Fiction Policy

Automated Psychiatrist Machine.

Are you tired of waiting fifteen minutes only to spend ten minutes with your psychiatrist? Do you hate rearranging your busy schedule, fighting traffic, and trolling for a parking space just to spend a few minutes with your doctor? Wouldn’t it be easier if you could take care of your mental health according to your schedule, instead of someone else’s?

We are pleased to introduce the Automated Psychiatrist Machine (APM). The APM is an advance in medical technology that dramatically increases the efficiency of patient care and results in high patient satisfaction scores.

We know what a typical appointment with your psychiatrist is like: You check in and sit in an uncomfortable, crowded waiting room with strangers. You then see your psychiatrist, who may (or may not) ask you about your current symptoms. Maybe you just talk about your recent vacation or your plans for the holidays. He might ask you about side effects. Maybe the only question he asks you is how many refills you want. You wish that you didn’t have to see him every three (or six… or nine…) months, but he won’t write prescriptions for you if he doesn’t see you.

“But I’m fine. Do I really need to come in every six months?” you ask. The meds help. You don’t want to talk about stuff. You are a busy person with things to do and multiple lives to live. Who has time for anything else?

This is where the Automated Psychiatrist Machine comes in.

Located outside of various medical centers, APMs allow you to take control of your care. Do you work day shifts or care for children and it’s just not convenient to see your doctor during the day? Go see the APM after work. Did you get sick and now must reschedule your appointment? Go see the APM when you are feeling better. The APM is open and available 24 hours a day, seven days a week.

The APM has a touchscreen that will guide you through questions your current psychiatrist may (or may not) ask:

  • How many hours are you sleeping?
  • Have you noticed any changes in your appetite or weight?
  • Are you experiencing any side effects from medication?

The entire interaction takes less than five minutes. Once you answer the short set of questions, the APM will print out your prescriptions that you can take to a pharmacy at your leisure. Additions and adjustments are made to your medication regimen according to an algorithm.[1. The APM medication algorithm may not be evidence-based or take into consideration your specific symptoms or side effects.]

There is no reason for you to see a real psychiatrist anymore. Make no mistake: your psychiatrist will still be your psychiatrist, but you just don’t need to actually see him.

Psychiatrists, the APM can increase your productivity and efficiency, too! A small videocamera on the APM captures video of the patient so you can document a mental status exam. The more patients you refer to the APM, the more patients you can “see” in one day! According to research, the average interaction with an APM lasts about four minutes. That means you could potentially “see” 120 patients a day![2. Psychiatrists using APM could potentially see 15 patients an hour. An eight hour day thus equals 120 patients. Compare this to the 25 to 30 patients you see a day now.] And if insurance companies are willing to reimburse $120 a patient, you can see how the numbers add up.

And because of advances in technology, psychiatrists can now work from home. You don’t need to get up and go to your office. APM can securely channel video to your home computer so you can both review the questions patients answer at the APM and perform mental status exams. You’ll essentially go through the same interactions that you had with your patients before, except you don’t even need to be in the same room as them. You can still assert that you’re a psychiatrist, even though you never actually directly interact with patients!

The Automated Psychiatrist Machine will improve quality of life for both patients and psychiatrists alike. Ask your psychiatrist about the APM today.

Fiction Lessons Observations



Her shouting is like a gas: It completely fills the space, regardless of the size of the container. The sound originates deep in her abdomen and bellows from her mouth before reverberating throughout the room.


Her wrinkled hands flecked with liver spots loosely hold a fashion magazine open. Long strands of her gray hair are falling into her dark eyes.


Spittle flies from her chapped lips as she roars. Her eyes are focused on the empty chair directly across from her.


A receptionist, a doctor, a nurse, and a dietician all stand around her in the waiting room. The shouting woman is waiting for her appointment. The staff are waiting either for her to calm down or for the last cue to escort her out.

Silence fills the room like a gas. The woman’s lips are stretched into an uncomfortable grimace.

Seated directly to her right is an older man. He still has not looked around the sheet of newsprint he is holding. He has not shifted position. The newspaper does not rustle.

