The Baron and the Medical Student

Kate did not want to specialize in psychiatry. “It just doesn’t grab me,” she said. I appreciated her candor, since most medical students profess a passing interest in psychiatry, or do so at least until their evaluations are in. I knew the statistics—less than 5% of medical students choose to specialize in psychiatry. We were, it seemed to me sometimes, the pariahs of the medical community.

But Kate was bright, empathetic, and still uncommitted to any specialty: surely, I could persuade her to see the glories of psychiatry, proselytize before she left the fold forever? “Psychiatry is both an art and a science,”

I said, irritated with myself for resorting to a cliché. She nodded politely.

Our first week on the psychiatry consult service had been unfortunately slow. We had a few cases of depression and anxiety, which were interesting and professionally gratifying for me, but not novel enough to enthuse Kate.

Come on, psychiatry! Show us something good! I silently exhorted, as if psychiatry were a trained monkey, obstinately refusing to display its most impressive tricks in front of a disbelieving spectator. And then, as if on cue, our luck changed. I received a page from Dr. Baker, a physician originally from England, who displayed a sensitivity to psychiatric issues unusual for a cardiologist. He wanted a consult for a patient with chest pain.

“I didn’t want to admit him,” he confessed. “They caught me at a weak moment, and flew him from Hillsboro where the ER physician knows him quite well; says the chap’s a frequent visitor. I don’t think his pain is car-diac,” he continued, in his crisp public school accent. “I was going to let him go, but he has some bizarre stories about being a physician and a lawyer. Could you please look him over? Cheers, then.”

Mr. Traylor was in his mid-50s. He had straight gray hair and looked quite distinguished despite the hospital robe, as he sat back in bed reading a newspaper. He shot us a questioning look over his bifocals as we walked into the room. I made the necessary introductions. He smiled politely and shook our hands, but when I informed him that I was a psychiatrist, his de-meanor changed.

“I come here with chest pain, and they send in a psychiatrist? You are aware that at my last cath, I had more than 60% stenosis in my circum-flex?” His irritation rapidly dissipated when I apologized for taking him by surprise.

“There must have been some miscommunication. Dr. Baker wanted us to ensure that you were dealing with the stress of all your medical problems,” I said, a bit uncomfortable about modeling psychiatric doublespeak in front of Kate. But if I told him the bald truth that we were here to screen for mental illness, I knew we would not get very far.

After talking briefly about his medical problems, I asked casually,

“What do you do for a living, Mr. Traylor?” Kate, perched on the edge of a chair next to me, was observing the interview with a level of interest she had not displayed before.

“It’s Dr. Traylor, actually,” he replied. “I’m a lawyer, but as you can probably tell, I’m also an M.D.”

“Tell me more,” I said.

“Well, I was 42. Older than you are now. I had just remarried, and one day, I woke up and said, ‘You know what? I think I want to be a doctor.’

In an instant, he had reduced my years of medical training to a whim, a midlife-crisis affectation, like a tattoo or a new BMW.

“Never really practiced medicine, though,” he said. “It was even more boring than law, if that’s possible.” He paused, and looked at me sympathetically. “Doesn’t pay too well, either.”

I was about to ask a question when he raised his hand:one moment. He pushed the call-button to summon the nurse. “She knows it’s time to give me my Lasix.” He looked at Kate. “Why is Lasix called Lasix?”

He asked this, not like a patient asking for information, but in the manner of a venerable professor on rounds asking the question of a particularly dull medical student. The situation was potentially awkward. Kate could not disregard the question, nor did she want to betray her own ignorance. She gave me a confused look.

“Kate knows it’s called Lasix because it lasts for 6 hours,” I said. Kate nodded, and the patient looked disappointed.

I continued the interview after the nurse left, looking carefully for signs of psychosis or an affective disorder. There were none. He was coherent, logical, and calm, and he denied any history of mood symptoms or problems with drugs or alcohol. I surrreptitiously looked at his urine toxicology screen on admission: negative.

As we talked, I wondered. Could he really be an M.D. and a J.D.? It was possible, but unlikely. We had the outlying ER physician’s report that the patient often slept in the streets, and even though reimbursement has fallen over the years, homelessness is not, thankfully, a huge problem in the medical community.

I saw that he had listed his wife as his next-of-kin. “Can we speak with your wife?” I asked.

He nodded, then fished around in a dirty-brown leather bag that I had not noticed before and pulled out a faded photograph of an austere looking brunette wearing an elaborate dress, holding a bouquet of roses in her hand.

Kate studied the photograph. “Very nice,” she said, handing it back to him.

“She’s an opera singer,” he said. “Her stage name is Madame Zarinski. You may never have heard of her, but she was fairly well known in Milan and Rome.” He closed his eyes. “She has the voice of an angel, but she can never perform again.”

“How come?” Kate asked.

“She’s paralyzed from the waist down after some surgeon screwed up. We are suing them for a few million dollars.” He pulled at the nasal cannula. “I asked myself why I did all those years of study—first law school and then medical school—and you know what? I think it was God’s way of preparing me for my day in court.”

This reference to God triggered an alarm. I raised my eyebrows at Kate. This could be a clue. The patient might be showing signs of pathological hyper-religiosity, not uncommon in cases of mania or schizophrenia.

Kate preempted me. “So, do you have a special connection with God?”

“I believe in him only when I’m in trouble,” he replied with a disarming smile.

Other than the possibly grandiose stories about himself and his wife, there were no other signs of psychopathology. His thought processes were linear, he displayed no pressure of speech, and he gave considered responses to our questions. And his obvious intelligence made even the routine cognitive exam seem like a game-show moment.

“Who was the president before this one?” I asked.

“Bill Clinton. Full name, William Jefferson Blythe,” he answered, and then countered, “Who was the third president?”

I was going to confess my ignorance of the fundamen tals of U.S. history, but Kate came to my rescue. “Thomas Jefferson,” she said, giving me a smile and a discreet thumbs-up.

“Mr., I mean, Dr. Traylor, thank you for talking with us,” I said, finally wrapping up.

“What are we going to tell Dr. Baker?” he asked.

“Well . . . . ” I replied carefully. “You don’t need to stay in hospital for a psychiatric reason. We will let Dr. Baker know that he can discharge you, when he thinks your chest pain is taken care of.”

“Thank you,” he said, shaking our hands. He turned to Kate. “And you, young lady. You will make a fine doctor.”

Kate beamed with obvious delight.

“Fascinating case,” I said to Kate as we sat at the nurses’ station, writing out our assessment. We discussed various differential diagnoses, including bipolar disorder, narcissistic personality disorder, and delusional disorder. I told her about the 18th century Baron Münchhausen, known for his grandiose stories, illustrating the parallels between this case and the late baron.

“I wish we could know for sure, though,” Kate said.

She laughed. “A lab test would be perfect in a situation like this, huh?”

It was at that moment that I knew Kate would join the majority of her peers: she would not specialize in psychiatry. Her need for certainty and closure outweighed the intellectual stimulation that even the most interesting case in psychiatry provided.

In addition, the lack of immediate gratification that is inherent to psychiatry—she had seen that the antidepressants we prescribed didn’t make a difference in the first few days—only made psychiatry all the more unappealing to her.

I never heard from that patient again. And, as for Kate, I saw her name on the list of graduating students and their residency match results. I thought it ironic that she chose anesthesiology, a specialty where neither the physician nor the patient does much talking.

November 24, 2018 | 10:19 am | By Dr Shyam Bhat
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