Your Heart is the Size of Your Fist

by Martina Scholtens

  Patients had to be matched to interpreters of the appropriate sex and ethnicity. Most women, particularly Muslims, were reluctant to share gynecologic complaints through a male interpreter. A subtler challenge was appropriately pairing an interpreter to a patient with regards to ethnicity. We organized a Kirundi interpreter for a patient from Burundi. The patient was Hutu and the interpreter was Tutsi. While this distinction was invisible to me, they instantly recognized each other’s ethnicity and refused to proceed with the visit.

  Shared backgrounds with interpreters could cause confidentiality and disclosure issues, though, especially within a small refugee community with a limited pool of interpreters. An Ethiopian woman refused an interpreter for her visits because she was terrified that her HIV diagnosis would be leaked to the African community in Vancouver. I wondered how likely an unmarried Karen woman with pelvic pain was to disclose sexual activity when the interpreter sat in the church pew behind her every Sunday, or a Muslim with liver disease to reveal alcohol consumption when the interpreter was wearing a hijab herself.

  Often the interpreter was beloved by the patient and became a confidant. Sometimes the interpreter supplemented the patient history with information from personal interactions in the community—at the mosque or grocery store. One of my patients, an elderly Vietnamese man, complained of poor vision. I was trying to establish the nature, severity, and progression of his symptoms when the interpreter cut in: “Doctor, I will tell you a story his granddaughter told me at church. He went to the grocery store this week to buy a birthday cake for her. He walked up and down the aisles until he found a large cake display.”

  She went on to describe how the patient selected a small, rectangular cake. It was light brown, and he assumed it was chocolate-flavoured, his granddaughter’s favourite. As he was having some difficulty seeing the product clearly, he patted it gently with his hands. Through the plastic wrap the cake felt firm, cool, and moist. Pleased with his find, he made the purchase and carried it home.

  He set it on the centre of the table in the dining room and went in search of birthday candles. As he rummaged in the kitchen drawer, his daughter entered the room and asked, “What’s that slab of pork doing on the dining room table?”

  With this exchange, the interpreter violated every rule in our staff educational video on professional interpretation. It was useful information, though. I decided my patient’s visual problems warranted further workup.

  14

  SHE HAD A GARDEN THE size of my exam room, the patient told me through the Karen interpreter, appraising my eight-by-ten-foot office. I had been nosing around with my questions, curious, trying to understand the mysterious daily life of the depressed Myanmar mother sitting in front of me. I’d asked about plants, and she’d perked up. What was she growing? Mustard, pumpkins, and four kinds of eggplant. She’d started them all from seed as soon as the grey Vancouver winter had lifted and the days began to warm. The plants had grown this big: she held her hands a few inches above the exam table. It was the most animated I’d ever seen her.

  “When she goes outside every day and sees that things have grown, she feels good inside,” said the interpreter.

  I understood. My own garden was a wild West Coast mess of sword ferns the size of small cars, mossy boulders, and drifts of cedar droppings like soggy orange feathers. Puttering in the yard for an hour after dinner was the perfect antidote to a day at the clinic. It was silent, except for the hum of boats motoring up Indian Arm. The work was manual and repetitive, and my mind could wander; gardening was meditative.

  Results in the yard were blessedly tangible. American writer Michael Pollan described gardening as “ways of rendering the world in rows.” 1 It was true: after the chaos of clinic it was a relief to engage in a pursuit where I could impose order. I decided what went where, and whatever threatened the plan I raked, weeded, and pruned, with visible and immediate effects. Measureable progress was directly proportional to the work I put into the project. Such were not the ways of medicine.

  The temptation when I headed out to the yard was to focus on what needed fixing. I deadheaded the hydrangeas, scraped away moss, and swept the walkways. I had to make a conscious effort to focus on what was remarkable, to fuss around the rhododendron with its huge pink blossoms and take a cutting for the kitchen table. I tried to do the same at work and in life: to avoid focusing on what needed a solution, and to celebrate what was in bloom.

