Your Heart is the Size of Your Fist

by Martina Scholtens

  When people learned what field I worked in, they often assumed that I did and commended me for it with an admiration that made me uncomfortable. It was too awkward to protest what was meant to be a compliment, so I let it go. Having a heart for refugees suggests that one is blessed with divine direction, certainty, and servitude—none of which I felt I could honestly own up to. My career has been a guided drift. While in hindsight there appears to be a logical development to my career path, as I’ve moved along it I’ve never been able to see beyond the next six weeks. Refugee medicine was never a goal I set my sights on. Yet here I was, with a job I loved so much that my six-year-old asked me, “I can never remember. Do they pay you to go to work, or do you pay them to let you work?”

  People love the narrative of a child being called to the medical profession. “Did you always know that you wanted to be a doctor?” I’m asked regularly. In fact, I didn’t consider medicine until I was twenty-one.

  I grew up in a conservative religious community in the Fraser Valley. I graduated from high school in a class of forty; every one of us was white and Dutch Canadian. Most of my classmates were engaged by twenty-one, with three or four kids by our ten-year reunion. As time went on, I would lag further and further behind those peers.

  I understood from kindergarten that if I were to pursue a career, the options were limited to those traditionally dominated by women, such as teaching elementary school or nursing. Once I married, I was expected to leave my career for motherhood. I didn’t protest this as a child; virtually all women in my community were homemakers. And I didn’t know anyone—man or woman—in medicine.

  I always had an inkling, though, that my path wouldn’t be traditional. First of all, my father was a university professor. Even when I was in elementary school, the potential track of education appeared infinite to me, extending far past high school.

  “Could I speak to Dr. Byl, please?” his students would say when I answered the phone in the evening.

  “He’s a teacher, not a doctor,” I’d say. “But you can speak to him.”

  I loved learning. I could remember where I sat and what I wore in Grade 8 science when Mr. Mans explained why a sugar cube dissolved more quickly in hot water than in cold. The concept of sugar crystals being bombarded by water molecules whose velocity increased with temperature gave me joy, although I was socially aware enough to keep it to myself.

  In high school, there were only five of us in Physics 12. We all had a literal front row seat to Mr. Koat, who taught with pleasure and marked with precision, down to the quarter point. At lunch one day my friends and I discovered a large empty barrel in the school parking lot. I climbed inside and they rolled me across the playing field. Mr. Koat was on lunch monitor duty and hurried over as I emerged from the barrel.

  “Martina, I saw what you did there,” he said. “With your aptitude for science and sense of adventure, perhaps you should consider becoming an astronaut.”

  I laughed, but he didn’t. Someone thought astronautics a viable career option for me. I was astonished. The narrow set of possibilities I’d grown up with started to fan open.

  For an English 12 assignment, we were to write an essay on a book that had influenced us. I wrote that I had been scarred by the fairy tale Cinderella, that I’d identified with the wicked stepsisters rather than the beautiful, meek heroine. When Mr. Schön handed back our essays, next to my score was a comment, circled emphatically: “Worthy of publication.”

  Again, I was presented with a possibility I’d never entertained. I submitted it to the Vancouver Sun, and they published it. This led to my first two reader responses, handwritten letters forwarded by the Sun: one from an elderly woman who called me a spoiled brat, and the other from a man who said he could relate to my experience and suggested we meet. (We didn’t.)

  I was lucky enough to have teachers who championed their students, who recognized what I enjoyed and excelled at, and suggested how that might be expanded.

  In high school, I had no clear idea about my future career, and that didn’t bother me. I loved learning and I simply planned to pursue higher education for as long as possible. Being equipped for a career would be a byproduct of my education, not the goal of it. But which direction to go? Arts or science?

  Lying on the floor of my bedroom in Grade 12, flipping through university catalogues, everything appealed to me: English, chemistry, business. It was my first step into that funnel of adulthood, where the act of choosing one thing went hand-in-hand with rejecting others. I thought I had to commit exclusively to one discipline—career monogamy—and I was sorry to have to break up with other subjects that I loved.

