason with him, but he was beyond their reason. Eventually, they used Velcro to affix his wrists and ankles to the plastic bed that was bolted to the floor of the windowless room, and they induced sleep with “10 and 2,” hospital slang for 10 milligrams of haloperidol and 2 milligrams of lorazepam, sedating doses of medications administered intramuscularly.
I read all this information at the nurses’ station on our ward, where I stop in each morning to review the records of the patients admitted overnight. After receiving his meds, Gregorio had been sent upstairs at four in the morning. When he arrived, the ward nurses could not get much out of him. Since he could no longer speak for himself, they described him. “Isolated. Calmed.” More euphemisms.
I let Gregorio continue sleeping while I saw other patients. Later in the morning, I found a room and a few chairs. I woke Gregorio and asked him to join me. We sat together and he told his story.
“My mother knows I’ve been under a lot of stress, stress, stress. I dropped out of school, school, school. I didn’t get the help I needed, so I hear voices, voices, voices. I want them to stop, stop, stop.” His words were staccato but clear.
My own hands and lips cannot play any instrument, but I have learned to follow along with people like Gregorio. They sing, they stutter, and I keep time with them, trying to discern why, why, why they are ill enough to be hospitalized. Every song is distinct, but I have learned how to accompany each player. Sometimes I summarize, sometimes I redirect, and sometimes I just listen.
When I started out as a student, I found these rhythms unintelligible, so I asked questions that made sense to me, mostly questions on the hospital forms I was completing. “What is your chief complaint? How would you describe your mood? Do you see things other people do not see?” My questions were informative for me, but not for my patients. They presented with personal concerns, and I responded with questions from a preprinted list of symptoms.
Fifteen years later, I find myself asking someone else to sing the tune so I can follow along. I start by asking people what they like to be called. I listen. I ask, “Why do you believe you are ill?” When I asked Gregorio this, he began to cry, then fell mute. After a few minutes, he said, “I cannot tell anyone, but maybe you . . .” He straightened his index finger and pointed at the hospital-issued identification badge that hung around my neck. My picture is on the badge, with my expanding forehead and the same tentative smile I offered to assistant principals who discovered me reading novels under the stairwell when I should have been in gym class.
As he pointed, Gregorio said, “The nerds. The nerds. The nerds have lost their luster.”
“Are you pointing at my badge because you see me as a nerd?” He nodded, looked up, and smiled. “Like you? Are we both nerds?” He nodded again, smiled again, and now we could talk. We talked about old records, obscure movies, and out-of-print books. The nerds were shining together. Skipping gym class together.
The languages of medicine are German and Greek, and they reflect our sense that health is an adherence to an ideal form and illness is a deviation. So when physicians account for our patients, we use terms that outline the geographies of these ideal forms. In psychiatry, the geographies can be imagined (id, ego, superego) or structural (amygdala, hippocampus, thalamus), but they are often descriptive. We describe a patient’s speech as slowed or rapid, alliterative or accented, aphonic or mute. We describe his or her affect as stable or labile, as restricted or constricted, euphoric or dysphoric. We describe the patient’s thought process as organized or derailed, logical or illogical, intact or circumstantial. Assign enough descriptions, and they assemble into a diagnosis.
The psychiatrist Paul McHugh charges that we have become birders, comparing people to our handbooks and determining their illness based on their external characteristics.1 Delusions? Hallucinations? Disorganized speech? Lasting at least six months? Must be schizophrenia.
As a word, schizophrenia sounds Greek, but it was introduced into the language by a psychiatrist lecturing in 1908.2 The name has little music to it. The five syllables that make up schizophrenia are of varying length. Two long Greek roots, “to split” and “mind,” bound together around that harsh o. The word is misused all the time. Psychiatrists dislike hearing it used to mean “of two minds” or “having multiple personalities.” The word was created by one of our own, and we claim the authority to use it.
But we have our own misuses of the word. We give it to other people as a name—they do not so much have schizophrenia as they become a schizophrenic. From there, it is easy to become a “schiz-o” a dulling name for a person.
Psychiatrists lament the stigmatization experienced by our patients, the way they are caricatured as dangerous, dim-witted, or dull. And yet our diagnostic system makes little room for the particular passions of a person. Our encounters focus on pathologies rather than strengths, and our language has no account for a man who, while he hears frightening voices, still shines.
Luster enters English from the French lustre, the Italian lustro, and the Latin lustrare. All the Romance words end with a vowel, with a sound that invites the lips to expand and the mind to alight upon some of its meanings: a reflected glory, a polished shine, an illuminating light.
That first night after I met him, I thought about Gregorio. How, exactly, did the nerds lose their luster? When engineers make billions as entrepreneurs, can the nerds possibly have any more luster?
I was a bookish boy and capitalized on my habits to become a physician. Gregorio was a bookish boy as well, but what had happened to his share of luster? I still do not know why some have many chances to shine and some have very few—these are questions for theodicy not psychiatry—but I know that I awoke the next day eager to speak with Gregorio.
