1 Boring Old Man

I was older than many of my fellow residents when I did my psychiatry residency and when I finished, I was already in analytic training and had a taxing job – which are the excuses I use to explain putting off taking my psychiatry board examination for a few extra years. The point of this story is that I found myself in Houston for my oral boards with my friends as young examiners, but I was there as an applicant. It was a few years after the DSM-III had come along, and I was familiar with it, but hardly a scholar. Day 1 was interviewing a live patient in 20 minutes while watched by three examiners, later discussing the patient with them. It was a yes or no test.

We loaded into a bus at the hotel for the reasonably long ride to the hospital site for the exam. I was over forty and the bus was full of people in their late twenties – chattering and asking each other questions about the finer points of the DSM-III diagnostic criteria. They were talking about how to precisely diagnose a Panic Attack, but I was having one – one of the few in my life. If I had to know that book the way they were talking about it, my goose was cooked. I could see the headlines before me, Psychiatry Residency Training Director Flunks Oral Boards.

My assigned patient was a cowboy, a real cowboy who worked in the stockyards. He was in the hospital because of suicide threats when his wife asked for a divorce and moved out. As I took his history, I began to relax. He’d grown up with his grandmother. He was the product of a teen pregnancy, and he and his mother lived with her mother. When he was very small, his mother had married a man who "didn’t want children" and moved into a house down the block, leaving him with his grandmother. He called his mother and grandmother both "Mom," and his mother visited "whenever she could." The step-father was nice, but uninvolved, rarely seen except when they "brought me my Christmas" or other such occasions. His grandmother was a loving parent surrogate – no complaints.

When I pressed him about what that was like for him, he said "no problem." But I pushed, and he reluctantly told us a secret. He would sneak out at night and go down the alley to where his mother lived and "peep" unseen from the yard, watching his mother and her husband talk, or watch television, or read – nothing Freudian, just everyday things. It had gone on for years. Well his wife’s complaint had been that he smothered her, always asking where she’d been, calling her at work, "showing up." He told her he wasn’t jealous, or even suspicious. And when she complained, all he would say, "I just wanted to see you." I need not go on because the connections are obvious. But here’s a tip. If you find out a secret on your psychiatry oral boards, you pass. I don’t know if that 20 minutes helped the lonesome cowboy. I hope so. But he sure helped me escape the feared grilling on the vicissitudes of the DSM-III criteria. The examiners stuck to talking about attachment problems, and I was well within my comfort zone.

A solid diagnostic system has to be comprehensive, but it needs to be in a form that can be adapted to its many uses. The human mind is not really like a computer SQL database. It’s in the form of what Piaget called a lattice, a term borrowed from theoretical mathematics. What that means is that the database can be accessed immediately based on yet another database of previous searches – searches done, imagined, or yet undone – it’s called experience or intuition. The ER doctor is in action almost immediately, absent any conscious thought while the poor medical student is bewildered and asks "how did he know that!?" The expert consultant using the same medical database plods slowly, moving only inches below the surface to carefully tease out the answer to a complex problem. In that case, no algorithm leads the way – rather careful attention to subtlety and an knack for knowing when you’re on the wrong path or jumping to conclusions [with the medical student wondering "will she ever even reach a conclusion?"].