  I decided to major in English. My freshman year at university was saturated with the arts. I studied Silas Marner, took a drawing class on Tuesday nights, and played Mote in the production of A Midsummer Night’s Dream, in which I sang and flitted across the stage in a swimsuit and gauzy wings. One day that spring, I walked into my English classroom just after it had been vacated by a chemistry class. On the board an elaborate equation was worked out, rows and rows of characters, and at the bottom, after the equals sign, was the singular, right answer.

  At that moment, I realized how much I longed for right answers, how much the softness and imprecision of the arts frustrated me. I had a vague sense of pursuing the “real thing”; I couldn’t articulate what it was, but I recognized it when I brushed by it. It would take me years to realize that the truest answers do lie in the arts. When I registered for the next semester that spring, I dropped drama and art and signed on for physics, chemistry, biology, and calculus. But for my fifth course, I chose creative writing.

  I decided to pursue veterinary medicine. I wanted the adventures of James Herriot, driving around the countryside and mucking around in barnyards. But I worried that I was too slight to handle livestock. And caring for domestic pets—canaries and Persian cats—struck me as frivolous, not the elusive “real thing” that I was chasing. When I overheard a dorm mate announce that she wanted to be a doctor, her sense of purpose resonated with me. I decided to pursue medicine as well.

  Of my three sisters, two became elementary school teachers and one a stay-at-home mother. I wanted a family too, eventually, and time to spend with it. I had no idea how it would all work.

  In my first year of medical school at the University of British Columbia, we were divided into groups of five and assigned a cadaver to dissect over the year. On that first August afternoon in the anatomy lab, two dozen bodies lay face down on stainless steel tables with cloth sacks over their heads. We were introduced to the body gradually. Our first assignment was to dissect the upper back, supposedly the most impersonal part of the anatomy. Weeks later, we flipped the body over, and eventually we revealed the face. We cut, we identified, we sketched diagrams. We wrote the exam. The bodies were cremated. First year was over.

  But it felt unfinished. There were other details on which we weren’t examined—details I knew I’d remember long after I’d forgotten the divisions of the brachial plexus. How we were so moved by a Band-Aid crossing our incision path on our cadaver’s forearm that we unanimously agreed to cut around it. The tattoo pigment accumulated in his lymph nodes, gathered from a faded inscription on his trunk, a name that we couldn’t decipher. How we lifted his heart from his chest and held it in our hands, reverent and terrified; how his heart was the size of his fist, just as we’d been taught, but so much heavier. Those details could be acknowledged in writing, though. My poem was published: “Reflections on Seven Months with a Cadaver.” American poet Mary Oliver, in her poem “Sometimes,” gave three “Instructions for living a life: Pay attention. Be astonished. Tell about it.” 1 I decided I would tell about medicine by writing.

  I went on to do a two-year residency in family medicine at St. Paul’s Hospital in Vancouver and then joined a private practice in Kitsilano. It was a practice filled with anxious professionals. One day, when yet another thirty-year-old woman came to see me because her hair wasn
’t as lustrous as it had been in her twenties, I realized that I hadn’t gone through the rigours of medical training to spend my days reassuring the worried well. They were the equivalent of the Persian cats I hadn’t wanted to see as a vet.

  I wanted to care for sick patients who needed a doctor. I started working in Vancouver’s Downtown Eastside and spent two years working at the BC Centre for Excellence in HIV/AIDS. But once I landed a position at Vancouver’s refugee clinic, I settled in for a good decade.

  The clinic was the real thing. Patients were suffering, and I had something to offer. The pathology was fascinating, and so were the stories. I adored my colleagues, deeply committed, generous people who were unconcerned with money or recognition. I was certain I had the best job of anyone I knew.

  The American writer and theologian Frederick Buechner said: “The place God calls you to is the place where your deep gladness and the world’s deep hunger meet.” 2

  So, in that sense: yes, I had a calling.