  While I enjoyed being industrious, the real events in the garden—like the clinic—happened independent of me. I was, at most, a facilitator. When I stepped away from patients or plants for a few weeks, all sorts of interesting and surprising things occurred in my absence. Things were never as I’d left them. Both gardening and medicine were organic, messy, and unpredictable. Both had inherent vitality, a life of their own. This satisfied me deeply.

  I was a permissive gardener. When I discovered cedars spontaneously sprouting in a corner of the yard, two inches tall and several shades brighter than their parents, I accommodated them. I weeded around them, thinned them, and cut back the salmonberry bushes so that they’d have more light. “Look how well my grove is doing,” I’d tell Pete, who’d humour me with a glance in their direction. I had a similar approach to patients. I enjoyed puttering and discovery.

  The pleasure of gardening—especially on days at home with my daughter—was sometimes sullied by my own speculation that it might be indulgent. Setting out slug bait felt frivolous when my patients were so traumatized by war experiences that they dissociated in English language class when they heard a siren. There was a wait for my patients to see me at the clinic, and here I was raking leaves. I was so acutely conscious of the needs of our patients that sometimes I was convinced that clinic work was the only activity worth my time.

  I felt differently, though, after I read the United Kingdom’s Project on Mental Capital and Wellbeing report.2 It includes an evidence-based list of five simple daily habits for mental well-being, which are likened to five daily servings of fruits and vegetables and recommended to every person in the UK:

  1.Connect. With the people around you. With family, friends, colleagues, and neighbours.

  2.Be active. Go for a walk or run. Step outside. Cycle. Garden.

  3.Take notice. Be curious. Catch sight of the beautiful. Remark on the unusual.

  4.Keep learning. Try something new. Rediscover an old interest. Take on a different responsibility at work.

  5.Give. Do something nice for a friend, or a stranger. Thank someone. Volunteer your time.

  The report, the result of a two-year study involving over 400 international experts, concluded that making these activities a part of daily life could have a profound impact on people’s happiness. This resonated with my professional experience. New Year’s resolutions and doctor recommendations usually revolved around physical fitness—losing weight, eating well, and working out. It was harder to be specific about pursuing optimal mental health, and therein lay the beauty of the concise, practical list. With some intention, these five items could be seamlessly woven into most people’s daily routines with little cost in terms of time or money. I wanted a prescription pad stamped with the list.

  The recommendations crystallized a few things for me personally as well. The checklist validated taking time during the day for pleasurable pursuits, such as gardening. Knitting while Ariana napped, bringing a book along to the beach, or fiddling with a camera setting during lunch all included several of the five happiness-inducing habits. Now I could articulate why tucking away pockets of time for those activities during the day was not wasteful. It might literally preserve my sanity.

  As well, the list explained why a day at the clinic was inherently satisfying, whereas a day at home with the kids required effort to produce the same sense of well-being. My work at the clinic ensured that I connected with colleagues and patients, took notice of the details of others’ lives, learned continually, and gave to others. I ticked off four of the five
mental health boxes just by going through my day. I checked off all five when I hunted for free parking and walked eight blocks to the clinic.

  When I stayed home with the kids, few of those five activities occurred spontaneously. When I followed the path of least resistance, a length of time at home seemed to naturally tend toward isolation and inactivity. Most of my days at home were pleasant, but only because of the work I put into making them so. While at-home mothering easily held its own in terms of isolated blissful moments and long-term gratification, my state of mind at dinner time was sometimes one of defeat. “Go for a walk,” Pete said when he got home from work and sensed such a mood. “Go walk in the woods.” We lived near Wickenden Park, a dark, still forest with footpaths winding through it. A half-hour alone surrounded by cedars, huckleberry bushes, and bird calls never failed to calm me. Just as my patient had said, going outside and seeing that things had grown made me feel good inside.

