The reason for Chandra’s office visit is to fill out form N-648. Chandra* is a fifty-nine-year-old Bhutanese refugee who has been my patient for the last nine months. Form N-648 is a six-page bureaucratic nightmare that is guaranteed to bring my clinic day to a grinding halt. My refugee patients bring me this form to certify that they are unable to take the test to become a U.S. citizen due to a severe, permanent neurologic disability.
My job is to document the extent of their disability and provide a detailed account of all of the factors that led up to it. The first question on the form reads: “Provide the clinical diagnosis and DSM-IV code (if applicable) of the applicant’s disability and/or impairment(s) that form the basis for seeking an exception to the English and/or civics requirements.” This is followed by five more pages of repetitive and equally baffling questions. The Department of Homeland Security is not easily placated. Successful completion of this form requires starting with the patient’s birth history and meticulously documenting an iron clad medical story to explain why they cannot learn to read and write in English or learn U.S. history.
For my patients, the N-648 is a golden ticket to the advantages of U.S. citizenship that most of us take for granted: access to Medicare and Social Security, the ability to travel and seek help from the U.S. government abroad, protection from deportation, the right to vote. For me, in my role as a family medicine physician, the N-648 is at least two hours of additional work at the end of an already long day. The time I am officially allotted to this task, like everything else, is a fifteen-minute office visit. Seeing “N-648” on my schedule never fails to incite panic: a sinking feeling in my gut, a quickening of my pulse. It feels like I’m on a roller coaster ride, being slowly pulled to the top of a long incline, before the inevitable drop. My brain fixates upon the myriad ways in which this piece of paper will ruin my day. I will run behind. My patients will peek their heads out of the exam rooms, scanning the harsh white hallways for somebody to ask how much longer they’ll have to wait to see their doctor. Those same patients will sense that I’m rushing, that I’m not paying as close attention to their problems as they deserve. I’ll miss my lunch break and my bathroom break. Prescription refill requests will pile up in my inbox unanswered. I’ll miss dinner with my loved ones at the end of the day.
Playing the lead role in today’s paperwork drama is Chandra, the fifty-nine-year-old Bhutanese woman. Her long black hair is flecked with silver and usually pinned up into a neat bun. Her weather-worn face and far-away black eyes rarely melt into a smile. She wears vibrant velvet tops draped with traditional beads and silk scarves. Her flowing, wrap around skirts are cinched at the waist by a broad gold scarf. Stooped over her plastic black cane, she limps and shuffles down the long hallways of my clinic. Chandra is four feet and eight inches tall. My five foot eight-inch physical presence towers over her.
Chandra’s native and only language is Nepali. After greeting each other with “Namaste, namaskar,” our heads bowing down to meet our pressed-together palms, the remainder of our visits are interpreted with varying degrees of quality by telephone or Skype-based interpreters. Chandra is a what we call a “frequent flyer” in the clinic, and I am well-versed in her multiple medical problems: depression, post-traumatic stress disorder, memory loss, and a rotating list of physical complaints that are hard to pin down. She is not unlike many of the patients in the community health center south of Seattle where I spend my days sifting through a large volume of newly-arrived refugees from Ethiopia, Eritrea, Somalia, the Democratic Republic of Congo, Iraq, Afghanistan, Burma, Bhutan. Many of my patients have traveled similar trauma-laden paths to my doorstep. Like Chandra, they have been driven from their homes by ethnic- or religious-fueled persecution and violence. They have spent long, mind-numbing years in refugee camps, unsure if a better future awaits. They have lost husbands, wives, and children to the sister plagues of poverty, warfare, and disease. When they finally arrive in the U.S., they carry with them a long list of mental and physical problems that have accumulated, untreated, over the years. Day after day, week after week, in 15-minute increments, I chip away at these lists.
At her weekly office visits, Chandra complains of pain. To my Western-medicine trained ear, her complaints are vague. I can never fit them into any diagnostic algorithm; I can never tie all of her symptoms into a nice bow that explains and connects everything. Occam’s razor does not apply here. If I ask how long she’s been in pain, first she’ll say two weeks, then later change the timeline to 2 years. Specific locations of pain are also chameleons: today it’s the right shoulder, tomorrow the left leg. Our too short visits too often end in frustration on both sides, with me persistently trying to track down unknowable medical details to hone in on the “correct” diagnosis, and Chandra becoming first confused and eventually bored by all of my questions. “Where does it hurt,” I query? “Is it your shoulder, your back, or your leg?” “Dukhccaa,” she says to the interpreter on speakerphone while rhythmically nodding her head at me. Dukhccaa (pronounced dook-sa) is the first Nepali word that I master at this job. Its translation: pain.
The day Chandra comes in with her eldest son to fill out the dreaded N-648 form is different. She is accompanied by a skilled live interpreter, a rare treat for both of us. The late autumn sunlight filters in through the clinic windows, warming and bathing the sterile space. I sense that this visit will bring me closer to understanding who she is and how I can be better care for her. I am, for once, ahead of schedule. The day is running smoothly; I am not rushed, stressed, tired, or hungry. Chandra won’t complain of pain today, and I won’t try to fix it. Instead, for the first time, I walk into the exam room, sit down, skip logging onto the computer, look her in the eye, and say, “Tell me your story.”
* All identifying information changed to protect patient privacy.
Xandra Rarden is a family physician.
Image credit: Shutterstock.com
