Medicine in Translation: Journeys with My Patients
As I contemplated this, it dawned on me how little I actually knew about the Muslim veil. No one in my personal life wore one. To be honest, the only information I had was from the news media and from seeing Muslim patients in the hospital; I had very little firsthand knowledge about Muslim dress. Perhaps it was time for me to learn.
I wasn't sure how sensitive a subject the veil was and wondered if it would be considered an affront to broach the issue. But I felt that I knew Mrs. Uddin -- and, by extension, Azina -- well enough by now, so I asked, somewhat timidly, if I might pose a question about the veil. They both nodded. I asked Azina if not removing her veil in my office like her mother did was a sign of increased religiosity.
Azina laughed uproariously as soon as the question left my mouth. Her ease with this, along with the magnitude of difference between my assumptions and her reality, relaxed the conversational berth. I felt comfortable now and asked all sorts of questions about the veil, even naive ones. Azina took the lead in answering, her infectious energy spilling out despite the tight veil that completely wrapped her face. I wanted to know if it was hot under there. Was it hard to breathe? How did she decide what color, what style? Was it a family norm? Or did each mosque prescribe a different style? Did she wear it at home? What was the significance of the veils that draped low over the bridge of the nose and the ones that were tight up against the eyes? Did veil traditions in Bangladesh differ from those in other countries?
Azina and her mother chatted amiably, seeming delighted to educate me in the nuances of this aspect of Muslim culture. While the subject had been a little touchy for me, it certainly wasn't for them.
Taking a bit of a risk and pressing further, I asked if there was any pressure or coercion about wearing the veil. Mrs. Uddin answered this one emphatically. "No. Veil is my choice. My husband, he tell me not to wear it. He say people treat me bad, that they say I am terrorist." Her voice grew more animated and assured. "But veil is between me and Allah," she said, pointing upward. "I wear veil no matter what anyone say. It is my connection to Allah." The conversation proceeded toward Islam in general, and I learned how devout Mrs. Uddin was and what pleasure religious observance gave her.
The most interesting thing for me -- besides all that I was learning -- was the transformation that occurred in Mrs. Uddin. While discussing Islam and the veil, she became buoyant. All her whininess disappeared. The aches and pains seemed to evaporate. Her voice and body language reclaimed the heft and vitality one would expect from an otherwise healthy forty-three-year-old woman.
This was not a meek, oppressed woman, I thought. This was not a woman beaten down by a patriarchal religion. This was a woman inspired and fortified -- dare I say empowered -- by her religion.
I pointed out my observation of Mrs. Uddin's rapid improvement. Mrs. Uddin and her daughter were impressed, though not necessarily surprised. As I finished up my visit with Mrs. Uddin, I realized that we'd just gained a new clinical insight, and perhaps a new therapeutic tool. I realized that I might, finally, look forward to Mrs. Uddin's clinic visits. Although I didn't want her to keep Azina out of school for her appointments, I hoped that Azina would come to some of the visits so we could continue my education as well as her mother's "treatment."
My morning session always overlapped into the afternoon session, no matter how hard I tried to discipline myself to stay within the fifteen-minute slot for each patient. Sometimes it was due to fascinating conversations -- as with Nazma Uddin and Azina -- but mostly it was because of the ungainly sprawl of multiple chronic illnesses that the majority of my patients had. Thursdays were the busiest days of the week. I had patients all morning and then my weekly precepting session in the afternoon.
The fun part about precepting was supervising house staff with their patients. Each time a resident saw a patient, he or she would present the case to me and we'd discuss the diagnosis and treatment plan. Each case offered a small opportunity for teaching, but there were so many residents and their schedules were so complicated that we had only these -- small moments. It was a stark contrast to the inpatient wards, in which we had a fixed team for a whole month with a dedicated ninety minutes of teaching rounds each day.
The not-so-fun part about precepting was everything else. The preceptor was the go-to person (some would say dumping ground) for refilling prescriptions, filling out forms, fixing scheduling snafus, reordering tests and labs whose requisitions had expired, dealing with panic values from the lab, handling abnormal results from radiology, and reviewing medication orders from visiting-nurse services -- a nonstop array of ongoing annoyances.
The afternoon precepting session was well under way when I finally closed the chart of my last patient of the morning and relocated myself and my accoutrements -- prescription pad, stamper, pocket medication guidebook, handful of pens, box of strawberries for the residents, sandwich that I hadn't had time to eat -- to the precepting room. There was already a pile waiting for me -- a mammogram needed to be reordered, a patient was confused about his hydralazine and his hydrochlorothiazide, a Celebrex prescription required prior authorization from the insurance company, a disability form needed to be filled out, a reflux medication wasn't covered by a patient's plan.
Two residents had already seen their first patients and were waiting to present to me. Luckily, they were senior residents and we could breeze easily through their cases -- an Armenian man recovering from gout, and a Nepalese woman with diabetes and hypothyroidism. The interns' cases were more protracted affairs. The medical students' cases could be epic in length.
