“Aren’t you contributing to the stigma by avoiding the correct terms?” a psychologist friend challenged me at one point. I did introduce the proper terminology, eventually, after the initial sensitive conversations had been had. But in cautiously broaching the subject of treating Yusef’s PTSD for the first time, I didn’t want to risk alienating him with jargon he might instinctively resist.
“All of my patients are refugees, and many have experienced awful things,” I told Yusef now. The torture prevalence among Iraqi refugees was 56 percent.1 “Many of them describe what you’ve told me: nightmares, constantly checking that the door is locked, feeling like they can’t control their thoughts.” I could see disbelief on his face, then relief.
“I think I am crazy,” he confessed in a soft voice.
“You’re not crazy. What you’re experiencing is a normal response to what happened.”
We sat quietly. “I am confident that you can be well again,” I offered. “There is no quick fix, but I am very hopeful that you can feel better again.”
Tears ran down Yusef’s face. There were medical differences of opinion on offering patients tissues. One camp encouraged it as an empathic gesture. The opposing view was that the message implicit in an offered tissue was, Stop crying! I took the middle ground by placing the tissue box in a conspicuous location, at arm’s reach from the patient, where he could serve himself. Yusef did not take a tissue. Neither of us made an effort to stop his tears.
“There are a few options for treatment,” I went on. I always provided these in the third person; this degree of separation seemed to offer patients some objectivity and make the choices less overwhelming. “Some people choose to wait and see. Sometimes, with time and settling into their new home, the symptoms resolve on their own.” Yusef had been in Canada for only four months.
“Some people get relief from medication,” I continued. This risked sounding horribly pat—writing a prescription to treat torture like you would an ear infection. “A pill can’t undo what happened to you. I wish it could,” I said. “What medications can do, though, is help your stressed nerves to rest, so they can heal. This takes time. You would have to commit to taking medication daily for at least six months.” Yusef said nothing to this.
“Some people find it helpful to see a counsellor,” I went on. I could see him about to protest, and I knew what his concern would be. “You don’t have to talk to the counsellor about what happened in the past, unless you want to. A counsellor can focus on how to feel better in daily life.” He looked unconvinced. The concept of confiding problems privately to a trained professional was foreign to most of my patients.
“Studies show that the best results happen when medication is combined with counselling,” I concluded. I waited for his response.
He didn’t hesitate. “No pills,” he said. “No counsellor. Just you.”
Torture involved loss of trust, a speaker had said at a refugee conference I’d recently attended, and patients were healed by re-establishment of trust. I might not be a psychotherapist, but I had excellent rapport with Yusef and I recognized the value of it.
I nodded. Today, I was just floating the idea. I hadn’t expected Yusef to do anything more than listen to it. I’d lost count of the patients who’d asked me months later, “Doctor, remember that pill for stressed nerves that you told me about?”
I gave him an Arabic handout on PTSD and offered some simple coping strategies. “More walking outdoors every day,” I said. “Less time reading Al Jazeera online.” I’d been taught that the most powerful words a doctor could say to a suffering patient were the ones I said next: “I want you to come back and see me in a week.”
“One week,” he said, slipping his arms into his coat sleeves. “One week.”
12
THE HADDADS HAD BEEN IN Canada for five months and I had not seen Nadia, the fourteen-year-old daughter, since the initial family visit. Twice I’d reserved an appointment slot for her when her parents and Layth were due to come in, but both times she hadn’t accompanied them. “Nadia at school,” her parents had said simply.
I was pleased that she took her studies seriously. Furthermore, I knew healthy teens typically did not prioritize visits to their family doctor, but I wanted to have at least one visit alone with her. I asked Hani to call her directly and book an appointment with me.
This afternoon she’d been waiting alone on one of the church pews, phone in her hand and backpack at her feet. I’d asked the family medicine resident who had joined the clinic for the month of February to assess her. Nadia had given an unexpected history of epilepsy. Like virtually all my patients, she had no medical records. She was on no medication and her physical exam, as reported by the resident, was unremarkable.
“You’re saying she’s faking it?” asked the resident. I leaned against the counter in the chart room, eating my bagged lunch at 2:30 PM and considering what she’d just presented to me. Nadia waited for us in Room 146.
“No, I don’t think this is malingering or Munchausen’s,” I said. I didn’t believe that Nadia was faking symptoms or harming herself for medical attention. “Conversion disorder is when psychological stress manifests as neurological symptoms, such as blindness or paralysis.”
The resident looked confused, and I didn’t blame her. Conversion disorder was a rare phenomenon, and I hadn’t seen any cases as a medical student or resident. I recalled one portion of one lecture covering conversion disorder in my medical training. It was memorable because the psychiatrist proposed that people miraculously healed by preachers at revival meetings were in fact simply having their conversion disorders reversed.
At the refugee clinic, though, I’d seen a half-dozen patients over the past year who responded to stress with impressive neurological symptoms. All of them were Iraqi.
One developed right-sided paralysis whenever he spoke to his elderly father in Baghdad. He’d been run through the stroke protocol at the emergency at his local hospital twice, both times resulting in a normal head CT and a shrugging neurologist.