At the hospital, the overnight notes indicated he had done well. I thought we would pick up where we left off the day before. Instead, when I approached him on the ward, he was shaking. Unbidden, my mind formulated a differential diagnosis—anxiety, withdrawal, adverse med effects—and I thought like a physician: “What part is broken?” We physicians think so much about broken parts that when we see something out of the ordinary, we immediately seek the fault, naming it with our distancing, dulling language. Was Gregorio anxious because of impaired activity in his amygdala, undisclosed alcohol dependence, or akathisia from excessive dopamine blockade?
I was trying to locate Gregorio’s experience on one of our geographies, when I saw what he was holding in his tremulous hands: stock reports. He was carrying the annual reports of Fortune 500 companies.
I asked why he carried them. His eyes welled with tears as he slowly handed me a glossy report, its cardstock pages fluttering in the air-conditioned breeze. I read the words on its cover—We’ve Got You Under Our Wing: Annual Report, Aflac Incorporated. A cartoon duck’s sheltering wings were spread out in invitation.
“Is that for me?”
Gregorio nodded.
“Why?”
He stammered, “I, I, I have been thinking you. I wanted to make sure that you were covered, that if anything happened to you, you could stay home, sit in your psychiatrist chair, and be safe.”
Usually, when patients say they have been thinking about me, they mean they have been thinking about how they will convince me to discharge them. Gregorio was thinking about the possibility that I might someday be ill or injured and need supplemental insurance. He was thinking about me as a person who could suffer. I was astounded.
Is the empathy of his prisoners too much for a jailer to ask?
I do not like to think of myself as a jailer, but that is how many of my patients conceive of me. After all, when society grants me the authority to define dangerousness and mental illness, it also grants me the authority to restrict the freedoms of the people I meet as patients. With the right words on the right form, I can hold a person, against his or her will, in our hospital for days, weeks, or even months. Under extreme circumstances, I can administer involuntary medications. “Please take this pill. If you do not, the nurses will have to inject you with these medicines.” My tongue has become accustomed to the language of coercion, with its careful phrases and its cloaked threats, followed by the nurses counting off one-two-three fingerbreadths below the shoulder’s bony acromion so they can sink the needle into the deltoid.
Gregorio was using a different language, the language of personal concern. Within a few days, he would still be hearing voices, but he would be able to talk back to them. He was engaged in treatment. He was making plans for the future. He was going to see a psychiatrist when he left. He was going to live with his mother again. He was thinking about other people.
This is a rare thing on the ward. A colleague of mine is legally blind. She wears glasses so powerful that her pupils appear twice as large as their actual size. She has worked on the ward for almost thirty years, but she has told me that only once, in all those years, did a patient pull out a chair for her. She was touched by his kindness, by his ability to perceive her impairment and to assist her. She says it is more typical for patients who observe her impairment to blurt out something rude. She knows this is often a symptom of the conditions our patients experience, that they forget how to interact with other people, so she no longer takes it personally. She chooses to take only the kindnesses personally. She remembers the gentleman who pulled out her chair.
I remember Gregorio.
After forming an alliance with Gregorio, we could listen to each other, and offer a warm concern for each other as fellow creatures. I could see that his concern for other people was the source of his luster. I could also see that sharing a bit of the luster of people like Gregorio is how we physicians will endure in medicine, even as healthcare reforms. Sitting with Gregorio I see that what passes for healthcare reform is variations on parts and money, with promises to hospitals, insurers, pharmaceutical manufacturers, and, yes, physicians, that their profits are assured. Sitting with Gregorio generates little income and requires me to think about him as something more than his parts. Sitting with Gregorio, searching for luster, is the grounds for the renewal of medicine. So I have learned to tinker with the various systems designed to optimize the treatment of parts and collection of money. I find cracks and crevices in the day where I can sit with a patient like Gregorio and attempt to see that patient as an individual and, on the best occasions, to be seen in turn by him or her. I feel often like the protagonist of Walker Percy’s novel The Moviegoer, who concludes “There is only one thing I can do: listen to people, see how they stick themselves into the world, hand them along a ways in their dark journey and be handed along, and for good and selfish reasons.”3 Percy was a physician. I imagine he would have liked Gregorio.
I know I did, because on that day, Gregorio saw me. In the midst of our dark journeys, we handed each other along, and I experienced the joy of healing someone who sought my help.
He returned a month later. He asked to see me. He wanted to give his card to the nerd.
I keep it on my desk. It is the standard size, a rectangle 3 1/2 by 2 inches, but it is oriented vertically, unlike most business cards. In the upper-right-hand corner is his name, followed by his occupation and phone number. In the lower-right-hand corner there is a picture of Gregorio, his lips pursed, preparing to blast straight 8s and push the rhythm.
I can only hope to keep up with those who, like Gregorio, seek my help.