The Line

When I first went to the US, I was very impressed by how people respected your turn in lines at public spaces: at coffee shops, bus terminals, airports. Once you were in a line, you held certain visibility and authority of your turn. It was in sharp contrast to public spaces in Nepal: here your visibility was determined by a complex set of factors that ultimately determined your power. Your turn at public places had a more blatant display of power play and authority. Most of the times, there were no lines, just an aggregation of people, pushing and pulling, more aggressive among the dogs snatching the bone first.

I thought the lines in the US were profoundly right. Especially impressive was when people would open and hold doors for others, especially women and children. This is profoundly and deeply right, I used to tell. And I tell myself now. For a South Asian in America, there was no option to disrespect this system, but I deeply admired it, regardless. I would follow these rules with a full conviction. I thought the habit had hammered in deep, irrevocably.

Apparently not!

I was with two other doctors, chatting, and we walked in the cafeteria. We ordered our coffee and were doing back and forth about one of us wanting to pay. A young woman who was ahead of us suddenly raised her voice.

"Why did you not complete my order?" she asked the man in the counter. Then she turned to us and said, "For him I am garbage. No. 1, I am a woman. No. 2, I am not wearing the white coat you guys are wearing."

What had happened was, the boy in the counter just stopped mid-order with the woman and took our order. We didn't even notice that the woman was ahead of us. She was short woman in simple kurtha surwal.  And in our jolly disposition we catered to the attention the boy in the counter paid us. It seemed all natural. And probably would have gone unnoticed in the incessant flow of things in this mighty nation of Nepal. Except that this young woman did not have penchant for the order of power in this cafeteria.

Suddenly I felt completely ashamed. But more than that I felt terrified. Consciously, and in deliberating mind, I would have never used my masculinity and white coat to trample over the line. But here I was, doing exactly that. Against the value I held dear. In this unconscious exercise, the woman without a white coat was an entirely invisible figure.

I apologized to her profusely. But the saltiness deep inside couldn't be washed away with those apologies. The uneasiness persisted for days.

In Ralph Ellison's fiction "Invisible Man" the reason for invisibility of the main character is largely racial. Or, at least, the narratives suggest such. It is one basis of invisibility. But in our society, as I ruminate, the bases for invisibility are plethoric.You could be a woman. You could be a consumer. You could be a filthy fellow covered in city dust or village mud. You could be old. You could be a child of a farmer. You could be a patient at a public hospital who does not know any body in the system. You could be a village student trying to get a citizenship certificate at the district administrative office....

We are a society of invisibles. Visibility assured only after mounting ourselves on top of other invisibles. Bigger the pile of those invisibles underneath our feet, the higher our cliff.

No one is spared in this dog fight, it seems. If you hang around long enough. However much you trumpet on the solidity of your moral foundations. 

River Ghost

She had a poetic aptitude for expression.

"I would let the chickens out of the coop. As they grazed, I would stare at the river. 'This is it, this has been the life for me that is about to end,' I would tell myself.

I was shaking. I was losing weight. I was sleepless at night and heart used to beat in a terrifying way. 'The river ghost has caught me and is bringing me down,' I thought. Little did I know that it could turn around so fast. I feel reborn," she narrated. A little perked up on this visit after medication dose adjustment on the last visit, a few days ago.

For those of us who have chosen medical subspecialties, this is as dramatic as it gets for the change in patient outcome. We are not the doctors who slit open the chest to plug the bleeding heart or crack open the skull to chop out a tumor from the brain or fix a broken leg after just a few hours of work. We are the ones who listen to vague prattle of patients, attempt to find what's bothering them by doing tests and tweak their physiology by several means to see if that helps. The outcomes are not necessarily dramatic.

At some level, the creed of medical subspecialty is an abstract one. We have to listen to vague words, grab non-verbal cues to direct us to the culprit. We do tests to explore our hunches. Abnormalities in these tests, we are asked to infer, reflect abnormality in certain body parts or processes. Based on these results we give our patients medications. We do not see these medications working with our bare eyes. But we take a leap of faith based on what someone else has told us about how it works. We work based on perception, hunches, and faith on certain tablets, capsules, injections or devices. It's a mushy field.

Yet, we choose this field with a notion that it helps suffering patients. And just like religious people who talk about their "doubts" on their god, we do have our doubts in our faith-heavy creed. I sometimes find myself asking, what are we really doing, when I see a patient who has to swallow twelve medications a day.

But the experiences of patients like our poet patient are what pulls us back to the vocation. Reaffirming our belief in the power and value of this creed.

However, Ms. poet's plight has another layer of story. Her suffering was largely inflicted on her and totally avoidable. The suffering, which spanned a length of life and death in her perceptual realms, was rather easily treatable and preventable. 

She saw a doctor about a year ago with several vague symptoms. Her doctor found out that her thyroid gland was not producing enough hormones. He put her on a relatively high dose of thyroid hormone. But she never had a follow up after that. Her thyroid hormone levels were never checked and she kept taking the medication. That dose was excessive for her and caused all her symptoms.

At technical level, it was a very simple and routine problem. There was not much of threat to her life and the problem was easily solvable. But her suffering was indeed not so benign. She thought she was dying from the wrath of an unkind river ghost.

The question of why she had to endure such a suffering is a complex one. Perhaps she ignored the doctor's instruction to have blood tested after a few weeks. Maybe it was entirely her fault.

But what bothers me is that more likely the fault was entirely ours. If you have interacted with our Nepali doctors and power holders, as a nobody, I am sure an impassive face will come to your mind. This face is quiet, distant, and almost conceited. For the things you need to do, you are expected to find out using intuition. By heavenly mistake, if you happen to inquire this godly creature, wrath might spill out in violent waves, drowning you in an utter indignity. So it would be no surprise if this patient was never explained that she needed to have levels of hormones tested after 6-8 weeks or she heard a babble that she didn't understand but didn't have courage to ask.

For those of us who have chosen medical subspecialties, making our patients understand things is not a luxury but a basic necessity. Their outcomes and sufferings depend on it. We will not succeed always. But we have no right to put on our smug face and ask our patients to intuit us. In our mushy world, our conscience demands that at least we try. 

(Addendum: This got published in Republica with some addition + editing on June 24th, 2014. They changed the title to "Cold shoulder" which I have a hard time relating to. But our mighty editors do not seek writer's consensus to change things. They just do it! Still, I have to take a solace because it is less cringe worthy than being changed to almost bigoted "White man's burden" for an article that guilelessly talked about "Resources and physicians" just because the patient context was the US.)