Chapter 71: Dual Diagnoses

November 27, 2000, Chicago, Illinois

“Hi, Tiger!” Jessica exclaimed when she walked into the house.

“Hi, Babe! How was your day?”

“You know those days when you want to beat your head into your desk? This was one. I swear, if there’s a dumber crop of first-year med students ANYWHERE, I’d be shocked.”

“I believe your dad said something similar about YOUR class when I first met you! And you were 2nd year students!”

“He meant the REST of the class! You did better on his pop quiz, by any measure, than anyone except for me! And you weren’t even a medical student!”

“He offered,” I chuckled. “I still have the lab coat upstairs! What happened today?”

“I gave a pop quiz, had them hand the paper to another student to grade, then wanted to cry. They’ve been studying anatomy with me for three months and YOU would do better than they did.”

“I do have an advantage,” I grinned. “I’ve been studying YOUR anatomy for fifteen years!”

“I need to change into comfortable clothes. Come upstairs?”

“Sure! Is there going to be a pop quiz?” I said, arching an eyebrow. “Dinner is in the oven.”

“We can discuss the quiz later! I need to change first!”

We headed up to the bedroom so Jessica could change from her blouse and skirt, which was the uniform for female professors.

“How was Saint Martin?” she asked.

“I had a nice relaxing time with Annette and also had the chance to explore some virgin territory.”

“OF COURSE YOU DID!” Jessica exclaimed, laughing softly.

“I also ran into a former dalliance, but I can’t tell you who or where because I can’t violate her privacy. Suffice it to say I followed all rules and it’s nobody that anyone would object to.”

Kara’s eyebrow raised, “Now this might be an interesting sleuthing opportunity!”

I shook my head, “The individual in question made it exceedingly clear that nobody could know, so I can’t play games with you. And this does fall under ‘manage your own sex life’.”

“It does...”

“I’m going to see Doctor Mercer on the 13th. I’ll be home in time for our anniversary dinner on the 15th.”

“Imbalance?” Jessica asked.

“I’m feeling that way, yes. I need to go someplace to restore «lagom». I really need to go to Oguni for a month or two, but it’s not practical. I mean, sure, we can afford it, but I can’t go away for that long. I’m hoping Doctor Mercer can suggest some strategies that will work right here.”

“Are you trying to say you feel manic?” Jessica asked warily.

I took a deep breath and let it out, “Yes.”

“See Doctor Mercer, but tomorrow we’re having a conference call with Dad, Mary, Maria Cristina, and Doctor Mercer. I’ll make the calls right now.”

“No drugs, Jess,” I said firmly.

“I know your position, Tiger,” she said tersely. “But I’m the physician.”

“That’s true; and I’m a patient who is knowledgeable and directly involved in determining his treatment.”

“Steve, Jess,” Kara said gently, “You’re both getting your backs up before we even know if this is related to Steve’s health problems.”

“He thinks it is,” Jessica said. “There’s no chance he’d have suggested that if he didn’t think it was.”

“Yes,” Kara agreed, “but until we know more, there’s no point in getting into an argument. Let’s have dinner then have a family sauna.”

“That’s a good plan,” I said.

“Yes,” Jessica agreed, a bit reluctantly. “It is. May I ask a question?”

“In love, Jess,” Kara interjected.

“Tiger, did you eat, sleep, and exercise properly in Saint Martin?”

I shook my head, “Eat? Yes. I was very careful. But I didn’t run or practice my kata, and I didn’t sleep nearly as much as I’m supposed to. But I felt the change before I went. I was already thinking about it.”

“This is the last I’ll say tonight, but I wonder if you never truly recovered from your trip to Argentina.”

“You can discuss it with the other doctors tomorrow,” Kara said gently. “Let’s go have dinner and a sauna.”

Jessica finished dressing and we headed downstairs.

November 28, 2000, Chicago, Illinois

“I think,” Mary said, “that we need to go back to a lower carb limit, with just your incidental carbs from things like broccoli. I also want you to religiously stick to your exercise regimen. And in order to keep on a proper sleep schedule, I really don’t think you should travel, except in controlled circumstances, so that you don’t mess up your sleep patterns.”