  “Junah is happier,” Yusef remarked offhandedly the next morning as I refilled his prescription. I’d asked after the family, as I always did. “She didn’t say that. But she must be, because over the past week she’s filled the apartment with plants.”

  15

  “GUESS HOW MANY TIMES NEIGHBOURS have come to visit,” commanded Junah.

  I guessed that it was exactly as often as I’d dropped in unexpectedly on my own neighbours. “Zero.”

  She looked taken aback by my certainty. “Yes! No one has come for tea.”

  “They probably think they’re being polite by leaving you alone. Try inviting them.” I appreciated Canadian reserve, but Junah looked indignant.

  Few patients were immune to loneliness. Sometimes I was tempted to connect two isolated patients with similar addresses, a friendly matchmaking service to combat loneliness. Patients needed to be part of a community, not just to fill the void of friends and family left behind but to be distracted from rumination about the past. Friendship offered an opportunity to practise English and learn the culture. Patients needed friends to feel Canadian.

  I wished the public knew how important small gestures could be. When I heard the stories of little kindnesses that patients told me, I wanted to broadcast them. “I was walking with groceries, heavy bags, when the bottom dropped out of one,” Yusef told me. “Potatoes, apples, cans—all rolling on the street. Then a car honked, and it was my neighbour! He helped me gather my groceries and drove me home in his car.” The pride with which he related this suggested that it was about more than practical assistance. He’d been recognized.

  I’d read a newspaper article about one of my Syrian patients. He described his new life in Burnaby with an anecdote about how he’d tripped and fallen on the sidewalk. Strangers had rushed to help him up. “Just like Damascus,” he’d said with satisfaction. Stories like these moved me more than anything else I heard in my exam room.

  I encouraged patients to connect with others, but I understood why it was so difficult. The language barrier was significant, as were cultural differences. In English classes, specific language groups stuck together. Mothers were intimidated by the other women clustered together at school pickup. The idea of joining the local recreation centre to swim or work out was often inconceivable, particularly to women.

  Some patients did take the initiative, reaching out and exploring, but they were the exception. “I had my son’s friends from college over for lunch on Sunday. An African and an Indian,” an Iranian man told me. He was fascinated by Vancouver’s diversity. Several of the Pashtun men from Afghanistan instantly recognized Canada for the playground that it is, cliff jumping in Lynn Canyon, taking road trips, camping in the wilderness, and reporting their exploits to their incredulous doctor.

  My patients weren’t the only ones who were lonely.

  On the face of it, a day at the clinic seemed social. I saw patients, one after the other, from nine until four, with a break for lunch. Most of my patients were well known to me. I’d get caught up on their lives—school, family, work. “How are your spirits these days?” I asked almost every time. It didn’t get much more personal than that. It was just me and the patient, our knees almost touching, in a small exam room with the door closed and an interpreter behind me.

  I left work after a day of this, drove the five minutes to pick up Ariana from preschool, and began the commute to Deep Cove. Suddenly I’d be ravenous. I’d ask Ariana what was left in her lunch box and she’d hand me some carrot sticks and cubes of cheddar from the back seat. Ten minutes later, around Grandview Highway and Nanaimo Street, I’d bottom out, utterly exhausted. The idea of having to shepherd kids through mealtime and bedtime chores felt impossible.

  If Pete wasn’t away on business, I came home to sous vide salmon and curried cauliflower, and we divided up the after-dinner work. If he was travelling, we’d eat the Costco lasagna my daughter put in the oven when she came home from school. Then I oversaw homework and lunch making, brushing teeth and laying out school uniforms for the next day.

  I cut corners. I picked the bedtime book with one sentence per page. I moved up the bedtimes of the kids too young to notice. I wanted the noise to stop, even the singing. They’re getting shortchanged, I’d think, but I’ll make it up to them later in the week.

