Still Standing, No Longer Seen

When, returning from an 8-month leave, Esther climbed up the familiar steps to Greenville Hospital, she noticed both the fatigue of the past months and the even more familiar habitual spring of energy that had accompanied these steps for nearly 30 years. Her 87-year-old widowed father, who lived alone in Florida, had been found after a fall by a cleaner. Fiercely independent, he had spent the past 8 months in a struggle with the inevitability of his decline and increasing impairment; while Esther in turn struggled with his determination to stay home, independent, at all costs. Esther felt as if these months had aged her a decade, and as she looked in the mirror that morning to dress for work, she saw the difference. Her hair was brittle and dry, her face sallower, the haggardness she felt coming through. She had certainly had no time for salon and spa during this leave.

Through her fatigue Esther was glad to be back at work, able to devote herself to her work as physician and researcher at this small but highly reputed psychiatric hospital. She loved taking care of the prickly, sullen, and deeply vulnerable kids who were the focus of her department — and of the lucrative, 5-year research grant she had helped secure. She was deeply sorry that her department chair and friend of twenty years, David, had retired just months earlier. The grant was up for renewal, and Esther realized she would have to step in now as Principal Investigator. The challenge filled her body with air and made her straighten up, even as she took a deep breath, realizing how hard she would have to work to meet deadlines, review data, manage the write-ups. Most important, though, was the vision. It was her vision, her passionate understanding of the needs of these teens at risk of addiction and school avoidance. Her decades’ tenure at Greenville had let her build the network that caught these kids before they fell out of the system — the social work, school, pediatric, and legal liaison network that had proven its effectiveness, anchored by the strong therapy program her department offered. These days it wasn’t just substances that endangered the kids, Esther mused. Now there were internet traps, social media, lures she could hardly begin to imagine but knew were obviously real. Esther resolved to discuss with her team expanding the renewal to include these newer forms of addiction too.

Esther had arrived before the clinic opened. The first thing that caught her eye was the fresh paint, the matching chairs that had replaced the decades-old mismatched ones, the vase of fake flowers. A brochure on the new bulletin board announced a roundtable on ‘Technology Tracking and AI in Adolescent Mental Health.’ Esther snorted. Walking the corridor to her office, she passed a couple of unfamiliar faces — no doubt new staff. They didn’t make eye contact, but drew aside slightly to make room. When she opened the door to her office, it was no longer hers — it had been set up as a shared therapy space. None of her things were there. With determined steps she made her way to Clarissa’s office, the Department Coordinator. Clarissa always started her day early.

A look of surprise, a pause, delayed recognition — and then the expected warm welcome and greeting. Therapy space was now at a premium, Clarissa said: a sign-up model for most clinical rooms. Esther’s things had been moved, temporarily, to a storage room rigged up as an office. Under budget constraints, the clinic was increasingly adding fee-for-service clinicians; many salaried therapists had moved on. Esther took this in with a thud, a feeling now familiar to her from the past months with her father. How’s it going with Stanley, she asked. Stan was the new department chair — Esther had trained him in his day, years earlier. Not her favorite, and not much of a clinician, but not a surprising appointment given his political smoothness. Clarissa’s face went reserved. ‘Well, it’s different,’ she said. ‘You’ll see.’

And Esther saw.

She called a research grant update meeting with her teammates, who greeted her return with the expected warmth and interest — but told her the meeting was already scheduled. When she walked in, Stan was there, and introduced Alina, an MD/PhD recruited from an adjacent hospital. To Esther’s surprise, Alina chaired the discussion, an apparent continuation of a process already underway to renew — and expand — the scope of the proposed research. The new proposal would extend to the department’s entire adolescent cohort, adding prediction alongside treatment, using surveys, trackers, school attendance data, and other metrics. Alina spoke with confidence, energy, and polish, dropping terms like digital phenotyping and algorithm-assisted triage that, to Esther’s ears, sounded like nonsense — far from what real kids needed.

Esther spoke up. But after months out of service, her voice came out raspy, uncertain. She objected, primarily, to the reality that the new model would move away from the core of her original proposal — a treatment and services network that was proven to work. Before she finished, Alina interrupted her — not rudely, but more crisply: ‘We have the opportunity here to move beyond a high-touch treatment model for a limited population toward something preventative and scalable.’

Esther looked at her erstwhile teammates. Jeannie was looking down at her notes. Paul met her eye with something of a rueful, sympathetic glance before looking away.

She tried again, wanting to fight against this wholesale takeover of everything she stood for. She had left the clinic one of the pillars of the department: a gifted clinician, a beloved and respected mentor, the undisputed owner of the most lucrative grant the place had ever produced. Every fiber of her values strained against this — this grasping after money and prestige under the guise of modernization, at the expense of real people, real lives. But after 30 years in the department she had helped build, she felt out of place. This articulate, savvy, attractive younger woman was, apparently, her heir apparent — without Esther ever having consented. Her wisdom and thoughtfulness did not stand up to the swifter articulation, the bright eye, the sympathetic presentation of Alina. Esther felt old. And with a start, she realized — she looked old.