Seated to her left is another man who is holding a small cell phone in his right hand. His right thumb periodically pushes a button on the phone and his eyes remain fixed on the small screen.

Two men and one woman are seated across the room. The woman continues to dip her crochet hook into the yarn; the hook has not stopped since the shouting began. One man has his arms crossed; his chin is tucked in and his eyes look closed. The other man rests his elbows on his knees, his fingertips lightly touching, and his eyes stare at the floor. If he has flinched, no one has noticed.


This story isn’t about her. It’s about the other people in the waiting room.

What happened in their lives that gave them the stoicism to completely ignore her?

They didn’t get up. They didn’t change seats. They didn’t stare with curiosity or fear. They didn’t look at each other with knowing eyes.

None of them had met her before, but they were already familiar with her behavior.

What happened to all of them?

Did their parents only scream at them? Was a shouting parent more comforting than silence, as that meant that at least a parent was present? Did they learn to tune out the shouting when they were incarcerated? Were they beaten as adolescents, such that shouting like this was a benign alternative? Did strangers only shout at them, making this situation nothing out of the ordinary?

How did they learn to cope like this? Who or what trained them to react like this, to react with nothing at all?

Education Fiction


It was 4:38pm and the consult pager beeped. The attending psychiatrist sighed with displeasure. That pager always seemed to go off during those last few minutes at work.

The resident returned from the phone call and reported, “It sounds like there’s a young woman who just got through surgery. She’s in the PACU (post anesthesia care unit) and won’t stop crying, no matter how much pain medication she gets. Surgery is asking for help.”

The attending looked at his watch and grunted. “We don’t have to do a full consult now. We can patch things over for the night and finish up tomorrow.”

His legs were long and the tassels on his loafers swished with each step he took. To keep up with him, the resident was almost running.

When they arrived in the PACU, the nurses looked up. As they put their heads back down, they wordlessly pointed to the other side of the room.

Laying in the gurney was a young woman who was sobbing. Her breaths were irregular, choked. Tears flooded her flushed cheeks and plastered locks of hair to her face. The hospital gown was too big for her and she was somehow slumped in a reclining position.

The attending approached and wrapped his hands around the railing of the patient’s gurney.

“My name is Dr. Tom.”

A new wave of tears washed over the patient. Shoulders quivering, she put her hands over her face and nodded at him.

“We’re from the psychiatry service.” He tilted his head to gesture at the resident standing behind him, who nodded and offered a meek smile. His speech was cool, clipped. “The surgeons say that you’ve been upset since the surgery. What happened?”

“I… don’t… know,” she sobbed through her fingers, her voice thin and strained.

“Are you feeling sad?”

Uncovering her face, she nodded. She raised a limp hand and wiped her eyes.

“Are you feeling scared?”

“I’m… so alone,” she blurted between gasps. “No one is here. No one is taking care of me.”

“Uh huh.”

The resident glanced at them. The patient looked distressed and the attending looked bored. The resident shifted uncomfortably.

“Miss, can I ask you a question?” Dr. Tom turned and cast a knowing glance at the resident: Pay attention. Here comes a clinical pearl.

The patient nodded, her red eyes still welling with tears.

“Were you sexually abused when you were a kid?”

The resident felt her breath catch in her throat.

The patient’s chin began to quiver. She tore her eyes away from the attending and buried her face in her hands. After choking on a few gasps, she mumbled, “Yeah.”

“Okay,” Dr. Tom said, leaning back and releasing the gurney rails. “Some people feel alone and scared after surgery. We’ll ask the nurses to give you more pain medication, that’ll help you feel more comfortable. We can talk more tomorrow morning, maybe about ways you can feel less lonely while you’re here.”

The patient nodded, sniffing.

“So we’ll see you tomorrow. Good-bye!” He flashed a toothy smile, waved, and walked away.

The patient looked at the resident, who waved weakly before turning to catch up with the attending.

Once out of PACU, the resident blurted, “Why did you ask her about sexual abuse?”

“Borderline personality disorder. They often have a history of sexual abuse. Her presentation was consistent with that diagnosis.”

She opened her mouth to say, No, I meant why did you ask her about it at that moment? Couldn’t it wait?