  For years, I’d seen patients Monday, Tuesday, and Friday. Mid-week I was home with my youngest, grateful that Deep Cove was off the beaten path. We couldn’t see our neighbours from our place. Standing at the kitchen sink, I could see a stand of waving cedars, the gunmetal grey winter waters of Indian Arm, and the dark bulk of forested mountains rising from the opposite shore. The solitude was perfect. No play dates, thanks. No community centres or meeting for lunch, either. I might be up for something on the weekend, but it took until Saturday evening to recover from Friday afternoon’s walk-in clinic. I needed a respite from human contact, and I preferred as much solitary time outside the clinic as three kids could give me.

  I’d forget, though, that seeing patients wasn’t at all a substitute for catching up with friends over drinks. At the clinic, the topics of conversation, the confidences, the complaints—they were all one-sided. There was pleasure in seeing patients, but really, it was business.

  I’d never have believed I would have three kids and eight hundred patients and feel lonely. But my work drained me to the point that all my spare time was spent trying to recuperate. Pete wanted to have people over more, and to vacation with other families. I had always imagined a noisy, boisterous home with friends and family coming and going, but with my work commitments, I didn’t have the psychological reserves to make it happen.

  My quietest sister lent me Susan Cain’s book Quiet: The Power of Introverts in a World That Can’t Stop Talking.1 I had never recognized the challenges that my introversion brought to clinical work. Cain advises creating as many restorative niches in daily life as possible: “Introverts should ask themselves: Will this job allow me to spend time on in-character activities like, for example, reading, strategizing, writing, and researching? . . . [If not,] will I have enough free time on evenings and weekends to grant them to myself?”

  No, and with three kids, no.

  I had an epiphany. Clinical work’s patient lineup exhausted me, and my social life was extremely limited because I needed stretches of alone time to recharge from work. I had to reverse this. I needed to implement more solitary time at work, and more people-time after hours.

  So I gave up my Friday clinic. I’d worked Fridays since I finished residency. Now I finished the week with administrative work and other projects instead, alone in my organization’s secret library. Just me, a row of computers with access to our clinic’s electronic medical records, shelves of journals on pediatric nutrition, and a yellowing poster on Boolean operators.

  I’d known since my residency training that I couldn’t see forty patients a day, five days a week. I found it hard to do half that. Maybe it was that my patient demographic, with their trauma histories and multiple barriers to care, were particularly challen
ging. Or maybe it was the demands of three kids. Maybe our clinic needed to use a different model of care. Maybe an office with some natural light and a view of the North Shore Mountains would help. There were probably other changes I could make to bolster my psychological fortitude and soldier on, even thrive, in this setting. But to start, I reduced my work hours devoted to direct patient care.

  After the switch, I had no regrets. Before, I felt like I spent everything at the office. Now I was making regular small deposits into my psychological savings account. I had the feeling of having extra pocket money. I heard the promising jingle of spare change.

  16

  AN OVERSIZED PINK UTERUS FLANKED by a matching set of ovaries was projected onto the wall. Eleven Myanmar women gazed at it, paper plates of cake balanced on their laps. As I began to explain the anatomy, one of them abruptly walked up to the screen, spread her arms wide, and clapped a hand over each ovary. “I know this,” she said, quiet and proud. “I know this!” The others murmured and nodded. She had been a health instructor at their refugee camp.

  The nurse and I had organized this women’s health group visit for the new Myanmar arrivals who had been attending our Vancouver clinic over the past few months. They were Karens, an ethnic minority who had lived for up to twenty years in remote camps along the Thai-Myanmar border. None of them were familiar with cervical screening or mammography, and most of their pregnancies were unplanned. Teaching them as a group, we reasoned, would be much more efficient than the individual counselling we were currently doing.

  And here they were, eating snacks in our clinic’s meeting room, a collection of women aged eighteen to seventy-eight who’d taken the bus in from Langley together that morning. I felt like a hostess, responsible for the event’s success and concerned that the guests enjoy themselves; I was relieved that they’d shown up at all. These were considerations foreign to a typical clinic day in my office.