Your Heart is the Size of Your Fist

by Martina Scholtens

  6

  PETE AND I WERE GETTING ready for work when he set down the iron, inspected his pants, and sighed, “Not these ones, too! All of my pants have grease stains across the thighs.”

  “So do mine!” I told him. “Grease stains, mid-thigh.”

  We puzzled over the consistent appearance and placement of the marks, and then we realized the cause. The range of the stains exactly matched the heights at which four-year-old Ariana planted her little hands when she grabbed us.

  I’d been a mother for nine years, and during that time I had never gone into work wholly pristine. I’d had breast milk spit-up on my shoulder, crusted rice cereal on my shirt cuffs, teething biscuits cemented to my pant legs, apple juice splash marks on my shoes, and now a tideline of grease across my thighs. I wondered if I should resume wearing a white coat, but anything short of floor length would be inadequate.

  I started work at nine. I got up at six. Even though we made lunches and laid out everyone’s clothes the night before, we needed that much time to get all five of us packaged and delivered to our respective places of work and play in good spirits. I showered, dressed, and helped the kids pull on play clothes and school cardigans while Pete made breakfast. There was a flurry of smoothing hair into pigtails, stowing rain boots in backpacks, pouring coffee, and hunting for library books. At 7:30 AM, with the front door open in readiness for the five of us to brave the November chill and head for the van, I crouched in the front entrance hurriedly stuffing Ariana’s hands into mittens.

  I ushered her out the door, entreating her to pick up the pace as she dawdled down the walkway, stuffing pine cones into her pockets. Once in the van, I reminded her repeatedly to climb into her car seat, as I deposited backpacks in the trunk. I had read that children had no sense of urgency, that it was a waste of time to try to make them hurry; my years of parenting confirmed this. However, from time to time I couldn’t resist trying to instill the importance of efficient routines. “Mommy and Daddy can’t be late for work,” I told Ariana urgently. “If we are, we could be fired!” Unlikely though that scenario was, the statement sounded sufficiently grim.

  My words seemed to have an effect. I had her full attention. “They would set you on fire?” she asked with real interest.

  We drove Saskia and Leif to before-care at their school. Then we headed over the bridge and into the city, where we brought Ariana to daycare. Finally, Pete swung by my clinic and dropped me off on his way downtown. I used the half hour before my first patient to review lab results and catch up on work email.

  At two minutes to nine my colleague burst through the door, unstrapping his bike helmet. He was forty and single. His hair was a mess, he was out of breath, and he seemed exhilarated. “I woke up ten minutes ago,” he announced. “I just rolled out of bed and out the door!”

  Watching him hang up his reflective jacket and rummage in his briefcase for a granola bar, I could vaguely recall a life where my only real responsibility between waking up and presenting myself at work or school was to put on clothes. Now, I could hardly remember what it was like to show up at the office without feeling like I’d already done a full day’s work. My colleague had the enviable ability to be single-minded. That was what I found most difficult about mixing medicine and motherhood: the diffusion of focus.

  My work in refugee medicine was profoundly rewarding; raising three little ones even more so. The two had proven to be compatible. And yet at some point the efforts put into one required sacrifices of the other. There simply were not enough hours in the day for me to invest what I wished into both spheres. I had erred on the side of mothering, and while I did good work at the clinic, I felt that my career trajectory had been modest.

  Caring for both patients and children was not easy. I’d attended a medical conference the year before where the presenter had flashed a list onto a giant screen, saying, “These are attributes of physicians that serve them well professionally: control; perfectionism; competitiveness; dedication; perennial caretaker; emotional remoteness.” The audience had nodded and murmured in recognition. He had continued, “And these are the attributes of physicians that are liabilities in family life.” He flipped to the next PowerPoint slide. It was an exact replica of the first. As the audience burst into appreciative, rueful laughter, I was struck by how neatly my domestic difficulties had just been explained. I’d often noticed that the very qualities that enabled me to do a good job at the clinic frustrated my efforts at caring for my family and our home.

