Your Heart is the Size of Your Fist

by Martina Scholtens

  Weeks later, I saw my doctor again. I was doing much better, and he seemed mystified as to why I’d come. I wanted to check in, I explained. I could see him trying to figure out what I wanted from him. He offered a medication, and I declined. He offered a different one, but I didn’t want any medications. He asked again why I’d come. He had no idea, I realized, how therapeutic his presence was. The simple answer was this: all I needed, quite literally, was to see the doctor.

  I saw him in the wild, once, months later. I came out of my clinic on the way to lunch and looked up from putting my stethoscope in my purse to see him hurrying along the sidewalk. It was a grey day, wet and blowing. His white hair was flying, his head hunched down. He wore a brown leather jacket and a red plaid scarf looped once around his neck.

  It was disorienting, seeing him as a civilian. I realized then that I had never seen him in outerwear. In fact, I had only seen him under the strictest of conditions: in dress pants and tie, in an eighty-square-foot exam room, between nine and five. This was, as birders say, a lifer.

  I felt as comfortable in his exam room as I did in mine. When he took my blood pressure, squeezing my arm, he was close enough that I could smell his laundry detergent. He wore button-down shirts with his initials monogrammed on the pocket. He recommended novels and told stories of his travels. He always ran late, but he never glanced at his watch when he was with me. At the end of the visit he would turn on his heel and hurry down the hall to the next patient. I chose not to think about the others.

  When he delivered terrible test results that time, and my husband and I were heartbroken, I learned later that he had gone to a community meeting that same night to speak against a proposed neighbourhood casino. Our devastation hadn’t followed him out of the office—of course it hadn’t—and the realization stung.

  When his notice of retirement came in the mail soon after, he thanked his patients for allowing him to share in their joys and sorrows. Not illness and health—joys and sorrows. He had had a front-row seat to mine. Mine, and those of a couple thousand other patients. This was a form letter, one of a massive mailing; my sinking heart was one of many.

  It felt awful, being forced to acknowledge the nature of our relationship: it was business. He was a professional friend, really—supportive, non-judgemental, reliable, accessible, and an excellent secret keeper, because he was paid to be. Who wants to acknowledge that they purchased care, paid for intimacy? The truth, though, was that he gave me what I couldn’t get anywhere else.

  I was embarrassed whenever I suspected a patient felt a strong personal attachment to me. I was willing to be appreciated for my medical skills, but I felt distinctly uncomfortable receiving anything resembling love. The obligation I felt to reciprocate in kind was in complete violation of my professional identity. And yet, my attitude toward my own doctor was one of devotion, and I expected nothing in return. He’d already given enough for a lifetime.

  I’d had three complaints about me brought to the clinic manager in almost a decade. All were in response to my efforts to discharge patients from the clinic to family doctors in their communities, three-zone SkyTrain fares away, after a year as my patient. Moving patients along was clinic policy.

  The first patient sent a letter, run through Google Translate to render the Arabic into English, pleading for “continued care under the prestigious auspices of the clinic, by the human being Dr. Martina Scholtens.” It would have been delightful if it weren’t so urgent. He dismissed any reassurance that he could get the same services—better, even—closer to his home. It wasn’t the service that he wanted. It was our relationship.

  Once when I called Yusef from the waiting room, and we were friendly and laughing as he gathered up his backpack and umbrella, I saw another patient across the room, watching us. From the look on his face, I knew I’d been found out; I wanted to turn his face away. I could see his expression: confused, disappointed, processing that what he was to me wasn’t special. How to make him understand that though our relationship wasn’t, in fact, exclusive, none of it was a lie, either? How, when I hardly understood it myself?

  10

  DURING MY RESIDENCY TRAINING AT the family practice office at Broadway and Granville, I had been amazed at the gingerbread houses, chocolate gift baskets, and wine that piled up on the counters during the Christmas season, as well as the tokens of appreciation that flowed into the clinic year round.

