Detach

When I was a little girl between the ages of six and eleven, I loved Barbie dolls. In my child-mind, Barbies (not just Barbie, but the other dolls in the line like Ken, Skipper, and Midge), with their anatomically incorrect, smooth, hairless, nipple-less, sex-organ-less bodies, silky hair, and infinite array of matching outfits represented the untarnished, uncomplicated yet glamorous life I might build for myself. Barbies in the seventies could become anything: executives, models, athletes, doctors, actresses, princesses. They had equally anatomically incorrect, well-dressed boyfriends, as well as cars, homes, and even castles. Barbies had beautiful friends, lovely cousins, and adorable little sisters. They were supposed to be teenagers but had no homework and no parents to tell them what to do. 

The heads of Barbie dolls were easily removed from their bodies, though I’ve heard the newer editions have a more secure attachment. My brother and his friends enjoyed beheading Barbie dolls much to my horror. But it also became an interesting pastime as I developed into an imperfect and anatomically correct teenager, outgrowing the fantasy of a doll’s life. Once a head was removed, you could stick it back on the neck, but the attachment was never secure. 

I am on the phone with Devon, a twenty-seven-year-old former patient. I took care of Devon from the time she was eighteen until I stopped practicing internal medicine a couple years ago. She had an eating disorder and was twenty pounds underweight when I first met her. Her skin was sallow with dark circles under her blue, dark-lashed eyes. Her long, blond hair was dull and thinning. 

She also struggled with a condition called fibromyalgia in which the brain amplifies pain signals. Her whole body hurt. She had stiffness, fatigue, and sleep problems. Both eating disorders and fibromyalgia are associated with depression. Despite antidepressant medications, Devon felt sad and despondent. 

Working with me, a psychiatrist and physical therapist, Devon gained weight and got better control over her pain through non-narcotic medications, physical therapy, and psychotherapy. Her depression waxed and waned, but she felt hopeful much of the time. She was doing well when I left practice. I turned her care over to a nurse practitioner who understood her problems.

Now, several years later, Devon still has my phone number and texts me, hoping we can talk.

“Thank you for calling me back,” she tells me softly. “The nurse practitioner you referred me to was great. But she moved to New York last year.” 

Uh, oh, I think. I know there aren’t a lot of people comfortable working with eating disorder patients, or with chronic pain. Recently, Devon’s psychiatrist stopped accepting her insurance. She’s been on a search for new medical care since. So far, she can’t locate any psychiatrists who take her insurance and have time for a new patient. Covid has made that worse; with the stress of the pandemic, there are long wait lists for mental health care. She’s seen two primary care doctors, but both deemed not only her depression but also her pain, psychiatric problems. They won’t adjust her medications, even though her fibromyalgia has flared. 

I give her a couple referrals, one to a rheumatologist I think can help with the pain and another to a mental health clinic near her. Mostly, I listen. She has developed a lot more resilience, but her current situation tests that. Some “tweaks” to her medications might help, but much of what she needs is understanding and support. Support to persevere through a difficult time and a reminder that things will get better. She has more strength than she recognizes. I know this about her because I’ve witnessed it. 

I feel a twinge of guilt. I’m not available to Devon as a doctor anymore. I can’t adjust her medications or prescribe a new course of physical therapy. I don’t have an office or the right malpractice insurance to provide ongoing care. 

I’m a tipping boat, trying to fix everything for everyone. I tip towards what broke me. We all need support. I didn’t have the help I needed to provide time-intensive, heart-intensive care for my patients. I’ve put my own pieces back together, but I can’t do it for others anymore. I quickly right myself.

 “Devon, let’s talk again in a couple weeks,” I say. “Hopefully by then you’ll have an appointment to see this new rheumatologist. I’m here to listen and support you for now.”

I hang up the phone, feeling sad and frustrated she’s being treated like a headless Barbie. She’s told she must have a psychiatrist fix her detached head. And there is nobody who seems willing or able to reattach it.

In anatomy lab, the first year of medical school, cadavers were dissected in stages. Muscles, nerves and blood vessels, bones, organs of the thorax and abdomen. The head came last. Toward the end of the first semester, there was a session devoted to the sinuses and cranium. The brains had been removed from the cadavers for separate examination in the neuroanatomy section. Our job in anatomy lab that day was to examine the inside of the head. Splitting the skull required first an axe and then a saw. 

I arrived at my table in the lab to find all three of my lab partners absent. How could they leave me to do this without them? Though I’d gotten used to dissection, this part seemed impossibly gruesome. I stood alone in jeans and a shirt infused with oily, sickly-sweet formaldehyde from previous dissection sessions, while other groups of three or four began their work. I heard the splintering bone and scraping of saws. 

I picked up the axe with the intention of making the first cut, but found myself unable to move, paralyzed by anxiety. I willed myself to raise my arm, but nothing happened.  

After a few minutes, my anatomy professor, Dr. H, lumbered over to me. He was a crusty old Scotsman, a retired orthopedic surgeon. 

“What the hell is the matter with you, girl?” he demanded. I just shook my head. I couldn’t explain my inertia. 

“Well, if you’re not going to do it, I’ll do it for you.” He grabbed the axe from me and, in a clear fell swoop, whacked the cadaver’s head apart. He picked up the saw, finished the job, and left me to study the structures. My face burned with shame; I’d failed to do what needed to be done.

Looking back, I wonder what Dr. H. was thinking. I questioned, at the time, how he became so inured to the cadavers. I pondered if he still had a soul. Now, I think he saw that I was struggling. He honored my emotional limits by cutting the skull instead of forcing me to do it. Regardless, the message was clear: toughen up. Stop having limits. Detach.

-Rosalind Kaplan

Rosalind Kaplan is a Philadelphia-based writer, physician and teacher of Narrative Medicine. She is a 2020 graduate of Lesley University’s MFA in Creative Nonfiction. Her full-length memoir, The Patient in the White Coat, was published in 2020. Shorter works can be found in a smattering of literary and medical journals, including Amarillo Bay, the Eastern Iowa Review, Brandeis Magazine, ‘On Being a Doctor,’ the humanities section of the Annals of Internal Medicine, and Prompted, a Philadelphia Stories Anthology. Dr. Kaplan lives with husband and rescue dog, and has two grown children.