  My days at work were organized exactly as I liked them, from the length of patients’ appointments to their medication lists to the position of the stapler on my desk. I interviewed patients, examined them, and ordered investigations. I didn’t determine who walked in the door, but I managed every aspect of the problem once it was presented to me. My life at home was an unpredictable, distracted mess. Urgent requests and displaced items greeted me at every turn. I might be the one guiding the day in a general sense, but the thousand details were determined by three spontaneous children.

  At the clinic, I took on challenging work, completed it, and turned to the next diagnostic puzzle. At home, I repeated menial tasks thousands of times while others undid them. The satisfaction of measuring performance by objective standards at work could not be achieved in the same way at home. I could pick up the faintest of heart murmurs, I could suture a laceration beautifully, I ran my clinics on time, but how do you grade yourself on raising a daughter well?

  Like most physicians, I thrive on competition. It has always motivated me, and winning is powerful affirmation. But motherhood is different from the MCAT, pharmacology prizes, and residency applications. No one is going to come out on top, and comparing oneself to other mothers is futile and dangerous ground. The competitive mother after gold stars is the one no one wants to be around.

  I wanted to be a great doctor and, even more, a great mother. But if the qualities of one could be the undoing of the other, it was no wonder my life felt like such a struggle some days.

  Despite these challenges, I had work-life balance. It was precarious, something that I knew could be toppled by illness or an aggravating colleague or a newborn, but I rated my satisfaction with both career and home life as high. The philosophical and practical guidelines that I followed were these:

  Accept that you can’t have it all. At least, you can’t have everything at once—but you can have a life that is rich and full and satisfying. I watched resignedly as other (childless) physicians at my clinic left to spend months working in Afghanistan and Peru. I was the mother who arrived late to the preschool Christmas potluck and set a box of Mandarin oranges next to the homemade cheesy noodle casseroles. I’d been meaning to replace my son’s embarrassingly short school uniform pants for months. I couldn’t attend a recent cross-cultural mental health conference because I was home with my daughter on Thursdays. But I had kind, secure children and what was arguably the most delightful patient population in the city. It was enough.

  Be clear about your boundaries. Don’t apologize for them. I worked part-time. I couldn’t start any earlier than 9 AM due to school drop-off. I’d had potential employers rework schedules and change clinic start times when I told them my availability.

  Don’t compare your finances to others’. Leif asked me once, “Where do you and Daddy get money from?” He was taken aback when I explained that we were paid for our work. All this time he had assumed we were going to work for pleasure and to help others. This pleased me to no end. I didn’t want money to be the prime consideration in my decisions.

  Every year the BC Ministry of Health puts out the “Blue Book,” which lists the amount every physician in the province bills the Medical Services Plan. I’d perused it before, but no good came from seeing that my family physician-neighbour billed more than five times what I did. I started to gauge the wrong things in terms of money; how could I put a price on quiet days at home puttering in the yard with my four-year-old?

  Say no. I cons
idered this the most important skill I’d learned in the last five years. If I felt awkward saying no to someone’s face, I’d say I’d consider their request. Then I’d say no by email. I didn’t bother with reasons or excuses. I came across a quote from Dr. Gabor Maté’s book When the Body Says No that I thought of almost daily: “If you face the choice between feeling guilt and resentment, choose the guilt every time.” 1

  Write. I took ten minutes once or twice a week to document what had been memorable recently. This had a magical way of allowing what was important to rise to the top while the irritations of daily life drifted away, affording perspective.

  Consider exhaustion the state of having given freely. One afternoon as I rounded the bend to approach the Second Narrows Bridge on my way home from work, the CBC’s Rich Terfry on the radio and Ariana strapped in the backseat, I thought with dismay how overwhelmed with fatigue I was. I felt drained, spent, exhausted. Reflecting on these words, I realized that resenting what others had taken from me was passive and inaccurate. I had given what I had by my own choice. When considering Dr. William Osler’s words, “Let each day’s work absorb your entire energy and satisfy your widest ambition,” 2 anything short of collapsing into bed each night, completely spent, felt like a waste.