“I agree, Steve,” Al said. “You are adamantly opposed to medication, and I understand your reasoning given the potentially serious side effects, but if you’re not going to take even small doses of mood altering medication, then you have to follow a very strict set of dietary, exercise, and sleep guidelines.”

“And,” Doctor Mercer added, “we need to talk often, even before the hypomanic episodes begin. I’m using that term because there is a developing understanding of hypomania, and, to be blunt, you fit it to a ‘T’. We’ll discuss it in more depth when you come see me, but the basic symptoms are grandiosity, distractibility, and hypersexuality. In psychology, grandiosity could be called, in shorthand, a big ego.”

I chuckled, “No shit, Doc!”

“Narcissism is a key feature of very successful entrepreneurs. If you don’t believe in yourself, I mean REALLY believe in yourself, it’s difficult to succeed like a Steve Jobs or Bill Gates, and as we’ve discussed, these symptoms are only a problem if they interfere with your life in negative ways. There are other characteristic symptoms, such as a notable decrease in the need for sleep, an overall increase in energy, and a markedly distinctive increase in talkativeness and confidence, commonly exhibited with a flight of creative ideas.”

“Those all sound like positive things for someone in my position,” I said.

“Yes, that’s true, and we’ll go more in-depth in a couple of weeks, but the perceived lack of need for sleep actually exacerbates your symptoms.”

“I’d say that’s because we’re dealing with two separate diagnoses,” Mary said. “At this point, we have the carbohydrate metabolism problem AND mild bipolar disorder. The first one exacerbates the second, but I’m convinced now that it’s two distinct diagnoses.”

“I think I have to agree,” Doctor Mercer said. “And certainly the two separate diagnoses conform to what I’ve seen in Steve’s life since I first met him twenty-two years ago.”

“Do you think this is what’s affecting my mom?” I asked.

“I can’t make a diagnosis of someone who isn’t a patient,” Doctor Mercer replied carefully, “but her described symptoms would certainly lead me to investigate that theory.”

“Steve, I want to see you twice a year,” Mary said.

“What about seeing Doctor Kulczycki for my annual check-ups?” I asked.

“Steve,” Al said, “I’d suggest making Mary your primary care physician at this point. If there’s something which needs immediate attention, but isn’t emergent, you can see me or one of your other doctor friends. Obviously, in an emergent situation, you’d come to the trauma center.”

“OK.”

“And Jessica,” Al said firmly. “You need to remember, he’s your husband, NOT your patient.”

“Yes, Dad,” Jessica said, though I was positive she didn’t actually agree.

“Steve, I want to see you next week,” Mary said.

“Didn’t you just tell me not to travel?” I asked snarkily.

“I said ‘except in controlled circumstances’. Flying up, even commercial, is controlled, so long as you book your flights so you get proper sleep.”

“OK. What about driving to Rutherford? It’s about six-and-a-half hours.”

“That should be OK, so long as you don’t interrupt your sleep patterns.”

“You know my patterns vary because of things like Guys’ Night and walking Jess to work on weekend mornings.”

“We’ll look at the totality of your life after you see Doctor Mercer. I’ll have the results of your tests by then. And Jess?”

“Yes?”

“Please don’t add stress.”

“I hear you,” Jessica said tersely.

“I’ll take care of it,” Al said firmly. “I think we have our plan. To reiterate, he’ll see you next week, Mary, then you, Fran, the following week.”

“Thanks, Al,” I said. “Mary, what day?”

“Tuesday would be best, but Wednesday is OK as well.”

“I’ll fly up on Monday afternoon,” I said. “And plan to fly back on Wednesday morning. Will that work?”

“Yes. Come up early enough and you can have dinner with Dan and me. Before I forget, is New Year’s weekend OK for a visit?”

“Yes, of course. We’re having a party on Sunday the 31st.”

“Thanks, everyone,” Al said.

We all disconnected from the call and I leaned back in my «zaisu» and looked over at Liz. We were sitting in the «washitsu» part of the office, with the glass doors and the sliding Japanese doors closed, something I didn’t do very often, but in this case I wanted privacy. Penny had her headphones on, so closing the Japanese doors hadn’t been strictly necessary, but it made the point.

