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Kheirbek, Raya Elfadel MD

doi: 10.1097/ACM.0000000000001786
Teaching and Learning Moments
AM Rounds Blog Post

R.E. Kheirbek is associate professor of medicine, George Washington University School of Medicine and Health Sciences, and geriatrician and palliative care physician, Washington DC VA Medical Center, Washington, DC; e-mail:; Twitter: @raya_kheirbekMD.

Author’s Note: The names in this essay have been changed to protect the identities of those described.

An Academic Medicine Podcast episode featuring this article is available through iTunes.

“Please help me,” she whispered.

The young woman standing before me held her head down. It was my first year working as an attending physician in a large academic medical center in the Syrian city of Damascus. Rima was my first patient of the day. She was accompanied by her mother Samira.

Rima was tall, thin, and pale. She wore a long, loose-fitting, buttoned-down green dress and a white hijab reflecting her Muslim identity. In the presence of her mother, Rima avoided eye contact and spoke very little.

I gently asked her what was wrong, but her mother responded instead. Rima had just graduated from high school, Samira said, in time to marry her cousin, a promise rendered by her father when she was a young girl. The wedding was a few weeks away.

Over the past few months, Rima had become withdrawn. She confined herself to her room, spoke very little, and refused to accompany the family on outings. Samira was very concerned. Most girls, she pointed out, would be excited at the prospect of getting married and starting a new life. Waiting outside were Rima’s brother Saeed, a farmer, and Nabila, Rima’s future mother-in-law. All were keen to be reassured that Rima was healthy and able to carry out her duties as a married woman.

Alone with Rima, I touched her arm and asked, “Tell me Rima, what help do you need?”

With tears in her eyes, she stood up and unbuttoned her dress, revealing a pregnant belly. “I pushed hard but could not get rid of it. Now there is a bulging bag of water between my legs,” she said, as she sat down and opened her legs slightly to reveal an amniotic sac the size of a tennis ball. “I have been seeing mucus all week and have had stabbing pain in my back. I am sweating and feel nauseous.” Rima talked about a loving relationship with Hamid, her best friend’s brother. They had both contemplated eloping, but with no money, relatives, or friends outside their small town, they had no option but to stay.

My thoughts were jumbled, and my heart was racing. I told Rima that we needed her mother on our side. Rima looked desperate. She knew her brother would kill her for dishonoring the family and wanted to protect her mother from the same fate. While the choices were limited, I could not let my patient face this alone. She needed to be on the maternity floor, which was inconveniently located in a different building. I left the room and met with Saeed. I told him Rima was very ill and needed to be hospitalized for a tumor in her belly. I then reached out to the social worker, who also scrambled to help us. The city’s protective services decided that they would rather not get involved in a “cultural issue” and recommended calling the police to escort Rima and her mother to the maternity ward and to ensure a warm handoff to the OB team. My patient left the clinic escorted by the police as planned. It was then out of my hands. I kept thinking of Rima, though, wondering about her fate.

Six months later, Samira came to see me at the clinic. She brought a sweet dish and thanked me for attempting to save her daughter. I confided in her that I kept Rima in my thoughts and prayers. Excited, I asked to see pictures of Rima and the baby, but Samira started sobbing. The infant boy was kept in the hospital for adoption; his mother and grandmother never saw him. Rima died shortly after being discharged. Back at home, thinking it was tea, Rima mistakenly drank a cup of pesticide her brother left on the table. The police ruled her death an accident.

Samira and I stared at each other in silence.

Although 25 years have passed since my encounter with Rima, the experience remains vivid in my mind.

We often are certain in the knowledge that we speak a familiar language. But we fail to recognize the subtle, whispered undercurrent of that language in many communities. In Rima’s case, that language was imbued with the complexities of honor killings, a global and cross-cultural issue that cleaves deeply into a mishmash of shame and honor.

As a physician, I have learned to open my heart and mind to absorb others’ experiences. It is only through this all-encompassing empathy that I can begin to offer myself to my patients and find time to help them, but I have also learned that sometimes offering all isn’t enough. Rima’s case taught me pride in acknowledging the power and capabilities of my profession and humility in learning its limitations, for I found myself powerless that day against the waves of life’s unpredictable forces.

Raya Elfadel Kheirbek, MD

R.E. Kheirbek is associate professor of medicine, George Washington University School of Medicine and Health Sciences, and geriatrician and palliative care physician, Washington DC VA Medical Center, Washington, DC; e-mail:; Twitter: @raya_kheirbekMD.

© 2017 by the Association of American Medical Colleges