  Travel lightly. I tried to apply minimalism to every aspect of my life. Visitors remarked on how tidy our home was, but the truth was that we had very little stuff. I decided early in my career to leave my part-time position at the HIV clinic to focus only on my work at the refugee clinic. We ate simply. Any commitments were carefully selected for a defined period.

  Hold an annual general meeting to evaluate your life. Once a year, Pete and I hired a babysitter and took an evening to take stock of where we were at in every major area of our life: his work, my work, finances, church, where we lived, parenting, friendships. We identified what was working, what needed to change, and when we ought to re-evaluate. We liked to feel that our choices were deliberate; we didn’t want to float up to our forties to say, “Huh! So this is how we live.”

  Find a great partner. Pete (who worked full-time in a non-medical field) was supportive, hands-on with the kids, and flexible around gender roles. We both made sacrifices. He was undoubtedly the linchpin to my contented state as mother-doctor.

  I’d loved William Wordsworth’s poem “Nuns Fret Not at Their Convent’s Narrow Room” since I studied it in English 103, particularly these lines: “In truth the prison, unto which we doom/Ourselves, no prison is.” 3 I was a mother in medicine by choice. I accepted any challenges and restrictions inherent to being a physician-mother, for that was exactly what I wished to be.

  7

  THE NEXT TIME I SAW Yusef it was November, the week before Remembrance Day. When I called him from the waiting room, he pointed proudly to the red poppy pinned to his coat. “I participate in the celebrations of my new country,” he said through the interpreter. My own lapel was bare.

  “Something strange happened last week,” he said as we headed down the hall. He described how at nightfall the streets around his apartment complex were overrun with people dressed as ghosts and vampires, knocking on doors, with a sound like gunfire in the background. Hallowe’en was always confusing to newcomers experiencing it for the first time, without warning. A nurse had told me about one of our patients, hospitalized on the seventh floor of St. Paul’s Hospital, who had asked politely when the fireworks began, “Excuse me, is there a war?”

  My own neighbour had set up a ghoulish scene in his yard, to the delight of the kids on our street. RIP: REST IN PIECES read one sign in dripping red paint. I was grateful that such violence was so far removed from Vancouver that my kids found the sign funny, but I had a patient whose brother had been macheted to death, who had collected the body parts in a box. I’d always been sensitive to violence, but with each story I heard in my exam room, my tolerance sank. Hallowe’en is for dress-up, not gore, I’d tell my kids. I went trick-or-treating with a chicken, a nurse, and José Bautista.

  Once Yusef had been briefed on Halloween, we moved into the reason for his visit. He wanted to donate blood. I double-checked with the interpreter that I’d understood the question correctly. “You’ve only been in the country for six weeks,” I said. “What’s the urgency?”

  “I want to pay Canada back,” he said. “And right now, the only thing I have to give is my blood.”

  “You can check with Canadian Blood Services to see if you’re eligible to donate,” I said. I found a pamphlet in the wall rack and handed it to him. He folded it carefully and slipped it into his back pocket, satisfied. I hadn’t donated blood in years.

  “Let’s review your lab results,” I said, turning to the computer.

  Upon arrival, the Haddads had been offered the usual screening blood tests for HIV, syphilis, hepatitis, and anemia. The tests were often misunderstood by patients. Many assumed that the government and employers could access the results and use them as a basis for deportation or employment. Some thought that the authorities used the blood for experiments; this idea was bolstered by the multitude of tubes required to collect even the basic screening, which struck patients as excessive. Patients worried that they would be scolded or shamed for any infections. Despite these fears, and the fact that the tests were not mandatory, patients never refused them.