“You didn’t let on I was here,” Liz said.

“No, I didn’t. I wanted you to listen and to tell me what you thought, without anyone modifying what they were saying because you were here.”

“What about YOU doing that?”

“When have I been anything but completely open and honest with you? Ever?”

“Never! That said, you didn’t say anything about Louise.”

“Because you knew, and because she asked me not to say anything to anyone. I told Kara and Jess I’d been with someone I’d been with before, but couldn’t tell them the person or place, nor would I allow any guessing games. And given that topic is basically off limits at Louise’s request, what’s your opinion of my situation?”

“Your wife is too close to the situation. It would be like me trying to defend a family member, or worse, myself. I suspect it’s the same with doctors trying to treat themselves.”

“They do,” I replied. “And it often turns out badly. Self-medicating rather than seeking professional mental healthcare is a serious problem in the medical community. What else?”

“Your aversion to pharmaceuticals takes a major tool out of their toolbox. But that said, I completely understand where you are coming from. The side effects Doctor Mercer discussed are, frankly, frightening. I’m not sure I’d accept that kind of risk, because while the risk is small in any instant, the accumulated risk is too high given how you’re functioning. I’m not a physician, obviously, but I took enough stats to properly understand the risk.

“That’s the concern with smoking, drinking, skydiving, or any other risky activity - a tiny chance of injury in any instant is greatly exacerbated by the length of time involved and the number of individual activities. You smoke maybe two cigars and two bowls of tobacco a year; that’s a far cry from half-a-pack a day or two packs a day. You drink a few ounces of bourbon a week; that’s a far cry from a six-pack a day or a bottle of whisky a week.”

I nodded, “It’s a fallacy that humans are prone to commit - this one instance isn’t very risky, so it’s no big deal. Multiply that by a thousand or ten thousand, and it’s a different story. Or they are stunningly bad at evaluating risk. That’s Jessica’s problem, by the way. Not that she’s bad at assessing risk, but that she knows how bad the average person is, so she overcompensates.”

“And she’s a wife and a mom!” Liz said with a smile. “I don’t have direct experience with that, but I am a woman...”

“No kidding!” I smirked, interrupting her.

“Steve will always be Steve!” she laughed. “What I was going to say, before I was so rudely interrupted, is that I can relate because I have a fairly strong mothering personality. I didn’t use it on you, because that is not what you need or want. But I had those feelings.”

“Similar to my sister growing up,” I said. “You know the abusive situation in which we grew up.”

“Yes. Anyway, as Consigliere, I’d say Doctor Al, Doctor Mary, and Doctor Mercer will figure out a way to address your health issues without medication, if possible. Doctor Al and Kara will have to work to keep Jessica from being ‘Doctor Jessica’ and a mother hen, so the other doctors can be successful. The more Jessica exhibits those traits, the more you’re going to get your back up about them. You need to let as much of it go as you can, and let Kara and Jessica’s dad deal with it. You don’t complain about it, you just let it be known when it’s causing you stress.”

“Whatever would I do without you?” I asked.

“I hope we never find out!”

“Me, too.”

November 29, 2000, Chicago, Illinois

“Thanks for meeting me for lunch,” Al said when we sat down at Medici on Wednesday afternoon.”

“I figured we needed to talk about Jessica.”

Al smiled, “She’s as headstrong as you are! I suffered from the same thing when I was your age, but the years have mellowed me just a bit.”

I laughed, “Care to revise your statement? I know quite a few medical students and Residents!”

Al laughed, “There’s a difference between demanding excellence and being bull-headed.”

“I’ll stick with my opinion, at least on certain topics.”

“You’re probably right, but I think the advantage of experience is to know how to properly pick your battles. You and Jess could take lessons from Kara in that area.”

“Or Belinda.”

“Touché!”

“How are Fawn and Gerry?”

“Everything is fine; I’m going to enjoy having additional grandkids by next summer.”

“Albert might get his nose bent out of joint a bit,” I replied.

