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The Art of Medicine


Katers, Laura MS, MCHS, PA-C

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Journal of the American Academy of Physician Assistants: July 2017 - Volume 30 - Issue 7 - p 58
doi: 10.1097/01.JAA.0000520534.10883.2d
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Fara is a 67-year-old Somali woman with a chief complaint of “all-over body pain.” She is with her daughter, who will be our main translator. Fara's last residence was a Somali refugee camp in Kenya. She has never been to a doctor. Her daughter has worked three different jobs for 2 years to save up the money to bring her to the United States.

Fara's pain complaints migrate from visit to visit. She reports fatigue, difficulty sleeping, an upset stomach, and intermittent heartburn. Initially, I pursue the full workup: radiographs of painful joints, blood work. My differential is short but reasonable: osteoarthritis, rheumatoid arthritis, GERD. I delve into a few zebras endemic to eastern Africa—schistosomiasis and other intestinal parasites. I check blood levels of vitamin D, thyroid hormones, iron.

Based on laboratory results and images alone, nothing is wrong with Fara. A year goes by. We chase the pain the way one might chase a butterfly through a field—a bit wildly but with a clear intention of catching it. I help her fill out an employment application and am even a reference for her. But the main jobs for a 67-year-old woman with limited English, all-over body pain, and little education are cleaning floors or houses, and Fara can do neither. The daughter picks up a fourth job.

During that same year I meet other women from eastern parts of Africa, many with all-over body pain. I befriend community members and am told I am likable, “because you believe in our pain.” I begin to learn about family members left behind and of the civil war that is a daily occurrence for many of the refugees I treat. I confront the genital mutilation still done to young women every day in parts of the world I have only dreamed of visiting. I experience both the fear and the absolute love and joy of a culture much different from mine. I learn that, for many, the turmoil of their loved ones back home keeps them paralyzed with worry. I also learn that the Muslim culture does not allow for discussion of the negative aspects of life when so much of life is good.

I wish for conversations without the need for interpreters. I long for an opportunity to get to know my patients at their core, their true thoughts and experiences. I long for connection. I long to try out words like depression and stress and anxiety to explain symptoms, but these are all Western words. I eventually find that the phrase thinking too much is one I can use without stigma in talking to all of my patients. Fara agrees that she does indeed think too much, but I still never know what of.

The last time I see Fara for her all-over body pain, I decide to ask questions about happiness and sadness. Discussing emotions is still taboo, but she has children who are still in Africa; I know she worries about them. Her eyes go soft. She listens to her daughter—our interpreter—but watches me, her humped back and stooped shoulders slowly opening like a book of hymns. I start a PHQ-9 depression screen and make it to question 2—the one about hopelessness—when I suddenly stand up and raise both of my hands to the ceiling. I watch myself offer up an image of a woman running to the street and yelling. “Do you ever just want to yell!?” I exclaim, loudly and with conviction, surprising all three of us.

“Yes!” she erupts, the only English word she knows. She clasps her hand to her mouth, then whispers, “Yes!” There are tears in her eyes.

The rest of the questions are suddenly unimportant. I realize in that moment that giving up our own suffering is perhaps the hardest thing any of us will do. And for many, including Fara, that weight is entirely too great to carry alone.

“How could you possibly know how I am feeling?” she asks, as if I have summed up her nearly 70 years and most of all given her permission. She repeats the question to her daughter to make sure I hear the translation, “How could you know?”

I want to tell her that I also know sadness and hopelessness at times, that I know depression, although mine is different. I want to tell her I believe in labs and images and Western medicine but that there is no test to measure heartache. There are no codes to diagnose and bill for love, or joy, or grief. No human is immune to emotional suffering. But medical education does not train us to share our own pain as a means to connect with another human. Putting on my medical hat, I attempt a brief discussion about psychosomatic pain and fibromyalgia. Fara doesn't hear it, her dark, earthy hands extending toward my pale hand—an offer, I've learned, of gratitude. Her face is wet with tears and so, so bright.

“No,” she says, and smiles the wide smile of a child in love. “You must be a magician.”

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