  Screening for disease, an important component of primary care in Canada, was a novel idea for many patients. Most were used to accessing healthcare when there was a problem: pain, bleeding, deformity, disability. The concept of searching out asymptomatic disease, or risk factors for a condition that might manifest itself in the future, was a foreign concept.

  “I’m not sick, but you want to find something wrong with me,” Yusef had commented wryly when I recommended we add a test for diabetes and cholesterol to his initial blood work, based on his age.

  It wasn’t the first time I’d heard that accusation. After a normal routine breast exam, I’d recommended that my fifty-five-year-old patient have a screening mammogram. “Why?” she’d asked. “You said my breasts felt normal.”

  “There are limits to what I can feel,” I’d explained. “An X-ray of your breasts can find even very tiny lumps.”

  She had been unconvinced. “Let’s not go looking for problems,” she’d said. “Bad luck.”

  She had a point. Mammograms often have false positives, and patients are called back for further testing that eventually, after provoking intense anxiety, proves to be nothing. Eighty-four women must be screened in order to prevent one breast cancer death.1 While this NNS—number needed to screen—might be acceptable to physicians, my patients were less impressed by it.

  Yusef’s initial blood sugar test had been elevated, and I’d asked him to repeat it. I looked up the most recent result: 7.3 mmol/L. “Your sugar is still a little higher than it should be,” I told him. “Let’s check your blood pressure.”

  I check blood pressure on almost every patient, in part as an excuse to touch them. It is therapeutic for patients, although the practice didn’t come naturally to me. My parents weren’t physically demonstrative. The Dutch cultural norm of greeting with three kisses on the cheek—right, left, right—was abandoned when the founders of my childhood community set sail for Canada on the Groote Beer.

  When we practiced physical exams on one another in medical school, I felt awkward and timid. On the receiving end of my classmates’ palpations, though, I noticed how much more pleasant touch was when it wasn’t tentative. I learned to touch patients with purpose. “Grip the patient!” I told my own students now when I saw them auscultating a chest, left hand hovering uncertainly over the patient’s shoulder. Touching patients establishes connection. It serves to comfort and reassure.

  Yusef heaved himself onto the exam table, unbuttoned the cuff of his dress shirt, and rolled up his sleeve. His exposed forearm was covered in dark hair. I could smell cologne, faintly. I wrapped the cuff around his arm, Velcroed it securely, and began to inflate it. I inserted my s
tethoscope eartips and watched the wall-mounted sphygmomanometer. Using my stethoscope always reminded me of snorkelling: the mysteries just under the surface, the privilege of listening in, and the muffled noise of the outside world. It was a thirty-second vacation from the rush of clinic. The needle dropped steadily to 142 and then began to bob, as the pulse became audible. This continued until the needle pointed to 86, when its movement slowed and the pulse disappeared.

  “It’s a little high,” I said as I released his arm and he rolled down his sleeve. “Same as last time. We’ll check it again next visit.”

  “When I left Iraq I was healthy,” said Yusef pointedly. “Canada has made me sick.”

  “Your blood pressure and sugars have probably been like this for a long time,” I said. “It’s just that we’re learning about it now.” I was careful not to slap a handful of labels on newly arrived patients. “You’re not sick,” I assured him. “These measurements are just a warning. They’re giving you a chance to make some changes, so that you don’t get sick in the future.”

  As we reviewed diet and exercise, I wondered at the practicality of the discussion. Health is already a low priority for most refugees, after more urgent issues like housing, employment, and learning English. With two kids starting high school, a wife attempting to conceive, and his insistence on paying Canada back, I didn’t expect Yusef to be particularly concerned about preventing a hypothetical future health event.

  I wondered how much he was currently affected by the trauma he’d experienced in Mosul. He hadn’t told me further details of his abduction since the initial family visit, and I hadn’t asked. It was a difficult line to straddle: ensuring that he understood that I was willing to hear the story, while giving him the space to decide whether to share it. Eliciting the story when the patient isn’t ready risks retraumatization.