Your Heart is the Size of Your Fist

by Martina Scholtens

  That nervous feeling—that I was on unfamiliar ground, outside the comfortable routine of one patient, one exam room, twenty minutes—was the first suggestion that moving all of us into this new context might result in something unexpected.

  Our experience to this point was that the Myanmar women were particularly pleasant patients: uncomplaining, compliant, deferential to a fault. Consequently, eliciting any kind of medical history was a real challenge. Repeatedly I found myself seated across from a slight, smiling woman in a bright woven skirt, with just a hint at a problem, doing the medical version of twenty questions. I worried that I’d miss a diagnosis because the history depended almost completely on me; I wasn’t sure a patient would divulge a symptom like severe right lower quadrant pain unless I enquired about it directly.

  But here as a group, with an interpreter, the women were transformed. They interrupted our presentations with comments and anecdotes. They asked questions and made jokes. There was a continuous soft running commentary the entire morning, and the atmosphere was congenial, even festive.

  Susu, the interpreter, had come to Canada as a Myanmar refugee herself ten years earlier. She interpreted at clinics and hospitals across the city, sometimes disregarding the rules and transporting patients to appointments in her own car. She interpreted the sermon on Sundays at the church the Karens attended. She wouldn’t call me by my first name, but surreptitiously paid for my lunch one day when we found ourselves at the same neighbourhood restaurant.

  The nurse showed a slide with an image of a heap of packaged condoms in a rainbow of colours. There was laughter and discussion in the Karen language. Susu relayed the joke: “When someone handed those out at the camp we took a lot, because we thought it was candy!”

  The nurse passed around an IUD, and the women closely examined the tiny T with long trailing strings. A discussion among them ensued. They looked concerned. “They’re wondering,” said the interpreter, “whether their husbands might become tangled in the strings. Trapped. Perhaps even injured.” We trimmed the threads for future demonstrations.

  As I explained the procedure of mammography, a woman raised her hand and asked slyly, elbowing her neighbour, “What about women with very small breasts—do they still need this test?” Giggling and more nudging ensued, and I realized that some jokes are universal.

  I went on to explain the purposes of cervical screening. A hand went up, waving urgently. I paused. “She says,” explained the interpreter, “that she needs that test. She must have it, right away.” There would be a chance at the end of the morning to have that exam, I informed her. Two more hands shot up. In the end, every woman in the group wanted a Pap test that morning.

  Once we’d finished the teaching, I distributed evaluation forms. Most of the women weren’t literate even in their first language, so we’d kept it simple: four statements for the interpreter to read out, and a choice of circling a happy or sad face to demonstrate whether the respondent agreed. “We’d like to know how to improve this visit,” I said. “This is anonymous. There’s no need to write your name on the paper.”

  “But they want to,” the interpreter relayed back to me. “They insist.”

  She read the first statement: “I liked the group visit today.”

  “Yes!” the women responded in chorus. The interpreter explained again that the answers needn’t be shared. The women continued to cheerfully voice their affirmative responses to each question. When I reviewed the evaluations later, sure enough, all eleven respondents had given us a perfect score.

  Each participant then had an opportunity to meet briefly with me one on one, so that I might answer any questions, and review contraceptive and screening needs. I’d expected that I could meet with each individual in the corner of the room, while the others visited and had more tea. But the other women gathered around my makeshift desk and listened intently to each exchange; the patient in question appeared entirely comfortable with this. I tried in vain to disperse the audience. I found myself whispering, as discreetly as possible, “When was the first day of your last menstrual period?” as the nurse tried to distract the women with more contraceptive demonstrations.

  Then followed a whirlwind of Pap tests, by three practitioners in three exam rooms, with one interpreter dashing from room to room. By the end of the morning, we’d done six Pap tests, discovered a pelvic mass, diagnosed a pregnancy, and written four prescriptions for birth control.

  It was a satisfying morning. I felt confident that the visit had solidified prior knowledge and would result in dissemination of new information to the Karen community. I anticipated that the women would feel more confident discussing women’s health issues with health providers in the future, and that there would be increased screening uptake.

  More than that, though, the group visit experience was unexpectedly moving. I was the guest: hearing stories of a jungle tree bark that would prevent pregnancy; watching the women banter with each other; answering their sometimes simple, sometimes sophisticated questions on pelvic anatomy. For once, I was the odd one out: they had the solidarity in numbers, language, culture. It was a reversal of positions. I felt equally humbled and privileged.

  At the end of the morning, one of the women looped her arm through mine as we walked back to the waiting room. It wasn’t just me, then, that felt that meeting in a group setting had done more for doctor-patient rapport than any private visit had.

  “Thank you, teacher,” she said in careful English.

  I didn’t let the interpreter correct her. She understood the role of physician perfectly.

  17

  AS WE REVIEWED THE KAREN women’s health group visit after their departure, the medical student sighed, “They were adorable.”

  I’d run across this sentiment before, in all sort of contexts. “My constituents want their refugee families by Christmas!” I’d heard a mayor say about his small town’s frustrations with delays in the private sponsorship system. “We are in love with our refugee family. Smitten!” wrote a blogger about the Iranian family for which her church was responsible.

