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Psychiatrist on the Road: Encounters in Healing and Healthcare
Reviewed by Jean Milofsky, M.D.
Am J Psychiatry 2010;167:221-222. doi:10.1176/appi.ajp.2009.09060772
View Author and Article Information
Denver, Colo.

The author reports no financial relationships with commercial interests.

Book review accepted for publication June 2009.

Accepted June , 2009.

Copyright © American Psychiatric Association

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Whether you enjoy Dr. Climo's book Psychiatrist on the Road might depend on how you feel about journaling. And I don't mean your own practice of journaling but rather your enjoyment of reading the raw musings of others.

You may feel privileged to get an up-close portrait of Dr. Climo's experiences as a locum tenens psychiatrist in some of our country's real health care backwaters. You may feel you are along for the journey, experiencing each encounter with him as he moves from Gallup Indian Medical Center in New Mexico to a state hospital in New England to a Southern inner-city outpatient clinic to a mental health center in Appalachia and finally to a VA hospital.

Your enjoyment might also depend on whether you're a lumper or a splitter. If you want insights that are generalizable or conclusions applicable to more than one of the dozens of vignettes in this book, you might be unsatisfied. As a lumper, I would have liked to see the emergence of overarching themes, values, or consistent clinical approaches to the multitude of situations in which the author found himself, so I was frustrated with the plan of this book.

I don't like reading journals. I don't like blogs either. I feel it's the writer's job to predigest his or her raw material and extract some of the buried riches for the reader. That could be because I am time-challenged. This may be a book better read in retirement. I didn't enjoy picking through Dr. Climo's hundreds of anecdotal sketches, though they often led to examples of diagnostic acumen, cultural sensitivity, and profound empathy for his patients as well as an acute sense of the difficulty of being in a clinical setting for such a short time.

This is a talented psychiatrist who turned the very painful experience of being terminated from an almost 20-year job as medical director in a big New England clinic into the beginning of the next chapter of his life. His decision took guts and heart, great flexibility, and apparently a great spouse. I would have liked to hear more about the transformation from a presumed sense of rejection and failure to a newfound sense of core worth and skill, which clearly emerged from these adventures. I would have liked to know what this was really like for this couple rather than get very occasional glimpses of his wife gamely going to the next town with Dr. Climo and exploring the Main Streets before disappearing again in the wealth of one- or two-page anecdotes about patients we meet only once. Surely, they had an occasional squabble or missed their home?

I think Dr. Climo takes this part of the journey for granted and doesn't feel it needs explication, but I would have found it the most important part of the narrative.

Dr. Climo has a great sense of humor. His Appalachian glossary is hilarious. One vignette involves a patient yo-yoing from discharge to non-discharge repeatedly because of meaningless bureaucracy having nothing to do with the patient's clinical readiness to leave the hospital. Anyone who has practiced in any agency, government or otherwise, will relate to the absurdity of this situation.

He also muses in interesting ways on what it means to be "an itinerant." He thinks it gives him more freedom to state his opinions and even to take decisive action. In one entry, he describes his own quick thinking when a violent patient with posttraumatic stress disorder threatens to lock a nurse into a room. He sizes the situation up accurately, subdues the patient, and likely saves the nurse from physical and psychological trauma or worse. He then muses that his itinerant status somehow plays a role in his decisiveness, hinting that perhaps the social pressure of disapproving colleagues who would be more permanent would inhibit him from taking charge or, in other instances, from speaking his mind.

Though Dr. Climo asks lots of questions about his own diagnostic skills, he never answers them; the answers, I think, would have knit this narrative together far more coherently. Dr. Climo presumably wrote his book before the current recession that likely affected many professional men and women as he had been affected. But being laid off has always been a devastating experience, and we get little sense of that from Dr. Climo's narrative. I wish he had applied more of his insight overtly to this part of his experience. Grief, loss of control, disruption, changes in one's life course at 65—this story lingers behind the book in a way that makes the strung-together anecdotes feel superficial and at times superfluous.

The most moving part of the book is the postscript. Dr. Climo acknowledges those who had been influential and supportive in his career and thanks them. With disruption, he still feels gratitude for a career and life well lived. He stresses his conviction that it is still important for young trainees in psychology and psychiatry to have psychoanalytic training—not to become analysts but to sharpen their ability to observe self and others and bring a scientific detachment to the observation of interactions and choices in treating patients. He thanks the Austen Riggs Center, the famous New England institute where he received such training. It is clear that he learned to listen with the "third ear." It is inspiring to watch him do that with impoverished, illiterate, desperate patients in poorly resourced parts of our country. How, I wonder, does he think such populations will ever get mental health care that is consistent and of high quality even as we move toward reforms in our system?

Unfortunately, to this reader, that just isn't the book Dr. Climo set out to write.




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