The Correct Dose
by Mike Litrel, M.D.

professional distance. Danielle made me mad.

Residency training felt like an assault on my soul. There were many reasons, perhaps. But the part that got me the most was seeing the innocent babies. You'd sweat and struggle to bring a baby safely into the world. And then send it home with a mother you wouldn't have trusted with a houseplant, let alone a baby.

Still, I had to believe there was hope. So I tried a new strategy with Danielle. I brought an ultrasound machine to the psychiatry floor. I wanted to show her the beautiful human being growing inside of her body. I wanted Danielle to know that her decisions were affecting someone else. I spent 30 minutes on the ultrasound and gave her a dozen photos. A few times I thought I saw a hint of a caring, expectant mother in her face. But as I was leaving she once again said, "I just need something more to hold me."

It was like a volcano erupting inside me. Never before had I yelled at a patient, but I began to yell at Danielle, and once I'd begun I was afraid I would never stop. "These psychiatrists may be interested in what you have to say! But I'm not a psychiatrist and I'm not interested in hearing all your psychobabble! That baby inside of you is as much my patient as you are - he's the only reason I'm here! And you are hurting that innocent child. You need to SHUT UP and change your life!"

It was perhaps not my most professional moment. As I angrily stomped off the psychiatry floor, the guard hesitated before letting me out. Like maybe he thought I was an escapee. I spent the rest of the day wondering how I would be fired. But the next morning found me still with a job, and even more remarkably, with a transformed patient. Danielle stopped running her mouth, and stopped asking me for more methadone. For the remainder of the month, the only thing I really heard from her was "Yes, sir," and "No, sir," and "Thank you, Dr. Litrel." I assumed she was just frightened for her life. But a few weeks after her discharge, when she showed up to the obstetrical clinic, she refused to see any doctor but me. I couldn't tell if I was more touched, or annoyed.

Her remaining prenatal appointments passed uneventfully. I didn't get to deliver her baby, but the day after, I took great pleasure in honoring her request to tie her fallopian tubes. I cut them, tied them, burned them - everything short of throwing them on the floor and stomping on them. Danielle's baby required a prolonged hospitalization for methadone withdrawal, as expected. And as with her first baby, Danielle lost her child to the foster child program. The DFACS case worker assured me Danielle would never regain custody of her child.

So I was shocked a couple months later when I looked through my clinic window and saw Danielle, pushing a baby carriage outside the hospital. Once again the system had failed. I suppose I shouldn't have been surprised. Danielle always was a good talker. I brooded for a few minutes, wondering what kind of mother a heroin addict makes. But then I shook it off; no sense crying over spilled milk.

But two years later Danielle surprised me again. She returned to my clinic - with her young son. She wanted me to know she had a good job, and that she had been off all drugs for almost a year. She thanked me for caring about her during her pregnancy. She even thanked me for getting angry with her. "But you know," she said as she was leaving, "you were wrong all along - and I was right." She dropped the bomb. "I really did need more to hold me."

My face constricted in disbelief, and my mouth opened to say God only knows what. But then I caught a glimpse of Danielle's face. Those intelligent eyes of hers were laughing at me. She watched me as she picked up her son, who threw his arms around her neck. And I got it. Danielle closed her eyes and squeezed him for a long moment.

Then her voice was serious. "You know, Dr. Litrel..." She took a deep breath to collect herself. "After all these years, I think I'm finally on the correct dose."

Dr. Litrel is in practice at Cherokee Women's OB/GYN in Woodstock and Canton and is a Clinical Assistant Professor at Emory University School of Medicine. He lives in Towne Lake with his wife Ann and their two sons Tyler and Joseph. (mikelitrel@attbi.com)

There came a day in my second year of residency when I couldn't take it any longer. I told my patient Danielle exactly what I thought. I pounded my fist on the table, pointed my index finger point blank at her forehead, and unloaded a full round of anger and frustration right in her face. Then I stormed off, exhilarated, like the winner of a street fight. After I calmed down, I realized I would probably be fired. But frankly, I was too tired and burnt out to really care.

The second year of the OB/GYN training program at Grady Hospital was a job anyone would be glad to lose. The workload was 80 to a 100 hours a week. "Downtime" was a nap in the call room. "Socializing" was a conversation about stopping blood loss. Furthermore, the stressful atmosphere of the operating room made for a bad work environment, where human beings were rude, demanding, and - let's face it - dysfunctional. And sad to say, I fit right in.

Thus, it was an interesting change, during my month of High Risk Obstetrics, to gain a patient on the psychiatric ward. The psych ward was a world apart from the rest of Grady Hospital. I noticed it right away: the attending physician actually asked me my name and where I was from. At first I was confused, and then I realized what was happening. I was having a civilized conversation.

On the psych ward, all the doctors were nicely dressed and appeared well-rested. With no impending medical emergencies, they were able to spend morning rounds in prolonged intellectual discussions, like something you'd hear in an Ivy League dorm. Dressed in my stained surgical scrubs, blurry-eyed and disheveled, I felt out of place. But sitting back, drinking coffee and eating crumb cake, I had to wonder if perhaps I'd missed my calling. It didn't take me long to figure out that I had not.

My pregnant patient - Danielle - was a heroin addict, and had been for longer than a decade. It was a point she brought up repeatedly in trying to persuade me to prescribe her more methadone, an alternative narcotic given to heroin addicts. Highly intelligent and very well-spoken, Danielle complained of so many varying psychological symptoms that the psychiatrists couldn't agree on her diagnosis. Over the course of the month that she was under my obstetrical care, her medical chart got thicker and thicker with the long notes penned daily by the psychiatrists. And almost daily, it seemed, they increased her dose of methadone. Until I recommended they stop for the sake of the pregnancy.

"I need more to hold me," Danielle would say. "My dose was almost twice as high when I was pregnant 10 years ago." Again and again, I explained that the baby inside her body was also addicted. It would suffer unimaginable withdrawal symptoms after its birth. But her other baby had done just fine, Danielle would counter. It was a comment that made my blood boil.

I thought about Danielle a lot. Why, after delivering a baby addicted to narcotics 10 years ago, was she still a heroin addict? Was drug abuse really the incurable disease to which the psychiatrists had surrendered her? Her chart connoted ideas like "victim" and "sickness" and "childhood angst." Nowhere to be found were words such as "responsibility," or "right and wrong." I couldn't seem to maintain proper