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Martina Scholtens: Know What You Don't Know

Book Cover Your Heart is the Size of Your Fist

Our editorial theme for January has been about coziness and notions of home, and Martina Scholtens memoir, Your Heart Is the Size of Your Fist, provides a unique twist on this idea. Scholtens' book is about her experiences as a doctor in a Vancouver refugee clinic, treating patients who are distinctly not at home, both literally but also in terms of their connections to the culture around them. And in her role as these patients' doctor, Scholtens, too, is often unsettled, navigating gaps in language and culture, her professional knowledge pitted against so much that she doesn't know and can only guess at.

In this excerpt pulled from the first part of the book, Sholtens writes about the importance of knowing what you don't know, and how a bit of humility and curiosity can go a long way in fostering connection. 

*****

As I drove the kids to school on my way to the clinic, winding along Dollarton Highway with the morning sun glinting off Burrard Inlet, my nine-year-old daughter told me about a mathematics contest she had written earlier in the week. 

“I left one question blank,” Saskia began. It was a confession: a perfect score was off the table. She didn’t add up test scores; she worked back from 100. “But I did that because of how the scoring system worked. You got six points for a right answer, two points if you left it blank, and zero points for a wrong answer. I wasn’t sure about the last question so I just left it.”

I made her repeat that, making sure I had it right. Making a wild stab at an answer was worth less than no response at all? This wasn’t the grading system I’d grown up with, which promoted doing one’s best even if it involved guesswork. I was pleased that she would be rewarded for acknowledging what she didn’t know. If only we’d all pause to consider whether we truly know the answer to a question at hand, I mused as I swung into the school parking lot. And if not, take two points for keeping our mouths shut. Over breakfast I’d read the comments on a CBC  article about refugees, scanning the vociferous opinions that were ignorant of the basic facts of the system. I was dismayed by the misinformation and the arrogance that was posted.

After Saskia and Leif extracted their backpacks from the trunk, I turned the car and my thoughts toward the clinic. A medical student would be shadowing me this week. I was a clinical instructor in the Faculty of Medicine at the University of British Columbia. The refugee clinic was a popular elective choice, and most days I supervised a student or resident. I considered the recognition of one’s limitations a critical component of physician training, albeit an uncomfortable one.

During my own two-year residency training at St. Paul’s Hospital I had been assigned to a family practice for several four-week blocks, with callback every Thursday afternoon. It was an established practice at the intersection of two arterial Vancouver roads, Broadway and Granville, and a good group of doctors. I dreaded seeing the patients, though—mostly well-heeled, reproductive-age women—because I couldn’t answer their questions.

Making a diagnosis and treatment plan on my surgery rotation or in the emergency room wasn’t a problem, but patients in this clinic kept bringing up issues that weren’t in any textbook. One couldn’t interpret her baby’s cries; another needed advice on dealing with strangers’ remarks on her child’s birthmark; the next had discovered her teenage son’s porn collection. I was twenty-six, childless, and had nothing to offer on subjects that weren’t in my medical library. I felt useless. I could only take a detailed history and call in my preceptor to finish the visit.

My preceptor and the other staff doctors took the entire clinic staff out for Christmas lunch that first year, between morning and afternoon clinics packed with patients wanting to be seen before the holidays. My preceptor paused during the meal and said to me congenially, “You know when we knew you were okay?”

I had no idea, but I was relieved they’d arrived at that conclusion.

“Remember that rash?” she asked. “The four-year-old with the vesicles on his legs who’d just come back from camping?”

I remembered. Yet another patient that had stumped me.

“When I asked what you thought it was, you said, ‘I don’t know,’” she went on. “That’s when we knew we had a good resident.”

The other physician agreed. “We don’t care what you know,” she said. “We care that you know what you don’t know.”

Now, a decade later at the refugee clinic, I was still keenly aware of the limits of what I could offer. Often there wasn’t a satisfying answer to a problem. I used the traditional soap format for my chart notes: Subjective, Objective, Assessment, Plan. Often, the P could feel terribly inadequate. Counselled meant I’d dispensed words, five to ten minutes’ worth. Conservative management meant I wasn’t going to do anything yet. Follow sounded the most like a fail, although it was in fact a promise: I will see you in my office, again and again, until you feel better. Doctors hear the God-complex jokes all the time, but I am well aware of my limitations. The practice of medicine teaches how very much is unknown.

The medical student who was shadowing me for the week was waiting in my office when I arrived at the clinic. We looked over the day sheet that had been printed and set on my desk. The morning’s first patient was an elderly Bedouin woman, recently arrived from Syria. “I don’t know anything about nomads,” the student confessed.

We were off to a good start. “That’s okay,” I said. “You’ll know something after the visit.”

New learners often expressed anxiety about cultural competence, a buzz phrase in medical education. They worried that they would inadvertently offend a patient whose customs and beliefs differed from their own. I think of culture as a system of permissions, or, How we do things around here. The term cultural competenceimplies mastery, an expert knowledge of all these systems. Without immersing oneself in a culture for many years, it’s impossible to appreciate all its nuances. American pediatrician and activist Melanie Tervalon suggests that we ought to strive for cultural humility instead. That was what I taught my students.

When our clinic did a community engagement survey to assess satisfaction with our services, not one respondent complained of cultural insensitivity. This was not because the staff never made blunders, I assured students. It was because patients were forgiving when they recognized that practitioners came from a place of humility and goodwill. 

Every year, I had to ask a Muslim patient to give me a refresher on Ramadan.What are the dates? What are the hours of fasting? Who is exempt?No patient ever scolded, “You’ve worked with refugees for ten years! Shouldn’t you know this by now?” They were always eager to educate me.