  Gift giving was an unusual event at the refugee clinic. The patients were typically of modest means; even bus fare was often an issue. The gifts that did arrive, though, were memorable. An elderly Afghani woman brought me a cardamom pastry made by her son, a baker. A mechanic gave me four blue air valve caps for my car tires. A Vietnamese couple brought me a straw hat with a message woven into it, which they declined to translate and I chose to assume was a positive one. A family whose mother I had treated presented me ceremoniously with a polished red apple. And I treasured the jewelry I had received from the Haddads, making a point of wearing the bracelet when I knew they were coming to the clinic.

  This list might be delightful, but the truth was, receiving gifts from patients made me uncomfortable. It was a distinctly personal exchange in what I took pains to keep a professional relationship. I was conscious of the financial sacrifice involved for people struggling to pay rent. Sometimes I was given a token of gratitude for a result to which I contributed nothing. The cultural nuances of gift giving could be tricky to navigate.

  When I was in the exam room, though, and the patient reached in her purse for a package, I learned to focus on one thing: respecting the meaning of the exchange to the patient. If I disliked feeling beholden after accepting a present, perhaps this was a taste of what the patient had felt for months. Maybe gift giving was a realization of the patient’s independence that we had worked to foster, a move away from the sense of obligation and deficiency that can accompany receiving help.

  After eighteen months at the clinic, I told an Arabic patient that he needed to move on to the family doctor he’d found in Richmond. He reluctantly agreed, but said that he needed to come back for one more visit, to bring me a parting gift. I told him that was thoughtful, but unnecessary. He insisted. I protested. I relented when he finally said, forceful with frustration, “You don’t need a gift. But I need to give one.”

  At the end of a visit, a Myanmar woman handed me something wrapped in a plastic shopping bag. It was a brilliant pink, hand-woven skirt. I promptly tried it on over my pants. It was a perfect fit. As I thanked her, overwhelmed with how kind the gesture was, but also how unnecessary and costly, she repeatedly asked through the interpreter if I liked it.

  When she had left the clinic, I pulled the interpreter aside and asked if it was appropriate for me to accept the gift. It was so generous, when all I had done was provide routine care.

  She shook her head before I had finished explaining my hesitation. “You must accept it!” she said emphatically. Gripping my arm, she said quietly and firmly, “The Karens give gifts to people who they feel in their hearts are looking out for them.”

  I had tears in my eyes, because she said so simply what we strove to do in medicine, particularly for the most vulnerable patients at our clinic.

  More embarrassing than accepting a gift was inadvertently requesting one.

  Hundreds of Karens, an ethnic minority from Myanmar, had come through our clinic over a five-year span. They were accomplished weavers and soon after arriving in Canada they resumed working on their looms. They wore skirts and scarves in a fine weave, with intricate patterns and gorgeous colours. I particularly admired the bags that both men and women wore slung over their shoulders.

  I finally asked Win, the Karen interpreter, where I could purchase such a bag. She had come into the exam room with a soft knock for me to sign her day sheet. She immediately looked excited. “What kind do you want? Zippers, to put lots of things in, or bag, or sling?”

  I described the bag my patients usually carried, a simple
tote. “Where can I buy one?” I already felt awkward; I could see exactly where this was heading, and it was too late to stop it.

  “What colour?” she asked.

  “Red and white,” I said, remembering a particularly beautiful one I had seen a few weeks ago.

  She started to thank me. “So many patients ask me if they can bring you a bag! But I didn’t know. My sister, she asked me last week if she could bring you a bag! Thank you! Sometimes we use four colours. What if it is red and white and black?”

  “Any colour is good.”

  “I will make it for you.”

  “No!” I protested. “Then I wouldn’t have asked you!” I explained how I had searched online for a vendor, hoping that the Langley Weavers and Spinners Guild would offer them for sale. “Where do you sell them?” I asked.

  “My house!” Win exclaimed. The interaction ended with her slightly bowing, hand over her chest, thanking me for the opportunity to make me a bag.

  The next time she came to the clinic to interpret, she delivered not one, but two bags. Of course, reimbursement was out of the question.

