“Hello, ma’am. I’m here to get cleared. I’m here because it’s time for me to get myself together. That’s all. It’s time.” Her smile cracked open, revealing so much hope.

It was strange meeting her here—that’s what I remember most. It felt as if I knew her already, as if we could have met as participants in the same noon yoga class on Tuesdays and Thursdays, or as volunteers with the annual Run for Peace 5K. This version of reality—our encounter behind the locked doors of the psychiatric unit in the emergency department—didn’t feel right.

“Ms. Victoria Honor . . . by the way, that’s a fantastic name!”

She laughed. “Yeah, well, I can’t say it was my idea. All thanks to my family. You can call me Vicki.”

“Well, Vicki, you sound strong and resolute. Excellent. Yes, I’m here to medically clear you.”

This was the standard process for a “psychiatric” patient, whether she was being admitted to an inpatient psychiatric unit for psychosis or being discharged home with a referral to outpatient services for prescription drug abuse treatment. Emergency medicine physicians have to conduct an examination to address any acute medical issue the patient might have before the patient is transitioned to the care of ER psychiatrists or nonmedical specialists.

“And today,” I continued, “what are we clearing you from? For?”

She recrossed her legs and raised the index and ring finger of each hand to her temples. She seemed to be focusing on something far away and hard to see, as if staring at shadows just beyond a noonday sun.

“I have to get my head straight. I went through terrible things in the military. Now it’s time for me to get past it all. So, I’m just here passing through to be placed in transitional housing for a while.”

“I see.” I didn’t really, but I said it partially out of habit—the habit of coming into the psychiatric ER and trying to get out as quickly as possible.

Upon badge entry to the locked unit, directly in front and to the right, the first thing you see is an arc of patient rooms. Unlike in the main ER, each room has a hospital recliner chair and most have a flat bed positioned against a side wall as well. Invariably, having opted to keep the lights off, each patient sits there in a separate dark room behind a closed curtain. The tracking board at the nurses’ station directly to the right of the unit’s entrance lists the reason for each patient’s visit, which is almost always some combination of suicidal ideation, homicidal ideation, psychosis, drug dependence, and alcohol abuse. Then you hear the click of the door’s metal hardware locking shut, reminding you that the unit is secured. Even after I’d entered this unit hundreds of times, that click still triggered in me the instinct to hurry my return to a place where the exit door wasn’t locked and the lights were always on.

“I see,” I said again. “I’m sorry, but I have to ask you the list of standard medical questions. Some may sound silly, but I just have to ask them for clearance.”

She nodded. “Sure, sure. Go ’head, Doctor. I’m here to be honest. I’m here for help, so ask me anything.”

“Any recent illness, infection, or anything?”

“No, no. I’ve been healthy,” she replied, knocking on the wood of the bedside table.

“Do you take any medications?”

“Nope.”

“Any allergies to medications?”

She shook her head.

“Any recent surgeries?”

I could see Vicki’s shoulders melt a little under the weight of her paper scrubs. After a pause, she continued: “No. No recent surgeries.” She rocked a little in her seat, moving rhythmically forward and back, touched her breast bone, and then cleared her throat. Then she appended: “Only one, but that was a couple of years ago.” She paused and looked at her hand as it lay on her chest, as if it could steady her, as if to remind herself that each word, each disclosure, was part of her process. She looked up and said, “Yes, one surgery, an abortion, years ago now.”

“Okay,” I responded. It’s tough to know when to ask a follow-up question. Clearly, something didn’t feel okay. We started off that way, with so much not feeling right about her presence here; her energy told me it had to do with the hesitation she had just displayed.

I told myself that she shouldn’t have been sitting there in blue paper scrubs, I shouldn’t have been in the psychiatric ER ten minutes before my shift was to end, and the hospital shouldn’t have been so packed that ten patients were boarding in the ER (that is, being admitted to the hospital but still waiting for beds to become available on the regular floors). The night doctor shouldn’t have been by himself, with me as his only support, and with only a few minutes before the end of my shift, so that he alone would have to care for twenty patients in the emergency department and another ten in the waiting room, because in this hospital, in contradiction to standard practice, it was the responsibility of the ER doctor to care for any boarding patient instead of the admitting inpatient team—the very reason I had ended up feeling guilty enough to see another patient right before I was to sign out and go home. I was here to do medical clearance. Follow-up questions could lead me into a fifteen-minute conversation, and honestly, that was the job of the social worker and psychiatrist. This young woman was the medical picture of health, and that made my job easy.

I continued with the standard questions. “Do you feel you want to hurt yourself or anyone else?”

“Oh goodness, no! No, none of that.” She smiled, raised her hand to her neck, and cleared her throat again.

“Now, if you don’t mind, just a quick physical exam. May I listen to your lungs and heart?” She agreed, and I completed the perfunctory exam.

“Well, everything’s good on my end. All clear! The psychiatrist and social worker should be speaking with you soon. Any questions for me before I go?”

I tucked my stethoscope back on my belt clip and swept back the rebellious locks of hair that had fallen forward on my face. Vicki watched me lift my deep brown hands to do this. I saw her scan my long, natural hair. I saw her watch me as I tied my dreadlocks to secure them neatly. She got it, and she smiled in gratitude for our similarities.

“No. I’m good.” She placed her hands in her lap. “It’s nice to see more of us here. I’ve been here at the VA a few times, and I haven’t seen many doctors of color. Before I started going to the new women’s health center, I didn’t see any women doctors, either. It’s really nice to see you. Thank you.”

That’s why I was there. The VA hospital had a reputation as the place where old doctors went to die. As medicine has evolved over time—or, more accurately, as the business of medicine has devolved over time—many physicians have thought of the VA as their medical home. True, some of the providers at the VA aren’t competent enough to practice elsewhere, but that’s not the case for all of us. The rest of us come here not out of necessity, but out of choice, to care for those who gave everything with the intention of service to our country and received so little in return. We come here to encounter again that lost heart of medicine. We come here, too, knowing the entrenched legacy of corruption of the VA hospital and still hoping to be at least a small agent of change anyway. While I knew this job would not be my last iteration of healing work, I knew it was an integral part of my path.

The dance of medicine these days is hard. I’m still of the generation that entered medicine to help people, not to be tethered to endless paperwork, bludgeoned by satisfaction surveys linked to nothing except ways to cut pay and staffing, demoralized by the expectation that we see more patients faster—not safer or better, but faster—and then taken to task when patients feel we don’t take the time to listen. So, the big consideration in comparing hospital jobs is which set of bureaucratic nightmares will cause the fewest number of sleepless nights. As a hospital-based health care provider, you have the luxury of staying in one job as long as it makes sense—until your provider group loses the contract or you lose your patience. I knew intuitively that the next best choice would come because my growth was ongoing. For the time being, though, I felt deeply that the VA would mark a critical transition point for me.