Ttoday's going to be a particularly busy one. Must be organized. Mustn't forget any of my hats. Not that the weather changes that much down here in Texas. But metaphorically speaking, I change my hats often on days when I return to the university and engage my residents in Socratic inquiry.
Donning my ‘treating clinician’ hat, I begin my day. It's an inquisitive looking hat with soft, firm edges, and it compliments my therapeutic approach. Ms. P has been trying to decipher the conundrum of feelings she's had ever since her mother died when she was but a youngster. Ms. T has been trying to sustain a marriage despite her husband's infidelity; taking a hard look at her own unknowing facilitation of what transpired, if any. I'm particularly proud of the therapeutic work both have done. My next patient, Mr. S, brings a bag of prescription bottles with him. I know what that means. The concerns I hear from him—that doctors don't spend enough time answering his questions—resonates in my office today as it once did when I spent time behind a prescription counter as a pharmacist. I had to pull this rather worn hat out of my closet when I started private practice. Somewhat clinical, yet definitely the next-door-neighbor type. I'm glad I kept it. The morning's just about up and it's time for a change. This one has a Sherlock Holmes feel and appearance to it. You see, I've been reviewing records on a forensic case and I'm meeting with an attorney to go over my forensic findings and clinical suspicions. This one's a sexual harassment case. Like many of the forensic cases that I review, this one has interesting undercurrents. I'll bet Tinsel Town would be interested. Two hours later, I'm off to the medical school after checking my voicemails and refill requests.
The pleasant melodies of Bromberg's latest CD are a welcome and soothing experience during my 25-minute trip. Sitting in the parking lot, I reserve a few minutes for return calls. Let's see. There it is. This hat's particularly noble looking. I speak with a state board investigator about reviewing another case for her. She banters that we've sat on the same side of the table these past 3 years (metaphorically speaking), caught off-guard by a recent report I submitted on behalf of a physician. There's just enough time to touch base with our state society's executive secretary on an upcoming ethics hearing that I'll preside over. What would I do without her? I've been looking for an ethics hat for some time, but just when it seems that I've narrowed my discernment, my certainty fades. Did I mention the hat I'm wearing now is white?
It's close to seminar time. I have to run. On my way, a resident catches me in the hall about a forensic selective in her last year. We exchange numbers and will talk later. Just before walking into the conference room, I catch my reflection in the adjoining hallway window and adjust my hat. This one's a bit lofty. My wife says that it projects knowledge and wisdom. I hope she's right. I see anxious faces again, not an unusual perception preceding my medical malpractice seminars. Today, we go over ‘deviation’ (from the standard of care). The residents promptly settle in as we cover psychiatric interventions targeting depression, much more quickly than last week's seminar when we discussed ‘duty’. I can feel their confidence on more familiar turf. I wait patiently as the discussion unfolds. They're on a roll. Soon, a remark briefly opens the door just enough so that I can impede their momentum with one full sweep of a question. Things are not as they seem. Are they? Anxious uncertainty prevails outside the box. Come on … think it through, I say to myself. Silence breaks with questions that I don't answer thoroughly. Less reluctant residents commence problem-solving aloud; others follow. I can feel their enthusiasm and insight building as we assimilate the day's topic. Time is up. Walking back to my car, I'm satisfied. You see, I remember a mentor's shared wisdom—that good teachers create just enough uncertainty in their pupils, such that their only escape (from it) is through deliberation. My hat came through again.
What I do is not unique. Physicians practicing in the community used to provide most clinical teaching in medical schools (1). This legacy persists in our department of psychiatry and others (2). However, I know that I'm one of the lucky ones who can still donate my time to fledgling clinicians, unlike the growing population of clinical faculty who have succumbed to changes in the American health care system (3). I can't quite put my finger on the root of my good fortune. Perhaps it's because I believe in the law of indirect effect (4). Perhaps it's because I observed the importance of duty and tradition in my father's life and other World War II veterans I came to know in my youth. I'm at a stoplight now and amidst a canvas of wandering thoughts, I recall that my favorite men's store is having a ‘sale’. Perhaps I'll check out their accessories.