Your Heart is the Size of Your Fist

by Martina Scholtens

  I thought back over various conversations I’d had with the Haddads in the clinic, and retrofitted them into the context of this apartment. I matched the insomnia to the bed, the trouble concentrating on homework to the shared bedroom, and the loneliness to the anonymous Surrey apartment complex. The family had been in clear focus for me in the clinic, the rest of their life a blurred abstract. They lived here, though—not in my exam room.

  “Eat!” Yusef commanded when we returned to the living room. It took me three servings to realize that clearing the plate indicated that I was still hungry, and signalled Junah to heap it with more dumplings and date-and-sesame balls. I finally tried setting it down with a few forkfuls of food remaining, and my hosts nodded with satisfaction.

  Shortly after, the other two guests excused themselves. I wanted to follow suit, but it hadn’t even been an hour since I’d arrived. With my departure, the celebration would be over. I remained seated on the couch and sipped the tea Junah served. After a few minutes of silence Yusef left the room and returned with a flat cardboard box the size of his hand. He set it on the coffee table, shook off the lid, and pushed the box toward me. Inside was a stack of photos. They were smaller than the standard four-by-six-inch Canadian prints, with rounded corners.

  I laughed with delight at the top one, an image of a much younger Yusef, with the lean build and unapologetic hair of a man in his twenties, leaning over the open hood of a car. The next was of an extraordinarily pudgy baby whose distinct facial characteristics I immediately knew to be Layth’s. Beneath this was a photo was of three children, two boys and a girl, seated on a blanket in a shaded courtyard filled with potted plants. These were the pictures the Haddads had brought with them when they fled Iraq, I realized. I went through the entire stack, exclaiming with recognition as I flipped through the catalogue of their life before we met.

  The Haddads gathered around me, pleased with my reaction and offering commentary on the different scenes. Yusef sat on one side of me, Junah on the other, and Nadia and Layth leaned on the arms of the couch. Ahmed slept in Junah’s lap, his right arm flung up over his head, hand balled into a little fist. His heart was the size of that fist, I thought, tiny but robust, and one day, God willing, it would be the size of his father’s. If he were anything like his parents that fist would be one of gripping strength, an antidote to the fists of aggression that had obliterated the life in the box of photos.

  An hour later I drove home to the North Shore, eyes drawn to where the silver of the March sky met the dark ridge of the mountains. The magic always seemed to be where two things brushed against each other, I thought. It was why I liked the beach, and conversation, and dusk. In the exam room, too, the patient and I were two eternal spheres that rubbed up against each other, making a little spark to see by. Most was left unknown. It was that thin line where we met that was beautiful.

  I pulled up to my weathered 1970s home overlooking the waters of Indian Arm, neighbours obscured by massive cedars, with a minivan in the driveway and bikes strewn across the yard. My home had never seemed so splendid, or so preposterous.

  A few days later I received an email from Yusef with a photo attached. The plant I had given Junah was in bloom. The text, poetic as always, had been garbled in translation. I gathered that the flowers reminded them of my visit, and both made them extraordinarily happy.

  Every few months I receive a message—usually from a patient, often stripped of the subtleties afforded by fluency in English—that reminds me why I am a family doctor. I read Yusef’s email twice, tagged it DON’T FORGET, and archived it.

  EPILOGUE

  SO MUCH OF MY REFUGEE patients’ health was influenced by external factors: housing, social connections, poverty, health insurance, employment, and access to trauma counselling. Most of this context in which patients live falls under the domain of public health, a field I became increasingly interested in during my time at the refugee clinic. I wanted to expand what I could do as a family physician, to move beyond retail medicine. I wanted to look at health through a wider lens and to work upstream to influence populations rather than individuals.

  After a dozen years at Main and Broadway, the health authority moved the clinic across town, further east, to the city outskirts. It was far more accessible to patients, most of whom didn’t live in Vancouver. It made my morning commute arduous. Everything shrank a little—the team, the exam rooms, parking options, morale. The move was layered onto the loss of clinic resources, years of advocating for adequate health insurance for refugees, and unending tales of trauma.

  It was an opportunity to make some changes. I felt the nudge to redirect my career. A year after the Haddads left the clinic, so did I. I decided to pursue further medical training, and entered a residency in Public Health and Preventive Medicine at the University of British Columbia. I’ve maintained my family physician licence; I can’t imagine anything replacing the satisfaction and privilege of the doctor-patient relationship. I want a public health practice that incorporates clinical care.

  I still live in Deep Cove, although I have less time to putter in the yard and I don’t run as often as I should. My son and three daughters still make me feel rich; so does Pete. My sleep has improved, but the worldwide refugee situation has not. I still think about my patients every day.

  ACKNOWLEDGEMENTS

  I AM DEEPLY GRATEFUL TO MY agent, Robert Mackwood, whom I had written off as out of my league before we were serendipitously connected. To my publisher, TouchWood Editions, and my editor, Lynne Van Luven. To my work family in Vancouver: physicians, nurses, counsellors, front desk staff, interpreters, settlement workers, and everyone else united by a commitment to do good hard work. To Pete and the kids—Saskia, Leif, Ariana, and Ilia—who were gracious enough to lower the volume when I had a sudden idea that needed to be dictated into my phone. And most of all, I am grateful to my patients, who taught me more than I bargained for. You brought me a lot of joy. I’m still looking out for you.

  I’VE BEEN WRITING ABOUT MY clinical work—formally and informally—for years, and have been published in print and online. Some of those articles provided ideas or descriptions that were included or expanded upon in this book. I wish to thank Mothers in Medicine (http://www.mothersinmedicine.com/), the Canadian Medical Association Journal (cmaj.ca), the College of Family Physicians of Canada’s Stories in Family Medicine (http://www.cfpc.ca/Stories/), and the San Francisco Medicine journal (sfmms.org) for publishing earlier pieces. I’d also like to thank Canadian Family Physician (http://www.cfpc.ca/CanadianFamilyPhysician/) for publishing “The Birthday Party” in January 2017, and the Province (theprovince.com) for publishing my opinion piece “BC Needs to Improve Care for Refugees” on May 4, 2015.