  3

  AS I DROVE THE KIDS to school on my way to the clinic, winding along Dollarton Highway with the morning sun glinting off Burrard Inlet, my nine-year-old daughter told me about a mathematics contest she had written earlier in the week.

  “I left one question blank,” Saskia began. It was a confession: a perfect score was off the table. She didn’t add up test scores; she worked back from 100. “But I did that because of how the scoring system worked. You got six points for a right answer, two points if you left it blank, and zero points for a wrong answer. I wasn’t sure about the last question so I just left it.”

  I made her repeat that, making sure I had it right. Making a wild stab at an answer was worth less than no response at all? This wasn’t the grading system I’d grown up with, which promoted doing one’s best even if it involved guesswork. I was pleased that she would be rewarded for acknowledging what she didn’t know. If only we’d all pause to consider whether we truly know the answer to a question at hand, I mused as I swung into the school parking lot. And if not, take two points for keeping our mouths shut. Over breakfast I’d read the comments on a CBC article about refugees, scanning the vociferous opinions that were ignorant of the basic facts of the system. I was dismayed by the misinformation and the arrogance that was posted.

  After Saskia and Leif extracted their backpacks from the trunk, I turned the car and my thoughts toward the clinic. A medical student would be shadowing me this week. I was a clinical instructor in the Faculty of Medicine at the University of British Columbia. The refugee clinic was a popular elective choice, and most days I supervised a student or resident. I considered the recognition of one’s limitations a critical component of physician training, albeit an uncomfortable one.

  During my own two-year residency training at St. Paul’s Hospital I had been assigned to a family practice for several four-week blocks, with callback every Thursday afternoon. It was an established practice at the intersection of two arterial Vancouver roads, Broadway and Granville, and a good group of doctors. I dreaded seeing the patients, though—mostly well-heeled, reproductive-age women—because I couldn’t answer their questions.

  Making a diagnosis and treatment plan on my surgery rotation or in the emergency room wasn’t a problem, but patients in this clinic kept bringing up issues that weren’t in any textbook. One couldn’t interpret her baby’s cries; another needed advice on dealing with strangers’ remarks on her child’s birthmark; the next had discovered her teenage son’s porn collection. I was twenty-six, childless, and had nothing to offer on subjects that weren’t in my medical library. I felt useless. I could only take a detailed history and call in my preceptor to finish the visit.

  My preceptor and the other staff doctors took the entire clinic staff out for Christmas lunch that first year, between morning and afternoon clinics packed with patients wanting to be seen before the holidays. My preceptor paused during the meal and said to me congenially, “You know when we knew you were okay?”

  I had no idea, but I was relieved they’d arrived at that conclusion.

  “Remember that rash?” she asked. “The four-year-old with the vesicles on his legs who’d just come back from camping?”

  I remembered. Yet another patient that had stumped me.

  “When I asked what you thought it was, you said, ‘I don’t know,’” she went on. “That’s when we knew we had a good resident.”

  The other physician agreed. “We don’t care what you know,” she said. “We care that you know what you don’t know.”

  Now, a decade later at the refugee clinic, I was still keenly aware of the limits of what I could offer. Often there wasn’t a satisfying answer to a problem. I used the traditional SOAP format for my chart notes: Subjective, Objective, Assessment, Plan. Often, the P could feel terribly inadequate. Counselled meant I’d dispensed words, five to ten minutes’ worth. Conservative management meant I wasn’t going to do anything yet. Follow sounded the most like a fail, although it was in fact a promise: I will see you in my office, again and again, until you feel better. Doctors hear the God-complex jokes all the time, but I am well aware of my limitations. The practice of medicine teaches how very much is unknown.

  The medical student who was shadowing me for the week was waiting in my office when I arrived at the clinic. We looked over the day sheet that had been printed and set on my desk. The morning’s first patient was an elderly Bedouin woman, recently arrived from Syria. “I don’t know anything about nomads,” the student confessed.

