You seem discouraged

“You seem discouraged,” my sister said to me one day, as we were watching the world go by from a terrace restaurant on Rue St. Laurent. “You usually like your work, but recently you are complaining a lot.” I sighed. Sometimes having a sister who knows you so well can be difficult. She was right, as usual. The job has been getting to me. I am not going to rant about the idiocy of the Quebec government’s policies which treat patients as beans to be counted; and health professionals as if they are all interchangeable widgets. I have lived through this for years. What is getting to me now is the increasingly Social Darwinist attitude of society as a whole. As someone who, for the majority of my practice, has cared for marginalized populations I knew that not everyone found this kind of work as interesting and rewarding as I do. However, there seemed to be a consensus that, even though other people didn’t want to do it, it was work that should be done. Now there seems to be an increasing societal attitude that these people deserve to simply die, preferably as far away from us as possible. I recently saw two patients who brought this home to me. One was an elderly Sikh gentleman, a unilingual Punjabi speaker. He was accompanied by his even more unilingual wife. Despite having been in Canada for over 20 years and having worked for most of that time, usually in warehouse jobs, his refugee claim has been refused. He has cancer, heart disease, diabetes and probably dementia. He was lost to follow-up for two years, was seen in our walk-in clinic a few weeks ago, where he had blood work and was sent for a geriatric consult. He now shows up in my R1's clinic as a new patient. Essentially, he was sent by his immigration lawyer in a last-ditch attempt to get his refugee claim accepted for compassionate reasons. Our tests show that his diabetes is poorly controlled and he is in pre-renal failure with mild hypernatremia. We are left untangling a medical rat's nest involving three hospitals and five specialists. We figure out that since his last refusal letter came, the patient has almost stopped eating and drinking. In the interview he sits, eyes on the floor, not speaking. I think he is trying to starve himself to death so that he will not be deported back to India, where he has no one and knows no one, and the political situation is so fraught. The half-hour allotted for this visit is long over when we finally put a preliminary action plan in place. His wife is distraught, but even using our interpreters she has trouble remembering or understanding his medical history and treatments and her history is very unreliable. When I review with the resident, we discuss mostly logistics. I give her tips on how to get our almost non-functional healthcare system to work. We send “patient known to you” consults to all his specialists. I page the geriatrician on call and discuss how his geriatrics consult went astray. “Do you want me to send him to the ER or can we expedite a fast consult?” I ask her, We assure her that we will call the patient and give his wife the appointment in Punjabi. We hook him up to our social worker. Our CLSC has translation services, but unlike Ontario, where the government mandates all hospitals must be able to provide translation services, Quebec has decreed that anyone who is not an historic anglophone must receive services in French. Therefore, in our hospital where we know that we provide service to people who speak 70 different languages, there is no funding for translators. The message seems to be, if you don’t speak French, please die. As my final teaching point of the day I ask my resident, who is kind, skilled and dedicated, about what she knows about the political situation in India, why Sikh’s are often refugees here and the strained relationships between Canada and India right now. “I have no idea,” she says. “Is this part of what I need to know?” “It is if you work here,” I say. “One of the four principles of family medicine is that we understand the context of our patients’ lives. She promises to read a few news reports and a Wikipedia article. This used to be easier. Why is it so hard? Who thinks sending this man away from two-decades of context is morally defensible? My second case was sent to me by an organization which helps refugees with their claims. They ask me to examine a patient and her daughters, to attest that the mother has female genital mutilation and that the daughters have not. I have done this before for this group. No problem.When she comes to see me, I am surprised that she is pregnant for a fourth time, and is being followed at the pre-eminent Pediatric and Obstetric hospital in Quebec. “Why do you need me?” I asked. “Can’t your obstetrician write the attestation and the girls pediatrician write theirs?” “We asked him.” Her husband is translating for her. “But he says that it’s not his job.” I listen to their story. They are from a country where the practice of female genital mutilation is common. The woman’s mother had begun pressing for the little girls to be cut when the eldest turned six. When the husband refused to allow it, they said to him: “You can’t watch them all the time!”This terrified him because he traveled for work. So, they decided to come here.In the office, I can see that they are a good couple. As my father used to say, “love and a cough cannot be hidden.” The two little girls are easy to examine in their mother’s lap and are completely normal. Their third daughter was born in Canada.When I examine the mother, I see that she has a Grade 2 mutilation and she says that when she has intercourse the pain is 5/10. This was not subtle, and I cannot believe that any obstetrician would be unable to tell the difference between her vulva and a normal one. Now I am extremely puzzled. Even if the obstetrician did not want to write the letter for her, why had he not sent her to his colleague after her last C-section? He works in the same institution as one of the country’s experts on female genital mutilation and its repair. Did he never ask her about pain? Did he just not care?Why could he not take the five minutes to find out her concerns and deal with them?At the end of the visit, I get that usual question, “Can I switch to you?” The husband translates for his wife, “I can see that you are a kind person, I trust you more than my other doctor, even after only one visit.” I ask myself why kindness is such an underrated virtue and skill in our system? “No, I am sorry,” I say to her. “You are having a fourth repeat C-Section, you need a high-risk specialist, but come back and see me after this baby, and I will refer you to the gynecologist who can fix your vulva so, maybe, you will not have pain.”“Will she feel any pleasure?” asks her husband eagerly. His wife chuckles at him, and takes his hand.“I honestly don’t know,” I say. “What’s gone is gone, but perhaps, there may be some pleasure after with the repair and physiotherapy.”His wife looks at him with a smile, and says something in her native tongue, her husband blushes and laughs. He doesn’t translate. I don’t only want my patients to not die. I want them not to suffer and perhaps find a little joy.

You seem discouraged

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