Another had a Bell’s palsy that recurred when the news reported a surge in violence in her home country. She’d come in with a drooping right eyelid and half of her mouth frozen in a downturn. A few days later she’d spontaneously recovered.
I suspected that Nadia, whose seizure-like activity began upon the death of her brother Sami in Mosul two years ago, was our latest case of conversion disorder.
“How do you want to work this up?” I asked the resident. Conversion disorder is a diagnosis of exclusion—you must rule out other causes first. I agreed with the resident’s plan for blood work, a head CT to rule out structural abnormalities, and an EEG to analyze the electrical activity of the brain.
I accompanied the resident to the exam room.
“Hi, Nadia.” She was seated as far back in the chair as was possible, the smooth wrap of a pink hijab framing her face. She wore a thick application of eyeliner, skinny jeans with a small deliberate rip over each knee, and Adidas sneakers. She stared at me with frank curiosity, as Muslim girls often did. I was a novelty, I knew: a female physician in a pantsuit with loose hair.
“This doctor told me you’ve been having some trouble with collapsing and losing consciousness,” I went on, nodding at the resident. I waited for the Arabic interpreter to relay this. “There are several possible causes. Let’s start with some basic tests, and we’ll see from there.”
She managed the smallest possible nod.
“How’s school?” I asked, while the resident completed the requisition forms.
“Okay.” Whispered.
“What grade are you in?”
“Nine.”
I could not imagine the challenges of navigating public high school as a recent immigrant with limited English skills. “In Canada, doctor visits are not just for when you’re sick,” I offered.
She waited.
“You can see a doctor about other things, too—trouble with friends, having a boyfrien
d, feeling worried or sad, your sleep. You can come to the clinic with questions about your body or your period.”
She was frozen in her chair. Then, without taking her eyes off me, she said a few quick words in Arabic.
“She doesn’t have a boyfriend,” said Hani.
My young patients often had misconceptions about Canadian social behavioural norms, assuming sex and substance abuse to be far more common than they are. If their culture endorsed abstinence, I worked to normalize it. “In Canada, some teenage kids have sex. Many don’t. Choosing not to have sex is a healthy choice,” I said. “If a man or boy wants you to do something that you don’t want to, tell them no,” I went on. “It’s your choice, and you can say no.” I was conscious of the vulnerability of my young female patients, and tried to have this conversation with each of them.
While Nadia said nothing in response, I could tell I had her full attention. I was sure she’d gotten more from this doctor visit than she’d bargained for. She looked shocked, but not displeased.
When I saw her again a month later, the results of the seizure investigations we’d ordered were normal. So were those ordered by the two different emergency doctors she’d seen in the meantime; both had been copied to our clinic.
Nadia seemed ambivalent when I gave her the results. She continued playing with a strand of hair. Both emergency consult notes indicated that paramedics had been called to her high school when she had a seizure. I asked her about this.
“I’m very embarrassed when an ambulance comes to the school for me,” she said through the interpreter. “Everyone looks at me.”
“I can see from the emergency doctor’s note that he arranged a neurology consult for you,” I told her. “And the second time you went to the emergency they set up an appointment with a cardiologist.” I made sure she had the details for those appointments.
During the entire visit, at the back of my mind, I’d noted that something was different about her. Suddenly I realized what it was. “You’re not wearing your hijab!” I said.
The headscarf was gone, and gleaming black hair hung to her mid-back. She tried to look nonchalant at my exclamation, but she couldn’t hide a small pleased smile. She spoke to Hani.
“Her parents said that because they are in Canada now, she can choose whether to wear the headscarf.”
Junah, I realized, had made a different choice for herself.
“At the last visit, you said she could ask you about her body,” Hani continued.
“That’s right.”
She went on to describe vaginal symptoms that sounded like a yeast infection.
Before I could ask her to undress, Nadia thrust her phone at me. “There’s no need for an exam,” said Hani. “She took pictures.”
On the phone’s screen was a macro shot of a vulva.
“There’s more than one,” said Hani. “Scroll through!”
There was an entire album of Nadia’s perineum. I hardly dared to handle the phone; I was acutely aware that I was a few swipes away from sexting her entire address book.
“I can give you a prescription for Canesten,” I said, “Please delete these.”
When I saw her next, the cardiology and neurology reports had been added to the growing list of reassuring results. Patients were never as pleased to receive normal results as one would expect. A normal finding meant that their question hadn’t been answered, which was frustrating. Some patients interpreted a negative test result as the medical system denying the existence of their symptoms, calling them a liar.
Broaching the subject of conversion disorder—suggesting to a patient that her symptoms were due to psychological distress—was always a sensitive task. I started by asking Nadia for her ideas on the cause of her fainting spells.
“They’re psychological,” she said simply. “I’m full of loneliness.” She’d seen a half-dozen doctors, holding the answer the entire time, and not one of us had thought to ask the question.
We talked about connecting with a counsellor. I suggested anxiety-reducing medication. We reviewed sleep and exercise.
I ended the visit with my standard question: “Anything else I can do for you today?”