  NOTES

  Chapter 1

  1“Committee to Protect Journalists,” https://www.cpj.org/killed/mideast/iraq/murder.php.

  Chapter 2

  1Mary Oliver, “Sometimes,” in Red Bird: Poems (Boston: Beacon Press, 2008).

  2Frederick Buechner, Wishful Thinking: A Theological ABC (New York: Harper & Row, 1973).

  Chapter 3

  1Melanie Tervalon, “Cultural Humility versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education.” Journal of Health Care for the Poor and Underserved, 9(2)(1998): 117–125.

  2Wade Davis in Carol Black’s Schooling the World: The White Man’s Last Burden, documentary film, (Lost People Films, 2010), available at www.Schoolingtheworld.com.

  Chapter 6

  1Gabor Maté, When the Body Says No: The Cost of Hidden Stress (Canada: Vintage Canada, 2004).

  2Mark E. Silverman, Jock T. Murray, & Charles S. Bryan, The Quotable Osler (American College of Physicians, 2002).

  3William Wordsworth, “Nuns Fret Not at Their Convent’s Narrow Room,” in The Sonnets of William Wordsworth (London: Edward Moxon, 1838).

  Chapter 7

  1R. Edward Hendrick & Mark A. Helvie, “Mammography screening: A new es
timate of number needed to screen to prevent one breast cancer death.” American Journal of Roentgenology, 198(3) (March, 2012): 723–728, doi: 10.2214/AJR.11.7146.

  2Kevin Pottie, Christina Greenaway, John Feightner et al, “Evidence-based Clinical Guidelines for Immigrants and Refugees.” CMAJ (June, 2010): E1-E102, doi: 10.1503/cmaj.090313.

  Chapter 8

  1Phyllis Theroux, California and other States of Grace (New York: W. Morrow, 1980).

  Chapter 11

  1Cynthia Willard, Mara Rabin, & Martha Lawless, “The Prevalence of Torture and Associated Symptoms in United States Iraqi Refugees.” Journal of Immigrant and Minority Health, 16(6) (December, 2014): 1069-76, doi: 10.1007/s10903-013-9817-5.

  Chapter 14

  1Michael Pollan, Second Nature (New York: Grove Press, 1991).

  2“Mental Capital and Wellbeing: Making the Most of Ourselves in the 21st Century.” (London: The Government Office for Science, 2008).

  Chapter 15

  1Susan Cain, Quiet: The Power of Introverts in a World That Can’t Stop Talking (New York: Crown Publishers, 2012).

  Chapter 17

  1Jacqueline Thousand, Richard Villa, & Ann Nevin, Creativity and Collaborative Learning: A Practical Guide to Empowering Students and Teachers (Baltimore: Paul Brookes, 1994).

  Chapter 24

  1Christina August Hecht & Ernest B. Hook, “Rates of Down Syndrome at Livebirth by One-Year Maternal Age Intervals in Studies With Apparent Close to Complete Ascertainment in Populations of European Origin: A Proposed Revised Rate Schedule for Use in Genetic and Prenatal Screening.” American Journal of Medical Genetics, 62(1996): 376–385.

  Chapter 26

  1Erik H. Erikson, Childhood and Society (New York: Norton, 1963).

  2Henry David Thoreau, Walden (London: J.M. Dent, 1908).

  Chapter 27

  1“BC Needs to Improve Care for Refugees,” the Province, May 4, 2015.

  DR. MARTINA SCHOLTENS is a clinical instructor with the Faculty of Medicine at the University of British Columbia and worked at the province’s only refugee clinic for ten years, caring for patients from around the globe. The recipient of the Mimi Divinsky Award for History and Narrative in Family Medicine (2016), she is currently completing her Master of Public Health degree. Scholtens has done extensive advocacy work around federal health insurance for refugees, and has a special interest in narrative medicine. For more information, visit martinascholtens.com.

  Copyright © 2017 by Martina Scholtens

  All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. For more information, contact the publisher at:

  Brindle & Glass

  An imprint of TouchWood Editions

  Brindleandglass.com

  The information in this book is true and complete to the best of the author’s knowledge. All recommendations are made without guarantee on the part of the author or the publisher.

  Edited by Lynne Van Luven

  Cover design by Tree Abraham

  Cover image by Rebecca Wellman

  Interior design by Pete Kohut

  Proofread by Claire Philipson

  Permission for the use of quote from Susan Cain’s Quiet: The Power of Introverts in a World That Can’t Stop Talking (New York: Crown Publishers, 2012) has been kindly granted by Penguin Random House LLC.

  LIBRARY AND ARCHIVES CANADA CATALOGUING IN PUBLICATION Scholtens, Martina, author

  Your heart is the size of your fist : a doctor reflects on ten years at a refugee clinic / Martina Scholtens.

  Issued in print and electronic formats.

  ISBN 978-1-927366-68-4 (softcover).

  1. Scholtens, Martina. 2. Refugees—Medical care—Canada—Anecdotes. 3. Clinics—Canada—Anecdotes 4. Physician and patient—Anecdotes. 5. Physicians—Canada—Biography. I. Title.

  RA564.9.R43S74 2017 362.1086'914 C2017-903017-5

  We acknowledge the financial support of the Government of Canada through the Canada Book Fund and the Canada Council for the Arts, and of the Province of British Columbia through the British Columbia Arts Council and the Book Publishing Tax Credit.