I had made plenty of gaffes over the years. I’d complimented a patient from Myanmar on her shoes, only to have her remove them; the interpreter chided me: “Now she must give them to you.” I’d routinely used a thumbs-up sign when delivering good test results to patients, only to learn that it was an extremely lewd gesture in Middle Eastern culture. I’d disgusted an Iranian patient when I passed him his shoes after his physical exam. “You’re a scientist!” he’d said in a pained voice. Touching shoes, the epitome of filth, should have been beneath me. And those were the faux pas I was aware of. 

“Just recognize that you don’t fully understand the patient’s context,” I told the student worrying about the nomad, as we headed toward the waiting room to call her in. “And be curious!”

He nodded.

We passed the weigh scale, where a nurse was encouraging a little Somali girl in a long orange dress to stand straight against the measuring stick with her head level. Three sisters under the age of seven looked on, giggling, their teeth flashing white in dark faces wrapped in bright scarves. The mother undressed the baby, a pudgy infant with dark curls who craned his neck to watch the girls. “Wow!” whispered the student as we passed by. He looked excited, nervous.

The family struck him as exotic, I knew. They were too beautiful and unusual not to comment on. I’d felt the same when I started at the clinic, impressed by what was foreign. The differences in language, clothing, skin, and customs were too much to ignore.

In my early years of practice, I attended a refugee health conference where a speaker shared the words of Canadian anthropologist Wade Davis: “Indigenous cultures are not failed attempts at modernity, let alone failed attempts to be us. They are unique expressions of the human imagination and heart, unique answers to a fundamental question: What does it mean to be human and alive?”  The first words stung. Was I guilty of this? Was my delight in my patients’ differences rooted in a subconscious interpretation of their failed attempts to be me?

I’d grown up with a church missionary calendar hanging in the kitchen, a new one every year. January’s picture was a woman in Papua, New Guinea, with a baby on each hip, in the doorway of a hut with a metal roof. February showed a dozen African boys playing soccer with a ball of tinfoil. March was a group of Indonesian women washing laundry in a river. Every month we looked at a new picture of people on the other side of the planet who needed the things we had: food, soap, salvation, modern cars. As an eight-year-old I felt sorry for them; I felt lucky to be me. I hoped I hadn’t carried this primitive thinking into my adult life. 

Wade Davis’ words challenged me to focus on something other than our differences: What made us human and alive? As a physician, seeing people at their most vulnerable, being privy to their deepest hurts and fears, I was afforded a little window into the human condition. Working at a refugee clinic offered me more clues as to what was universal about humankind. What did my vastly diverse patients share with each other, and with me? I’d determined a few commonalities over the years. We all loved our children with the same devotion. Everyone sought community of some sort. We all understood the language of kindness and humour. We sought purpose and meaning. No one escaped brokenness.

In the exam room, I sat facing the Bedouin patient, a tiny woman with white hair who appeared to weigh ninety pounds. She looked around the room with interest. The interpreter was seated to my left, and the medical student sat next to her, entranced. The patient looked at me with bright eyes, and I gazed back. She wore brown robes and had tribal markings on her face, dark blue geometric figures on her forehead and chin. I wore a navy suit and mascara. She didn’t speak English, and I didn’t speak Arabic. She was from the Syrian desert, and I’d grown up in the Pacific Northwest. We regarded each other with mutual curiosity.

The nurse had noted high blood pressure during the assessment at Welcome House. I gestured for the patient to push up her right sleeve and took the blood pressure cuff from its holder on the wall. She appeared frail, so I decided to forgo the complicated task of helping her climb from a step stool onto the exam table, and to take the measurement from where she sat next to my desk. The coiled black cord connecting the cuff to the wall-mounted sphygmomanometer stretched taut as I gently Velcroed the cuff around her arm. The room was quiet except for rhythmic puffing as I began to inflate the cuff. Suddenly, there was a loud pop as the cord, stretched to its limits, snapped from the wall, struck me across the torso and then dangled, tightly coiled again, from the patient’s arm. I jumped. The patient looked up at me, and when she saw I wasn’t hurt, she squeezed my arm and laughed out loud. So did I. And there it was, a foothold on common ground.

We spent the next half hour taking a proper blood pressure measurement, reviewing blood work, talking about her grown sons, and discussing her housing situation in Coquitlam. When I ushered her out after the visit, the interpreter said to me, “She wants to know if you have children.”

“Yes.”

“She wishes God’s blessings on them.”

Excerpt from Your Heart Is the Size of Your Fist, by Martina Scholtens. Reprinted with the permission of Brindle & Glass.

About the book: Your Heart Is the Size of Your Fist draws readers into the complicated, poignant, and often-overlooked daily happenings of a busy urban medical clinic for refugees.

An Iraqi journalist whose son has been been murdered develops post-traumatic stress disorder and mourns his loss of vocation. A Congolese woman refuses antiretroviral treatment for her new HIV diagnosis, and instead places her trust in Jesus. Two conservative Muslim Iraqi women are inadvertently exposed to pornography when a doctor uses Google Images to supplement a medical discussion. By turns humorous, distressing, and moving, these stories offer insight into the people seeking a new life while navigating poverty, language barriers, and neighbours who aren’t always friendly.

This riveting collection of true stories from Dr. Martina Scholtens is filled with hope and humour, and together make up a deeply moving portrait of how one doctor attempts to provide quality care and advocacy for patients while remaining culturally sensitive, even as she wrestles with guilt, awareness of her own privilege, the faith she was raised with, and vicarious trauma after hearing countless stories of brutality and suffering.

In the spirit of Louise Aronson and Atul Gawande, Scholtens’ writing is based on her personal experiences and explores the transformative moments in which a clinical doctor-patient relationship becomes a profound human-human connection.

January 29, 2018

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