Nadia hesitated, looked down, and asked quietly, “Could you help me find some friends?”
13
I OFTEN TURNED TO GOOGLE IMAGES to help supplement instructions to patients whose English was limited. I’d pull up a picture of prunes for the constipated patient, or a humidifier for parents with a coughing baby. A few words typed into the search box and the screen was populated with helpful images.
Patients that I’d seen often over the past year, an elderly Iraqi woman and her adult daughter, came to see me about the mother’s shingles. She had terrible pain to her right trunk and as part of her treatment I advised that she apply lidocaine ointment to the affected area. The ointment worked best when an occlusive dressing was applied over top, but Saran Wrap was a cheaper alternative.
They were not familiar with Saran Wrap. Cling wrap? Plastic wrap? A see-through cover that could be stretched over food? Miming pulling the wrap from the roll and wrapping a sandwich didn’t help.
I turned to the computer and typed in my search terms. Mother and daughter leaned forward and looked expectantly at the screen. And then, multiple images of naked women bound in cling wrap appeared. I quickly turned the monitor away, but not before these two conservative Muslim women had been confronted with several seconds’ worth of pornography.
This possibility had never entered my mind. Was this an established practice about which I was extraordinarily naive? We were all horrified, but I was the only one who blushed, and this, with my profuse apologies, seemed to amuse them. They made a sly reference to the incident at every visit I had with them after that.
Since then, it felt like a gamble to search even seemingly innocuous terms in front of patients, and I began to discreetly turn the monitor out of the patient’s line of vision for a preview when I needed an image.
And then a Nepali-speaking family came in with a boy who had olecranon bursitis, an inflammation of the elbow. I advised icing it—with a bag of frozen vegetables, for example. They were confused, and I turned to my computer, screen carefully angled away. But they gathered around and watched over my shoulder. What could I do? I would have to chance it.
Bag of frozen vegetables, I typed. I couldn’t think of any way that this could be abused, but I’d been wrong before. I held my breath. The results came up.
Peas and carrots. Oh, sweet relief. Nothing more than peas and carrots.
Communication with patients was always a challenge. Eighty percent of clinic visits required interpreters. Patients spoke Arabic, Farsi, Swahili, Oromo, Spanish, French, Nepali, and a dozen other languages.
I was effectively and unfortunately monolingual. As a Canadian, it embarrassed me to request a French interpreter. When I took government-mandated Grade 10 French in British Columbia, I didn’t have the slightest inkling that fifteen years later I’d be a physician to French-speaking Africans. If only I had learned how to ask about chest pain or bowel movements, instead of memorizing all the items one would bring à la plage, and the gender of a hundred fruits and vegetables.
Farsi or Arabic would have been more useful than French. I had investigated language courses at UBC and the local community colleges, but couldn’t find any offerings that fit with my schedule. I had acquired few foreign language skills over the years despite constant exposure; I was focused on the medicine and the linguistics were just the backdrop to my work.
When seeing Spanish-speaking patients, sangria was one word that I heard regularly. It was usually buried in a long descriptive passage by the patient, and while I waited for the English version, I thought of a chilled red wine beverage with brandy and floating citrus slices. Finally, I asked the interpreter why the word kept cropping up. Sangria meant bleeding, it turned out, and my pleasant reveries had been completely at odds with the experiences patients were recounting. I think I may
even have been smiling while someone described a hemorrhage.
According to a demonstration video we watched at a staff meeting, the interpreter ought to be seated behind the physician’s left shoulder. Eye contact was to be maintained between doctor and patient; the interpreter was to function as a kind of unobtrusive machine, providing literal phrase-by-phrase interpretation. It didn’t work quite like that. Sometimes the interpreter came with a large personality, extra commentary, or cologne that couldn’t be ignored. We would compete for the attention of the patient, whose gaze would oscillate distractedly between us. Having a third party in the room could make it difficult to develop rapport with the patient.
Although I could never know for certain what was said by the interpreter, I needed to have reasonable confidence that the dialogue was being conveyed accurately. The regular interpreters were excellent and I trusted them. Sometimes I’d work with someone new, though, who would relay my carefully detailed instructions to the patient in five words. Or the reverse: my one-word answer would be interpreted to the patient in an excited tirade lasting minutes. Some interpreters had such strong accents that I misunderstood their English. One of the Swahili interpreters pronounced angry and hungry identically. I went through a painstaking history trying to sort out why my patient was angry all the time but it turned out he couldn’t stop eating.
Literal translation was helpful for medical details, but sometimes the more nuanced meanings behind my questions were lost. When I asked whether a patient was sexually active she considered the question carefully and replied, “Usually I lie quite still.” I stopped asking, “What brings you in today?” when one too many patients responded, “SkyTrain.” When it came to patient stories, most interpreters used cultural interpretation, listening to the patient’s entire story and then retelling it to me with cultural explanations. Sometimes I preferred the literal interpretation. I wanted to hear that a Somali woman’s anger at those who killed her newborn was “like an animal chewing on my insides.” I didn’t want a Westernized description.
Your Heart is the Size of Your Fist Page 7