Autobiography Among Bureaucracy
One life in medicine, in two parts
The New Physician July-August 2010
by Eva Mathews, M.D.Volume 59, Number 5
The Kitchen Shrink: A Psychiatrist’s Reflections on Healing in a Changing World, by Dr. Dora Calott Wang, reads like it was written by two authors.
Wang writes from two perspectives and writing styles. The first is broad and serene: life as a medical stu-dent, resident and attending. In simple and elegant words, she chronicles her life as a wife and a mother, of patches of snow melting into puddles on her walk to the hospital.
The second perspective is a stark contrast, written with efficiency and a sense of urgency. There, The Kitchen Shrink (Riverhead Books, $25.95) describes how psychiatry and health care changed for the worse since Wang began medical school at Yale University in 1985.
Wang writes of her psychiatry residency, which began in the early 1990s when SSRIs were sweeping the psychiatric field, and the nation. Everyone was starry-eyed about these new drugs. This began the “decade of the brain” and the decade that psychotherapy began to take a back seat to medications. She describes the creation of HMOs and insurance companies increasingly controlling more patient care decisions and doctors’ time.
This history was illuminating to me. As a recent medical school graduate headed for my psychiatric resi-dency, I knew the details of the current state of psychiatry and health care, but I didn’t know how we got there.
Now I understand why the first words my preceptor uttered to me in my first year of medical school were, “Don’t go into medicine” (to which I jokingly replied that it was too late and that I was already too much in debt).
At the time, I did not understand where my preceptor was coming from. Why would he tell a first-year med-ical student not to become a doctor? As an optimist, I didn’t listen to his advice. I was excited about becoming a scientist and a healer—in a word, a physician.
Now, as I enter residency, I’m still excited. That’s why this book seemed daunting at first. It looks critically at the current state of medicine, which Wang considers a wreck. I didn’t want to think that doctors and the health care system were failing patients. However, she presents significant evidence to back up her claims: Patients can’t afford health care; doctors can’t get paid to care for patients as well as they know they should; and insurance companies run the show.
Wang described moving to a small town and partnering with another new psychiatrist to cover weekends at an inpatient hospital. The hospital administrator described the other psychiatrist, whom the author calls “Dr. Purple,” as “efficient.” The doctor wore fitted suits and had immaculate blond hair. She drove a Cadillac and, in short order, her husband was already “chumming with the good ol’ boys at the country club.”
Dr. Purple may have looked the part, but whenever Wang saw her counterpart’s patients, she found mis-diagnoses, inappropriate medications and prescriptions that were causing harsh side effects.
This “efficient” doctor also kept insured patients longer than Wang thought was necessary and discharged uninsured patients sooner than the author thought she should have. Wang recounts a nurse on the ward de-scribing this practice by saying, “The ones with insurance get the white glove. And the other patients, I don’t even want to say.”
By all appearances, the author suggests the all-business, well-manicured Dr. Purple could as well have been mistaken as working for the insurance companies.
Wang wrote that her counterpart did what made the most money, not what was best for her patients. And this kind of doctoring was handsomely rewarded. While Dr. Purple spent less time with her patients than Wang, she made far more money.
In an example of the strange and flawed health care system, although Wang taught psychotherapy as pro-fessor of psychiatry at the University of New Mexico School of Medicine, she could not practice it.
Wang wanted to provide psychotherapy to all her patients, but insurance companies would not pay for it.
The author decided she could not, in good faith, teach therapy without providing it herself. As a compro-mise, Wang saw one psychotherapy patient on her lunch hour, for free, so she could keep up her skills and teach with integrity.
The book’s power is in its demand for change. Physicians and medical students need to know the history of what led us into a system that won’t pay for a patient’s dialysis, but will pay for a helicopter to pick up the same patient days after.
The book changed the way I thought about the health care system. Before, I was not interested in involving myself with health care reform and legislation. Now, I realize that I must be involved if I ever want the system to change.
It was doctors leaving themselves out of the decision-making process that led to a health care system that’s all about money and the insurance companies, and not about doctors and patients.
Wang’s narratives about her life and real patients back up her message about our broken health care sys-tem. But some of her autobiographical details distract from her overall message about our broken health care system. The way she combined her personal narratives with her critique of health care makes the book a bit disjointed. That said, her words could be better applied in a work such as a pure autobiography, instead of working to change a bureaucratic system of health care delivery.
Adding to that disjointed quality is a confusing chronology that begins in the early 2000s, flashes back to 1985 and then leaps to 2007. I would like to see her use that simple, elegant prose more. Yet its grace is lost in a book whose overall purpose is to deliver an urgent message about the destructive direction that health care is heading in this country.
Don’t get me wrong. I would enjoy getting lost in her lovely words. But I feel it would be in another book that would more effectively showcase her literary talents.
Eva Mathews is a recent graduate of Tulane University School of Medicine.