Instead, she heard herself say, “Oh. Thanks.”

“No problem,” he said, flashing that toothy smile at her. “Now you know what to ask when you see a similar patient in the future. Have a good evening!”

She watched him walk away and wondered if she had done the right thing.


Just a Little.

Originally written in 2004.

It’s just a little after five o’ clock in the morning and I’ve come to see you. I ask if I can perform a pelvic exam on you; you reluctantly say yes. I try not to think about it too much as I insert my gloved fingers into your vagina, feeling your body tense with pain as I try to hasten my examination. I withdraw my hand from you, the fingers glistening with millions of particles of HIV.

It’s just a little after five o’ clock in the evening and I’ve come to see you. You’re not in the room, but your vomit is. Bright, chunky, thick red stuff that has splattered all over the white tiles of the floor. You didn’t even have to stick a finger down your throat. You’re 19 with a variant of anorexia and bulimia. All you have to do is think about it and you can make yourself throw up. You’re thin, almost too thin, but you think you’re terribly fat. You’re also terribly lonely, terribly empty, and terribly beautiful, but never beautiful enough.

It’s just a little after one o’clock in the morning and I’ve come to see you. You’re ignoring me but you roar to life when I dig my knuckles into your chest. You shout at me that you f—ing have respiratory problems and that you have a f—ing difficult time breathing and that you f—ing just want me to leave you alone, goddammit, because you’re in the f—ing hospital and why can’t you just f—ing be left alone in the f—ing hospital because you just don’t feel like you can f—ing breathe, goddammit. So why don’t you f—ing just go away, goddammit. And then you ignore me completely, pretending you are asleep.

And then you assault the nurses and we put you in three-point restraints.

It’s just a little after two o’ clock in the afternoon and I’ve come to see you. There is only one thing left to do before we can send you home. You’re doped up on morphine because your back is killing you. Your mother died last year, your wife died this year, and you live alone with your seventeen-year old daughter. Alcohol helps take the pain (which pain?) away. Neither you nor I are pleased about what I need to do, but we get it done quickly: You roll over, I pull down your pants, you shift slightly, I put on the glove, you breathe in, I insert my finger, you tense up, I withdraw my finger, and we both exhale in relief.

No blood in your stool, sir. Now we can send you home.

It’s just a little after two o’ clock in the afternoon and I’ve come to see you. Your feet are purple, your face is red. Chocolate brownie is in your hair and tears stream down your face. You lean forward, I try to sit you up. You keep leaning forward, choking on your tears, drowning in your love for methadone. If you don’t have it, surely your heart will break. You’re acting weird, why? Your body is acting weird, why? I want you to get better now, now, NOW, because I want to go home. I’m tired and I can’t think straight. And yet you look sicker and sicker and sicker.

It’s just a little after four o’clock in the morning and I’ve come to see you. The water reflects the slightly orange lights of the city. Layers of grey clouds coat the horizon. I see the trails of lights of the city streets. It is a different world, a silent world, a world where people aren’t sick. It seems so far away, even though the realms are separated only by a plate of thick glass.


The Illustrious Dr. Vane.

I originally wrote the following in 2006. The character of Dr. Vane is based on two physicians at the medical school I attended. One evening, a good friend of mine, now a radiologist, saw one of the physicians walk out of the hospital. Struck by what she saw, she uttered the last line of the story. That line inspired me to write this tale.

Once upon a time, in a hospital far, far, away, there was an aging man. His name was Dr. Vane.

Dr. Vane was a senior attending surgeon and tenured as a professor. His fellow surgical colleagues viewed him with great admiration; the surgery residents deferred to him with great reverence; the medical students shied away from him with quivering fear.