  Weeks later, I thanked her again for the bags, and told her that I thought of her every time I used them. She nodded vigorously and said in a serious voice, “I think of you all the time, too.”

  Sometimes I was recognized for work that I didn’t do.

  When I did a routine breast exam on an Iranian patient, I discovered an abnormality. I arranged some investigations. The patient was distraught, and no amount of discussion could calm her. The imaging confirmed a suspicious lesion, and a biopsy was organized. It came back benign.

  She came in for the results a week later. When I gave her the good news, she began to sob. She briefly buried her head in her husband’s shoulder, and then pulled out her cell phone and made a series of calls. All the while, via the interpreter, she asked me repeatedly to confirm that she didn’t have cancer.

  Then the thanking began. Profuse thanksgiving, to me. The interpreter could hardly keep up with the flood of appreciation. The gratitude made me uncomfortable, and I tried in vain to deflect it. At one point the patient uttered the first English phrase I’d heard from her: “I love you!” They finally left, clasping my hand on the way out.

  When I came back from lunch, there was a package of chocolate pastries on my desk. I suppose that what I ought to have done was to store up this appreciation, undeserved though it was, and dole it back to myself to salve my wounds if next time, as the messenger, I got shot.

  My favourite gift came from the Prairies, was given out of a misunderstanding, and was very difficult to explain to my family when I pulled it out of my briefcase at the end of the day. I had cared for an Iraqi family for almost a year, parents and four children, all of whom I’d seen regularly. One of the adult sons was a dentist, and was working toward his Canadian professional credentials. He needed to travel to Saskatchewan for an exam, he emailed me, and his dad was going with him. They’d need to cancel next week’s appointments.

  “No problem,” I emailed back.

  “Want anything from Saskatoon?” he asked.

  “Some wheat?” I joked. “Have a good trip.”

  A few weeks later, I called the dad in from the waiting room. He cradled a Bulk Barn plastic bag on his lap. I started to sweat.

  “What kind of wheat did you want?” he began, through the Arabic interpreter. “Because we went to four different stores, and said, ‘Our doctor wants some wheat,’ and at every store they asked, ‘What kind of wheat?’ We didn’t know, so I hope this is what you wanted.”

  He passed me the sack and waited anxiously for my reaction. It was fluidly hefty. I looked inside, and there were several bulk bin scoops of hulled, unmilled wheat kernels.

  We had long since passed the point of no return. “This is perfect,” I said. “Thank you so much.”

  After the visit, the interpreter couldn’t help herself. “Why did you ask him for wheat?” she asked.

  “Because they went to Saskatchewan,” I explained. She had immigrated to Canada a half dozen years ago; this ought to make perfect sense to her.

  She looked at me blankly.

  “Saskatchewan is famous for wheat,” I continued, lamely. “Here, watch what happens when I do a Google Image search for ‘Saskatchewan.’” She looked over my shoulder as my screen filled with scenes of golden wheat fields receding to a point on the horizon, under wide blue skies.

  “Oh,” she said dubiously. “I had no idea.”

  11

  THE CLINIC LOST THE FEDERAL funding for its trauma program, a critical service for refugees who had experienced terrible events. I was dismayed by the decision, worried for my patients’ well-being, and frustrated by the dismissal with which mental health services so often seemed to be treated. I wrote an appeal for its restoration. I worked on it for a week, in the evenings, after the kids were in bed.

  I began the article with a litany of horrors that I’d seen at the clinic. I knew the names of everyone I described.

  I’ve seen an Iraqi mother disabled by a car bomb, and a journalist who was tortured with electrocution in an Iranian prison. I’ve cared for a Somali family whose newborn babe was flung to the ground and killed by rebel fighters, and Congolese women who were forced to watch the executions of their husbands and sons. I’ve met Afghani and Pakistani women who were threatened with acid or death as they walked to school or work.

