My Dad’s Law of Psychiatry: The most important tool in your shop is a white handkerchief.
When I was an intern, I was pretty good at procedures. Which means I could stick needles in people and hit the right unseen person part (good) and not the wrong one (occasionally disastrous).
When you are a medical intern, this matters. The ability to get access to a large central vein or an artery can save someone from being far up Excrement Creek with no means of propulsion.
This might be an odd point of pride for a psychiatrist, but I think the way I sank those central lines is much the same way I approach psychiatry.
You will occasionally hear people talk about how medicine is an art, not a science. This is utter crap. Medicine is neither an art nor a science, and frankly I think doctors just love to portray it as either because we sound far more highfalutin than what we are.
Medicine is a craft.
We are trades(wo)men.
Science is concerned with developing knowledge through a rigorous system of doubt and observation. Medicine, in the sense of doing medicine, is not about making knowledge. It’s about using that knowledge to get a result.
Art is about getting a result too, but it’s an aesthetic one. Medicine is not about aesthetics.
A carpenter can make an absolutely beautiful joint. If it doesn’t hold, it’s still a failure. The fundamental aesthetic of the crafts(wo)man is in how simply, elegantly, and cleverly he can make something that works.
My father is a mechanic by trade, though he’s the sort of Southern post-Depression farm boy who knows how to do a little of everything. Most of the house where I grew up, he put together. He can fix damn near anything that rolls and a significant number of things that float.
He taught me his Law of Psychiatry, which really is a fundamental law of all trades, when he showed me how to rebuild a carburetor.
My Dad worked mostly on small engines, like lawn mowers. The fuel and air mixture is controlled by a device called a carburetor. Most of these look like a miniature Borg cube on the outside and the nest of an aluminum-eating termite on the interior. They use a set of diaphragms, springs, and valves to meter the flow of fuel into the air stream entering the engine.
On small engines, some of these bits are minuscule. One bit of grit, a drop of water, or a hardened seal that allows a little leakage can turn it into a paperweight. Which is why they often have to be cleaned and rebuilt.
When my father taught me how to do that, he pulled out the white handkerchief he carries everywhere and laid it on a bare area of the bench.
“This,” he announced, in that weighty I’m teaching you something so listen up kid tone, “is the most important tool you have.”
Into the center he placed the carburetor. As he disassembled it, he placed each part at progressively smaller distances from the carburetor body, until upon that white handkerchief sat a realized version of the schematic from a parts book, with the carburetor exploded yet the place of each piece in the whole obvious.
Because you saw how they came apart, you saw how they came together. The notch in the needle valve obviously fit that tab in the float, and the spring pressed in the opposite direction. So there, on that white handkerchief, three little chunks of metal turned into a poised equilibrium between buoyance, tension, and resistance.
After that, Dad replaced each of the old parts on the white handkerchief with the new ones, and put the whole thing together again with an almost musical rhythm.
In my memory, this is the place where the value of method crystallized. The pragmatics of the method are obvious – it keeps you from losing stuff and helps you remember what you did.
There’s more to it, though. Method, you see, is a means to understanding. Because we’re talking about craftsmanship here we are talking about understanding that works; the kind of knowledge that really is power. It’s the way you break something hopelessly complicated into pieces that can be managed, which lets you encompass all that hopeless complexity and do something useful in spite of it.
I remember in residency a meeting with a group of psychoanalysts who were to teach us psychotherapeutic technique. One of them, when discussing a particularly algorithmic form of psychotherapy, disparagingly compared it to “paint by numbers” while implying psychoanalysis was more akin to “van Gogh.”
See, the thing is: I’m not @#$%ing van Gogh. If I did paint-by-numbers, at least I’d come out with something recognizeable. If I tried being van Gogh, I’d have something only my relatives would hang on a wall, and that would be in the basement.
People aren’t canvases and the goal when you’re dealing with someone who’s suffering is not to use her to demonstrate your artistic psychotherapeutic genius to your artistic therapeutic genius pals. It’s to do something that works in a way that it keeps working. It is this emphasis on the literary over method that is my major gripe with analysis, and I think its ultimate downfall.
The methodical way leaves you with a working carburetor, repaired quickly, efficiently, and with a bare minimum of cursing. (In fairness, those little springs are %^~@#ers. They can fly like bullets and render themselves invisible instantly.) It ain’t Starry Night, but it will cut grass.
(I challenge anyone to produce a metaphor more mixed than that one.)
When I was an intern and opened the central line kit the first time, I instantly recognized the most important tool in the box. It was the spare sterile towel that wrapped the kit. It was blue paper, but I knew it for what it was. The White Handkerchief.
Upon that blue towel, I extracted every bit of that kit, lined up at increasing distance from my hand in order of need. Looking at that setup was like Satori, coming home, and a pulled pork sandwich all rolled into one.
That’s the aesthetic of the thing. The beauty of the system, that clean white surface like an inhaled breath waiting.
Yeah. I am a compulsive freak.
The White Handkerchief, of course, isn’t necessarily a thing. Sometimes it is that most wondrous and useful of medical tools, the 3×5 card. Sometimes it is the three seconds at the end of the interview when you take a breath, close your eyes, and all those pathways you’ve burned into your head over the last two decades spit out what they’ve been semiconsciously processing while you’ve been listening, lined up left to right: behaviors, reinforcers, alternate behaviors, new contingencies. Syndrome, course, response to prior treatment, next option.
Most of the time, though, it’s the few minutes before I sit down with a new patient. In my head I have a square of white cotton unfolding over a banged-up metal bench, between two thick hands on which small cuts and grease are so constant they are part of the flesh.
Then, I’m ready.