The pate of his balding head, ringed with neatly-trimmed grey hair, gleamed underneath the fluorescent lights of the hospital. Deep-set eyes of liquid jade, an aquiline nose, and a strong jawline created a profile that commanded respect and communicated confidence. Time had left multiple wrinkles in his face and the looser skin gently dangled from the scaffolding of his skull. A sharp dresser, he always wore crisp, long-sleeved dress shirts of muted, solid colors; dark, pleated slacks that fell perfectly along his legs, such that the one-inch cuff stopped only one-half inch from the floor; a brightly patterned (but tasteful) necktie in a Windsor knot; and black leather loafers without any scuffs. Over this ensemble was his long, white coat that lacked any blemishes or loose threads. Christopher Vane, MD was embroidered upon the left chest of his coat with royal blue thread. One single pen, encased in a shell of polished silver, was clipped inside his pocket.

(When he wasn’t in the operating room, of course.)

He shuffled quickly. Although he was only leaning forward from the waist, people often thought that his entire body was tilted forward as he walked through the hallways. It was as if his body was trying to keep up with his head, that cranium that held the brain that knew so, so much.

Everyone—everyone—gave him a wide berth when they saw him approaching. It mattered not if he was in the cafeteria, purchasing a small cup of coffee—”no cream or sugar”—during the morning rush or if he was leading rounds in the intensive care unit (ICU) with the sixteen-member surgical team; the sea of people parted around him upon sensing his presence.

“Good morning, Dr. Vane,” everyone breathed, hushing their voices a bit as they greeted him. Sometimes people would try to hold his piercing gaze, but most failed. They had to look away—down to the floor, specifically.

Sometimes Dr. Vane offered a terse reply with his solid, tenor voice: “Morning.” Other times, he simply continued walking, the slight breeze from his rapid ambulation the only evidence that he was present.

“GET OUT OF MY OPERATING ROOM!” he occasionally roared, hurling the Kelly scissors across the room. They landed with an unsettling clatter on the drab green tiles. The scrub nurses simply turned to the steel table covered with sterile blue cloths and plucked another pair of Kelly scissors from the smorgasbord of surgical instruments before them. The medical students pulled on the retractors a little harder. And the stunned resident paused, still clutching the Mathieu needleholder.


The resident, shunned, plodded from the operating room. Dr. Vane muttered obscenities under his breath.

“What is a reducible hernia?”

Dr. Vane believed in, practiced, and was well-versed in the art of pimping.

“And an incarcerated hernia?”

Medical students never felt at ease around him.

“And strangulated?”

At least one of them burst into tears in front of the entire team during each rotation.

“How about a pantaloon hernia?”

Everyone said, though, that Dr. Vane was incredibly smart and talented. Everyone could learn something from him and that encyclopedic brain of his.

“What? You don’t know? Have you even opened a book since you’ve started this rotation? You must be one of the laziest medical students on rotation right now. How about Littre’s hernia?”

“No? Then go home. You’re useless. Don’t come back until you know the different hernias.”

Dr. Vane seemed to always be in the hospital. Some of the residents (privately) joked that he never left. “He’s dedicated to his work,” they remarked. “When he’s not operating, he’s writing journal articles and book chapters. Have you seen his CV? It goes on for pages and pages!”

And there was some truth to their words: Residents had witnessed him breezing through the ICU while they were frantically pre-rounding before twilight had melted into dawn. Medical students attempted (and failed) to discreetly walk past his office, the door usually ajar, after their morning lectures. He was invariably the first person present for morning report. The on-call residents noted that he frequently answered their pages from a hospital telephone. Even if it was well past 11:00pm.

Dr. Vane, however, did leave the hospital, although he always longed to return. He did not enjoy shopping for groceries, getting gasoline for his car, standing in line at baseball games, or dining with his family at restaurants.

Other people never gave him any respect. The young lady at the grocer accidentally hit him in the right hip with her cart and she did not even notice (let alone apologize) for her error. The attendant at the gas station didn’t say anything; he just took his money and crassly chewed on gum with his mouth open while Dr. Vane sat in the leather seat of his luxury sedan, waiting for the time to pass. The people sitting in front of him at the baseball game frequently stood up (thus obstructing his view) and the crush of people frequently wobbled into him, jostling him much more often than he liked. Some of the teenagers looked at him and smiled in apology—always with a somewhat pitiful expression on their faces. Waiters and waitresses brought the cheque too early and did little to mask their impatience while he pored over the menu.

Outside of the hospital, he was not the illustrious Dr. Vane.

He was just another old man.