The clerk was already back with more. "Med refill," she said, adding a paper to the top of my pile. "He's here for oxycodone. Says his pills were stolen. Needs a new prescription plus a letter for the pharmacy, otherwise they won't refill it."
Medication requests for other doctors' patients were an irritation. Medication requests for controlled substances were purgatory.
Further prescriptions would be given until he saw these specialists.
That was three days ago. Now Mr. Kaczmarek was back. Stolen pills. Needed a doctor's letter for the pharmacy. I could feel the anger begin to simmer at the base of my gut.
Why couldn't this patient be requesting something innocuous, like atenolol, instead of oxycodone? Why did he have to come on a day that his doctor wasn't here? Why did he have to put me in the position of having to decide whether or not he was telling the truth? Was he a disorganized patient who missed appointments and lost prescriptions, or was he a drug seeker or a drug dealer hustling us for narcotics?
More than anything, I wanted to shove the paper to the bottom of the pile and deal with it later. These messes were always dumped in the laps of the doctors. When I had confronted our administration about this, I was told that renewing controlled substances was "at the discretion of the doctor." Great advice. Thanks.
I reordered the mammogram. I explained the difference between hydralazine and hydrochlorothiazide. I filled out the disability form. I hunted through the fine print of the drug formulary for a reflux medication that was covered, though it took another ten minutes to decipher the three-tiered co-pay plan. I precepted three more cases, letting the discussion of the relative cardiovascular benefits of lipid lowering versus blood-pressure lowering go on a little longer than usual.
When I could avoid it no more, I steeled myself for confrontation and strode out to the waiting room. "Mr. Kaczmarek," I called out.
A scrawny man with craggy, ductile features and several days' of beard growth stood up. His hair was a worn shade of brownish blond, the top part cut short and spiky, the rest reaching to his shoulders. Thin, ropy arms protruded from a sleeveless T-shirt that depicted a rock band I'd never heard of. His denim jacket was tied tightly around his narrow waist. I beckoned him over to a corner of the waiting room where we could speak with some degree of privacy.
"Mr. Kaczmarek," I said, clipping my syllables to sound as dispassionate as possible. "You just got a refill of oxycodone three days ago, and now you're telling me that it was stolen?"
"I live in shelter," he said, jamming his thumbs into the sleeves of his jacket that formed a lumpy denim belt. "They steal all the time." His accent was a blend of Brooklyn and Poland.
"Your doctor has made several appointments for you to see the pain management specialists," I said tightly, "but you've missed them all."
"Shelter moves us all the time," he said, sniffing twice. His right hand pulled up from his waist, rubbed the side of his nose, then dropped back into its nook. "I moved from Bronx to Brooklyn, back to Bronx. All my papers lost."
The steam was rising inside my throat. Why couldn't he have given me a lamer story so I could just brush aside his request? Why couldn't he have confabulated something completely ridiculous? But no, he had to go ahead and say things that were entirely plausible: Shelter residents were constantly transferred between facilities. Theft was rampant. How was I to know whether he was being truthful?
The simplest thing for me, the easiest way to make the problem disappear, would be to take his words at face value and hand him a prescription along with a letter to the pharmacy that vouched for his story. I'd be done with it.
But the possibility that he could be using me to score more hits or make a quick buck infuriated me. I'd been dragged over the coals more than once by the plausible-story scam. Once, as a second-year resident, I'd sat in the ER pumping morphine into a freckle-faced young Canadian while the nurses derisively rolled their eyes. But the patient's story had been plausible, so I'd erred on the side of helping the patient, despite my doubts. Of course the nurses turned out to be right -- the patient had been lying -- and I was left with a hangover of embarrassment and anger.
But that's how they got you, with that plausible story. They milked you for the constitutional weakness that was built right into the Hippocratic oath -- it was your job to help patients in pain, and they knew that. A doctor could be exploited on the very basis of his or her ethical commitment to patients.
I narrowed my eyes and gave Mr. Kaczmarek the once-over. He sniffed and rubbed his nose again. I dropped my gaze and scanned his forearms for track marks, but the light in this corner was too poor for me to tell. His hand went up a third time to rub his nose.
It was time to lay down the law, I decided. There were enough holes in his story to send this sociopath out the door. It was time to state unequivocally -- at the discretion of this doctor, on behalf of all the doctors at Bellevue -- that we would no longer give any narcotics to Tadeusz Kaczmarek. Then I'd pivot on my heel and retreat to the precepting room to document the official medical clinic policy according to Danielle Ofri, MD, in Mr. Kaczmarek's chart.
What if he really had been robbed? What if he really did miss his appointments because his life had been rendered completely ungovernable by the combination of poverty, homelessness, and illness, not to mention displacement from his native country?
Mr. Kaczmarek rubbed his nose again, and I was annoyed at the whole situation. "Did you report the theft to the police?" I asked, listening in disgust to myself sounding like a gumshoe in a B movie.