  We were off to a good start. “That’s okay,” I said. “You’ll know something after the visit.”

  New learners often expressed anxiety about cultural competence, a buzz phrase in medical education. They worried that they would inadvertently offend a patient whose customs and beliefs differed from their own. I think of culture as a system of permissions, or, How we do things around here. The term cultural competence implies mastery, an expert knowledge of all these systems. Without immersing oneself in a culture for many years, it’s impossible to appreciate all its nuances. American pediatrician and activist Melanie Tervalon suggests that we ought to strive for cultural humility instead.1 That was what I taught my students.

  When our clinic did a community engagement survey to assess satisfaction with our services, not one respondent complained of cultural insensitivity. This was not because the staff never made blunders, I assured students. It was because patients were forgiving when they recognized that practitioners came from a place of humility and goodwill.

  Every year, I had to ask a Muslim patient to give me a refresher on Ramadan. What are the dates? What are the hours of fasting? Who is exempt? No patient ever scolded, “You’ve worked with refugees for ten years! Shouldn’t you know this by now?” They were always eager to educate me.

  I had made plenty of gaffes over the years. I’d complimented a patient from Myanmar on her shoes, only to have her remove them; the interpreter chided me: “Now she must give them to you.” I’d routinely used a thumbs-up sign when delivering good test results to patients, only to learn that it was an extremely lewd gesture in Middle Eastern culture. I’d disgusted an Iranian patient when I passed him his shoes after his physical exam. “You’re a scientist!” he’d said in a pained voice. Touching shoes, the epitome of filth, should have been beneath me. And those were the faux pas I was aware of.

  “Just recognize that you don’t fully understand the patient’s context,” I told the student worrying about the nomad, as we headed toward the waiting room to call her in. “And be curious!”

  He nodded.

  We passed the weigh scale, where a nurse was encouraging a little Somali girl in a long orange dress to stand straight against the measuring stick with her head level. Three sisters under the age of seven looked on, giggling, their teeth flashing white in dark faces wrapped in bright scarves. The mother undressed the baby, a pudgy infant with dark curls who craned his neck to watch the girls. “Wow!” whispered the student as we passed by. He lo
oked excited, nervous.

  The family struck him as exotic, I knew. They were too beautiful and unusual not to comment on. I’d felt the same when I started at the clinic, impressed by what was foreign. The differences in language, clothing, skin, and customs were too much to ignore.

  In my early years of practice, I attended a refugee health conference where a speaker shared the words of Canadian anthropologist Wade Davis: “Indigenous cultures are not failed attempts at modernity, let alone failed attempts to be us. They are unique expressions of the human imagination and heart, unique answers to a fundamental question: What does it mean to be human and alive?” 2 The first words stung. Was I guilty of this? Was my delight in my patients’ differences rooted in a subconscious interpretation of their failed attempts to be me?

  I’d grown up with a church missionary calendar hanging in the kitchen, a new one every year. January’s picture was a woman in Papua, New Guinea, with a baby on each hip, in the doorway of a hut with a metal roof. February showed a dozen African boys playing soccer with a ball of tinfoil. March was a group of Indonesian women washing laundry in a river. Every month we looked at a new picture of people on the other side of the planet who needed the things we had: food, soap, salvation, modern cars. As an eight-year-old I felt sorry for them; I felt lucky to be me. I hoped I hadn’t carried this primitive thinking into my adult life.

  Wade Davis’ words challenged me to focus on something other than our differences: What made us human and alive? As a physician, seeing people at their most vulnerable, being privy to their deepest hurts and fears, I was afforded a little window into the human condition. Working at a refugee clinic offered me more clues as to what was universal about humankind. What did my vastly diverse patients share with each other, and with me? I’d determined a few commonalities over the years. We all loved our children with the same devotion. Everyone sought community of some sort. We all understood the language of kindness and humour. We sought purpose and meaning. No one escaped brokenness.