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March 5, 2003

First Day

JAMA. 2003;289(9):1168. doi:10.1001/jama.289.9.1168

At 8 AM on the first day of my clerkship, the head psychiatrist herded me into the elevator with two grim-looking residents.

"So?" Dr Stone strained to read my ID. "Rubens, you want to learn psychiatry?"

I looked around. I was the only student. I nodded.

"Tell me, Rubens," Stone smiled, "what sort of doctor do you want to be?"

At the eighth floor, an old man with a hearing aid was wheeled into the elevator on a gurney. He was thin, his face was still, but his arms and legs were shaking all over.

"Rubens, I asked you a question," Stone raised his voice. "What kind of doctor?"

"I am having a colonoscopy," the old man said. "Don't ask me questions."

"What kind of doctor?" Stone whispered.

"I have no idea," I said.

"Good." Stone said. "This is your first day. You have an open mind."

Two of my cousins were surgeons and I had scrubbed in first year. Still, I was left-handed and the sight of too much blood worried me. My uncle Morris said the future was in radiology. "Listen, Howie, don't be stupid like your cousins," Morris said. "Surgeons don't sleep." I had another uncle who was a GP. Harry was a tough army doctor who had taken me on house calls when I was a kid. He thought I should join his practice, together with his two sons. My father, an old-time druggist, had advice too: "Stay away from drug stores," he said. "Fighting discount chains is no life." My dad had wanted to be a doctor like the rest of the family.

I felt uneasy around psychiatrists. They stared at you like they were window shopping. I thought they looked inside and read my mind. Dr Stone was six foot four with black frizzy hair. Everyone else in the hospital wore white or green, but Stone dressed in black. Stay out of Stone's way, the residents said.

"Who's seen a Munchausen's?" Stone asked.

By now the elevator was on the sixth floor. It took exactly a half hour to get from the tenth floor to main. Patients gave birth in the elevators, they died in the elevators. You could read two chapters of The Brothers Karamazov from top to bottom.

"Dr Rubens, have you heard of Baron Munchausen?" Stone smiled.

"No. I'm sorry."

"Don't be sorry. Look him up in your Kaplan and Saddock."

I wrote down the names. I had never heard of Kaplan or the other guy.

"Dr Rubens. What is the difference between a psychosis and neurosis?"

I opened my mouth, like I was going to speak. Nothing came out. I had read somewhere that a neurotic dreams of castles in Spain, while a psychotic lives in them, but I was not sure. To tell you the truth, I was never sure of anything. I was the guy in class who never put up his hand.

Eventually we got out of the elevator and one of the grim-faced residents reviewed the overnight emergency cases. He had been up half the night. The other resident was on call that day. No one in that room was happy except Dr Stone who smiled like Hannibal Lecter and asked questions. I never actually thought he was going to eat my face, but who could be sure? Stone interrupted the resident and asked what his diagnosis was. He asked about drug doses and sites of action.

"Dr Rubens," Stone smiled and turned to me. "What's the standard drug of choice for agitated or manic patients?"

"Haloperidol," I said.

"Not bad." Stone turned to the two residents. "Would you try anything else?"

"Olanzapine," the woman resident said.

"Quetiapine possibly," I said. My dad had told me about the new antipsychotics.

Stone nodded. "Rubens. What is the typical starting dose of haloperidol?"

I had no idea. I said, "40 milligrams."

"Oh." Stone had a big smile on his face. "You say only 40?"

"I mean 400," I said. "Yes. 400 milligrams."

"Are you sure? Wouldn't 4000 milligrams be more appropriate?"

Stone's face had become still. His smile had vanished. I turned to look at the two residents. Their faces were gray.

"400 milligrams," I said again.

"I see. 400 milligrams of haloperidol," Stone said. "You give it all at once?"



"In the buttock," I said. "Intramuscular."

"Intramuscular, Rubens. That's very good," Stone said. "Very good."

The two residents had stopped breathing. They sat like statues, staring at me.

"And which country will you be practicing in?" Stone asked.

"Did I do something wrong?"

"If you were practicing veterinary medicine, 400 milligrams IM is a good dose. Of course it would have to be on something large. A bull elephant, perhaps."

That afternoon I bought Kaplan and Saddock. For the next few days and nights I read like a fiend and made notes. Then I made notes of my notes. My cousins, my uncles, and my father looked over my shoulder and held their heads in shame.