  I call this phenomenon maternalism—the misapplication of motherly sentiments that serve to infantilize the object of care. I first encountered this as a child, watching adults outside the family interact with my older sister, Julia, who has cerebral palsy. She pushed a little yellow walker, braced legs moving jerkily, and her speech was unclear. There was nothing wrong with her mind, though. I’d watch cashiers carefully enunciate their words, or ladies at church rummage in their purses for peppermints, and cringe. She’s not a baby! I would think. She’s eight! And later, Eleven! Fourteen! Seventeen! I can’t say how it felt to be treated that way, but from my view, the sister on the sidelines, their concern diminished her; what she deserved was respect. My medical training emphasized avoiding paternalism, the use of physician authority to restrict the freedom and responsibilities of patients in their supposed best interest. But maternalism was never mentioned.

  When I was a resident running the family practice ward, I would come up to the unit after supper to finish dictations and complete paperwork. At the end of the evening, I’d ask the charge nurse if there were any patients she was concerned about or orders that needed to be written. Having tied up all the loose ends, I’d head to the basement call room, where the resident on duty spent the night. I distinctly remember how I felt walking down the corridor at eleven at night. The ward was hushed and still, with the patients’ lights off and just one or two staff at the nursing station. Heading back to the elevator, I walked past rooms of four beds apiece with patients resting under blue cotton blankets. I had brought my charges through another day.

  Now, a few years later, I made the rounds of my own children every night before bed. The gratification as I adjusted the covers over small sleeping bodies was remarkably similar to walking down the corridor of 7B late at night—the sense of having tucked the kids in for the night. It was a powerful emotion, a combination of affection and respect for those
under my care, the satisfaction of having managed the day’s problems, the weight of responsibility, and humility and gratitude for my own position.

  I raised New Zealand rabbits as a kid; they were white with ruby eyes. The smell of the nesting box with eight kits in it was strangely heady to a thirteen-year-old, offering the intimate smell of birth, fur, and urine, at the same time attractive and repulsive. The scent was the essence of something that I couldn’t quite recognize.

  As a mother, twenty years later, not many things moved me as strongly as lifting the lids from my Rubbermaid bins of newborn baby clothes, long since packed away. It was the smell that made me weak in the knees. It wasn’t exactly a baby scent, and it wasn’t even entirely pleasant. It was the smell of laundry detergent brands I had used back then, and the smell of the houses my babies were raised in. There was a musty scent, a whiff of spit-up, the faintest trace of Johnson’s baby shampoo. I could hold a newborn onesie to my face, breathe it in, and feel dizzy with nostalgia. Pete did not have the same inclination to do this.

  It took me years to connect the two scents. The smell of the rabbit nest was motherhood; the smell of the baby clothes was that of the nest I’d made for my own children. That it affected me so strongly made sense: I’d always loved to nurture things. Dolls, tadpoles, rabbits, sheep, a German Shepherd, petri dishes inoculated with E. coli—if it could grow, I wanted to be there cheering it on. At eight, I wanted to be a farmer; at eighteen, a veterinarian. At twenty-eight, I finished a family medicine residency. Now I spent my evenings puttering in the garden.

  Nurturing is a natural fit with medicine. So are other qualities commonly considered maternal: tenderness, warmth, the ability to comfort. What my patients at the refugee clinic needed most, though, was to regain independence. I saw the clinic as a temporary home, a safe and familiar place where patients could anchor themselves in their first year in the country. It was a kind of nest, and the goal was to launch them from it.

  Sometimes I’d run into former patients years later.

  “Two items?” asked the Winners change room attendant, briskly, with accented English. And then, seeing my face: “Bridge Clinic!” The clinic was just a memory, something she’d long since moved on from, and witnessing her settled in her new life brought me joy. Or was it maternal pride?

  Maternalism risked infantilizing the patient just as paternalism did. I’d noticed that refugees seemed particularly able to inspire and amplify maternal feelings in medical practitioners, sponsors, and other front-line workers. I had a theory about that. Many refugees had child-like qualities: they had difficulty communicating in English, they were initially dependent on others, and they were deferential. These features made them non-threatening, and set up an automatic power differential. Helpers swooped in. Paternalism exerted power deliberately; I worried that maternalism did too, just more subtly.

  I enjoyed my compliant patients, even as I urged them to self-advocate. In general, refugees were less demanding than the Canadian-born patients at my first practice in Kitsilano, although the trends varied by group. Patient behaviour appeared to be influenced by cultural attitudes toward doctors; the medical system with which patients were familiar; gender; education; and wealth and status prior to coming to Canada. Most patients were grateful to finally have access to medical treatment, while others protested the Canadian wait times and claimed they’d received better care in the refugee camp.

  I was guilty of checking the schedule of interpreters booked for my patients at the start of clinic and projecting, based on the languages listed, whether the day would unfold at a peaceful pace or progress at breakneck speed and end with me staying an hour late to catch up on paperwork. Ideally, there was a mix of patients, and those with higher needs were balanced by those who required less. My heart could sink or soar depending on the list.