  I appealed to empathy:

  And still I watch as resilient and resourceful patients find a home, learn English, and seek employment. But for some, the trauma they have suffered continues to torment them. They relive horrific events through nightmares and flashbacks. They experience continuous fear, mistrust, and hopelessness. Sirens, police, or loud noise trigger panic. Psychological pain manifests as crippling physical symptoms. They mourn for and worry about family left behind. I see children who hurt themselves, mothers crumpled by shame for being raped, and fathers who cry when left alone.

  I appealed to pragmatism:

  Someone in that state cannot learn a new language, gain employment, or develop social networks. Adjustment to life in a new country is challenging enough when attempted with optimism and energy; it is next to impossible for someone whose psychological reserves have been completely drained.

  These patients require intervention to achieve a level of peace necessary to function. Medication offers some benefit, as does primary care, but connecting the patient with a trauma counsellor is essential. Counselling enables the patient to process past events, achieve respite from psychological pain, and move forward with life. I’ve depended on Vancouver’s trauma counselling services for my patients, and my colleagues and I are now forced to cobble together treatment plans as best we can from the limited resources that remain.

  I voiced my frustration at mental health getting short shrift, again:

  Mental health should not be an add-on, the icing on the cake of medical care. It is foundational to the care of the patient. Stabilizing mental health ought to precede, or occur alongside, diabetes management, hip replacement, and prenatal care—not act as an optional part of patient care to be tackled at the end of the list, should there be leftover resources.

  The word patient has its roots in the Latin patiens, meaning one who suffers or endures. That is what I seek to do as a physician at a refugee clinic: to relieve suffering. With this population, I need mental health services to do it.

  I submitted the article to two national newspapers. There was no response. I widened the net, sending it to local papers, news blogs, and medical journals. Only one deigned to reply, with a polite rejection.

  I couldn’t believe it. Was it poorly written? Was the issue too narrow and specific? Or—and this idea upset me most of all—did the editors know that it would bore the Canadian public? The lack of interest in publicizing the issue was a stinging second blow.

  At the clinic, we triaged the patients in need of counselling and directed the most urgent cases to the
Vancouver Association for Survivors of Torture. The others would have to wait, supported by their physicians, while we searched for more resources in the community. Finding counsellors who specialized in trauma, offered interpretation, and were accepting new clients was next to impossible. The list of patients waiting for care continued to grow. The most prevalent diagnostic codes at the clinic were for depression and anxiety.

  Over the past months, I’d determined that Yusef met the criteria for post-traumatic stress disorder—PTSD. Details gleaned from his visits and from Junah’s offhand accounts of life in their Surrey apartment led to my diagnosis. His abduction and torture in Mosul, and Sami’s death, intruded into his daily life as flashbacks and nightmares. He went to great lengths to avoid reminders of his past. If he saw a dark blue sedan similar to the vehicle that his abductors had used, he froze until it passed out of sight. When he walked to get groceries, he made an elaborate detour around the neighbourhood parks and playgrounds with soccer pitches, fearful of a reminder of the after-dinner game he’d enjoyed with Sami in the final moments of their former life. He couldn’t bear being near the water’s edge and avoided the beaches for which Vancouver was renowned. He was hypervigilant, insisting that Layth and Nadia stay indoors when they weren’t at school. He was easily startled and angered by something as benign as a slammed door. His sleep was poor.

  I’d read once that an ideal story—dilemma, crisis, resolution—could be represented by punctuation marks: ? ! . It struck me that Yusef’s story was the reverse: a peaceful life disrupted by horror, with no resolution: . ! ?

  “Your nerves are tired,” I told Yusef one morning in January. He nodded warily as Hani repeated this. “Humans are only built to withstand so much,” I continued. “If you try to lift something very heavy, you’ll hurt your back. In a similar way, there are limits to the suffering that people can endure. If it’s too much, damage is done.”

  This was how I approached mental health, avoiding clinical, stigma-laden terms like depression and referring to suffering and nerves instead. “I’d rather have cancer than depression,” a patient had wailed once, devastated with her diagnosis.