“He’s WAY too busy with Scouts and flying to notice! We still have our time together, but he’s got his eyes set on the Academy, and Grandpa has to adjust his time demands! And the other grandkids will be in New York and Florida. Back to our topic, how did things go with Jess last night?”

“Kara kept things calm,” I replied. “I’m pretty sure she talked to Jess before I got home. I know Jess was very annoyed with being told to, in effect, butt out and to not nag me.”

“That’s putting it mildly.”

“Oh, I know. I could hear it in her voice. I’m guessing you reminded her of the protocol in trauma which says you avoid working on family or close friends except in extremis.”

“I did. But remember, it’s protocol, not forbidden by medical ethics. That said, I’m a stickler for it because it clouds a person’s judgment; they’re just too close. And on that topic, that’s a bit of a concern with your relationship with Mary Whittaker. We don’t have the same rule about dual relationships that someone like Doctor Mercer does, but we do want to be careful. I am NOT telling you not to be friendly with her or socialize with her, just to be aware.”

“You mean like you and me?” I asked with a smirk.

“You can be a real ass at times!” Al said, laughing.

“Who? Me?”

“You have that Alfred E. Neuman ‘What? Me worry?’ look down pat. But you know the risks and the problems from your relationship with Bethany.”

“True. So, what’s your unvarnished opinion?”

We were interrupted by the waiter coming to take our orders. When he left, I prompted Al to answer the question I’d asked before we were interrupted.

“So, your opinion?”

“I don’t want to see you on long-term maintenance drugs because of the side effects. That said, at some point, it could get bad enough that some sort of medication will be necessary. One thing you should discuss with Fran Mercer is lifestyle changes. I’m not an expert, but I’d guess you aren’t getting enough ‘Steve time’ where you can just completely unwind. I know you are refreshed by your work, but even so, there is built-in stress that you can’t avoid.”

“I know. The main point of seeing Doctor Mercer is to figure out what changes I can make without disrupting my work or family. I don’t like the alternatives.”

Al nodded, “In the end, and I say this advisedly, you could step back at work without creating a significant hardship. Right? Be truthful now.”

“I could, but I’d have to be very careful not to disrupt things.”

“Is Dave coming back?”

“We’ve danced around the idea of him coming back next summer, with allowances for teaching at IIT. There are plenty of ways to structure it. I’m not sure Terry is ready to take over Athena, but if he was, in effect, managing director, with Mario supervising, that would let Mario focus more on the overall business in the Eastern Region. As you know, John has picked up a lot of Mario’s workload, but he’s not Mario.”

“If I can speak out of school for a moment, Mario and Barbara were the two best hires and promotions you’ve made. Without those two, I don’t know where we’d be.”

I nodded, “I agree, in general, though I might add some names. Fortunately neither of them is ready to retire nor do they want to move on.”

“How could they? Lucrative salaries and benefits, and what amounts to complete control of their regions? And serious stock options which basically everyone wants to hold until you retire and sell the company so they can cash out.”

“That’s a long time in the future, and I haven’t, beyond immediate succession planning, given any thought to what happens to NIKA when it’s time to move on.”

“I notice you studiously avoided the use of the word retire.”

“Are YOU going to retire, Al? Sure, you might stop taking trauma shifts, which we’ve discussed, but you’ll teach until your dying breath. Maybe you’ll even leave UofC, but it would be to become dean of a medical school or something similar, and you’ll still teach.”

“Remember this conversation when you talk to Fran Mercer - if something has to be disrupted, it’s work, not family. NIKA will survive with reduced time from you. You’ve put a great team in place, even if you and Bob fight like Jesse and Birgit used to!”

I smirked, “It takes a wise, confident man to hire someone with whom he regularly disagrees to do a job which that wise, confident man doesn’t actually want done!”

Al laughed, “You sound like me when we schedule our JCAHO certification reviews. I know they’re necessary, but I hate them and I fight with them non-stop over the interpretation of State and Federal law, as well as their own standards. You know we built a state-of-the-art trauma center and JCACHO had ‘concerns’ about some of the decisions we made. Total crap, mind you, but I had to deal with it, AND with lawyers. And you know my take on lawyers!”