  Some groups were more medically complex than others. The Bhutanese patients had lived in refugee camps since the 1980s and their trauma history, if any, was remote. Other groups had fled recent conflict and their fresh wounds—physical and psychological—necessitated more intense care. Clinicians have finite reserves of time, patience, and resilience, and some patients tax these more than others. It’s natural to prefer the less depleting patient encounters. I enjoy some patient visits more than others in the same way that I prefer my daughter lying in the hammock with a book for hours on end to my son thudding down the stairs in a cardboard box. At home and at the clinic, some days I want fewer demands and more compliance. Some days I want my own job made easier.

  An attitude that I frequently encountered outside of the clinic was the expectation that refugees act from a position of obligation and inferiority. “We helped a refugee family, once; we let them stay in the suite over our garage for next to nothing,” began a woman I’d just met at a birthday party, upon learning what I did for a living. I knew exactly what was coming next, because I’d heard a variation of it countless times before: “And they asked if our son could stop shooting hoops in the driveway after eight, because it kept the baby awake.”

  The other women gathered in the kitchen shook their heads at the gall, the lack of proper gratitude. Someone chimed in, “Our church helped out a Congolese family for an entire year, and then they left for a Pentecostal church.” Sympathetic murmurs. “And! They didn’t want to buy their clothes second-hand.”

  I once came across an article on assisting children with special needs, contrasting the helper to the helped.1 Helping affirms capacity, worth, and superiority; being helped implies deficiency, burden, and inferiority. The helper is owed; the helped is obligated. Providing help, one’s vulnerability is masked, while the other’s is highlighted. Helping others is not necessarily altruistic.

  The article made me examine my motivation for the work I did. Was I drawn to care for marginalized populations because of a moral imperative, or because the distinction between the capable helper and the deficient recipient was that much clearer? But gifts from patients made me uncomfortable precisely because I worried that the patient felt obligated to me. Much of my work focused on affirming the patient’s own worth and capacity. I knew that my strongest quality as a physician was the ability to make patients feel they were being treated as equals.

  When I prepared a presentation on refugee health for a group of private sponsors on Vancouver Island a few months later, I made the final slide about the contrast between helper and helped. I wondered whether it was unfair to challenge the motivation of well-meaning volunteers. I needn’t have worried. It was the most well-received part of the presentation, prompting an audience-led discussion of how one might smooth the differences in position of sponsor and refugee. I was relieved. I wanted to encourage their generosity. I just wanted a little dose of self-reflection to accompany it.

  18

  WHEN OUR CLINIC DID A patient survey, several respondents noted favourably: The doctor always asks about my house. It was true. I did, although I had no idea that patients appreciated it so much. I asked because it was a benign entry into a patient visit, with easy questions to answer, and it yielded useful information. Five people in a three-bedroom, top-floor apartment overlooking New Westminster had completely different implications for health than the same family in a two-bedroom, windowless basement suite a mile and a half from the nearest bus stop.

  “Tell me about your home,” I’d say. “How many bedrooms? Who sleeps where? Is there a quiet place to study? Is it bright? Is it adequate?”

  Some patients who moved up from cooking over fires in jungle camps to apartments in downtown Langley needed to be taught to operate a stove. They felt they lived like kings. Others gave up beautiful family estates with gardens in the Middle East for a dark, mouldy rental. They were reminded constantly of what they had lost.

  Some cultural groups clustered together, while others scattered widely. Almost all my Bhutanese patients lived in one of two apartment complexes in Coquitlam. Iraqi patients tended to settle where they felt they were least likely to encou
nter other Iraqis.

  The Haddads lived in a two-bedroom apartment in Surrey.

  “How’s your place?” I asked Yusef. “How are your neighbours?”

  “No good,” he said. “Brown people everywhere.” He mimed a turban on his head.

  I looked at the address on file. I had lived in the area years before. It had a sizable Punjabi Sikh population.

  “I want to live with Canadians,” Yusef went on earnestly.

  “They are Canadians.” I knew what he would say next, because I’d had this conversation with other patients.

  “Canadians like you.” He pointed at my face. “White.”

  “I’m not any more Canadian than your neighbours are,” I said. “My parents were immigrants.” Both of my parents had emigrated from the Netherlands as children.

  That made no difference to him. “I want to live with white people,” he said. “Not Surrey. Where?”

  “All of Greater Vancouver is very multicultural,” I told him. “Everyone’s mixed together—Asians, Africans, Middle Easterners, Europeans.” I loved the city’s diversity. Pete and I were pleased that our kids’ school had an ethnic mix that was representative of Vancouver, rather than the homogenous Dutch composition of our own childhood classrooms, comfortable though that had been. I’d assumed that refugees would feel more at home in a multicultural city than in one where they were the only visible minority.

  “No good,” he said again.

  “You could try somewhere in the Interior,” I said. “You might like Kelowna.”

  I was half joking. I was at a loss as to what to advise him. His stated preference for white neighbours was at odds with Canadian multiculturalism, but he’d only been in the country for three months. I couldn’t pretend to understand the culture, history, and experiences that informed his mindset. While the conversation disturbed me, I didn’t judge him for it. I wondered, though, if my lenience was a luxury I could afford because I was white.