Book of the Week: Matters of Life and Death, and Worse

ReadingRoom

A doctor reviews a doctor

Dr Himali McInnes’ thought-provoking collection of essays The Unexpected Patient opens with a whakataukī: “Ko te kaha kei te tinanan, ko te mana kei te wairua. The strength is in the body, but the power is in the spirit.” These words came back to me, again and again, as I read through the stories of the patients and their healthcare providers. I took notes as I read, often writing ‘yes!’ when something particularly resonated with me, especially from my own viewpoint as a medical professional – or at other times, relating to an experience I might have had as a patient.

McInnes is a family doctor who works in a busy Auckland general practice and in the prison system. She is also a well-known writer of short stories, essays, articles, flash fiction and poetry; she was the inaugural Verb Wellington Writers Resident in October 2020. Quite apart from enjoying careers centred in both the sciences and the arts, being a doctor-writer enables her to more readily translate often-confusing medical jargon and complex medical issues into language that a lay person will understand.

The introduction begins with the Covid-19 pandemic and the first of New Zealand’s lockdowns: “Just like that, the swell of patients in our waiting rooms dwindled to a trickle.”  Around this time, McInnes was asked to write an essay for ReadingRoom on the effects of Covid-19 on general practice. After  a second commission was published, HarperCollins approached her to write more. The Unexpected Patient is the result.

It’s not merely a collection of medical anecdotes, however. There is an overarching theme, one that is hard to ignore. “Over time,” McInnes writes, “I’ve started to think about the invisible things that push and pull us. It’s made me realise, time and time again, that what I see on the surface of another human being is not the main thing, or the only thing.” She reminds us that the true joy in the patient-doctor interaction is not merely a case of a patient coming in with malady A (and sometimes, especially for GPs, maladies B, C and D as well), and the doctor attempting to fix those. I’ve often found that the most valuable question any doctor can ask their patient is, “What is the biggest problem facing you today?” The answers are always enlightening and sometimes surprising. It may not be their new diagnosis of life-threatening cancer that is most worrying for them, but rather that they have no one to look after their dog when they are admitted for their surgery or chemotherapy.

In a similar vein, each of McInnes’ 14 essays are not just a scratch beneath the surface, but often a deep dive into the person behind the malady, and often, the generations of trauma and cycles of poverty that have culminated in that disease or illness. It’s these stories that not only burrow deep into the stories of those afflicted, but in turn burrow deep into the reader.

There were two chapters that I read twice, once quickly and the next time slowly. These were essays that contained unsettling truths. The first focuses on a well-known paediatrician’s encounter with a Cambodian girl with the pseudonym Bopha. The paediatrician is Jin Russell, a prolific tweeter and passionate advocate for public health, especially as it relates to the effects of poverty and disadvantage on children’s development. Russell meets Bopha when working as a paediatric registrar (junior doctor) at Middlemore Hospital’s busy emergency department. Bopha is brought in by her father with an exacerbation of asthma. They live in damp, crowded rental accommodation, which undoubtedly plays a large role in Bopha’s repeated emergency presentations. When Russell asks where Bopha’s mother is, Bopha’s father tells her that she is working night shift at a chicken factory.

It’s at this point that Russell has an epiphany when she realises the magnitude of disadvantage that children such as Bopha face: poor quality housing with mould on the ceilings, overcrowding leading to increased transmission of infectious disease; parents who are migrants with poor English, leading to a greater risk of miscommunication and inadequate healthcare; fragmented parental care due to parents having to work long, unsociable hours. Later in the same chapter, Russell’s colleague remarks, “Look at this (Emergency Department) whiteboard. Croups, asthma, wheezing, skin infections, rheumatic fever. What is the single underlying disease for all these children? Poverty.”

We learn that children exposed to toxic stress and/or poverty exhibit structural changes in their brains and that this can account for almost 20 percent of the difference in their academic achievement when compared to peers from higher-income families. This is the sobering reality that those working at the coalface face. Advocating for, and instituting change, is difficult with many obstacles, but vital if we are to improve patient outcomes and break cycles of poverty.

The other chapter that stuck with me relayed the author’s encounter with a Māori patient in his fifties with a chesty cough. Arama (not his real name) is a lifelong smoker with a drinking problem; he and his partner are living in a cold, draughty garage. McInnes encourages him to stop smoking, discusses community services to help him reduce his alcohol intake, writes letters to Housing New Zealand to plead his case. Arama continues to turn up with the same ailments.

One day, he lets slip that he was molested as a child. And McInnes listens, lets the appointment run half an hour over so that she can take notice, for the first time, of his “iceberg… that submerged clod of memories, experiences and beliefs we drag around with us… the things we carry from our childhood. The thumbprints of our ancestors on our souls.” McInnes explains (to the reader) how this can affect health in multiple ways; how this is often more important than the complaint the patient came in with. She considers the generational ramifications of trauma on health, including the ongoing effects of loss of land and culture on the health of their descendants.

Other essays bring insight into the lives of those working in rural medicine, the changing face of general practice, the integration of alternative medicine into the care plan for someone with a cancer diagnosis, and the importance of palliative care, along with a brief mention of the euthanasia bill and the potential ramifications of this. Ahmed, one of the victims of the mosque attacks, and his rehabilitation physician are brought to centre stage in the essay “One Bullet, One Man”. In another essay, “Hongi the wairua”, a patient with post-traumatic stress disorder receives effective therapy using a marae and wairua (spirit) based approach, which highlights the fundamental importance of the spiritual and family aspects of Māori healthcare.

McInnes is to be congratulated for her extremely readable, thought-provoking, wise and at times heart-wrenching collection of essays that will strike a chord with both healthcare providers and the general public alike. For me, these were stories of hope. It’s only by understanding the root causes of many diseases and the behaviours that drive them that we could ever hope to reduce rates of “lifestyle” disease such lung cancer, diabetes, addiction and obesity.

As psychiatrist Dr Andrew Howie states in his chapter, “Sometimes the best course of action is be cognisant of the limitations of one’s own knowledge, bias and experience.” Perhaps the Hippocratic oath needs to be amended for this less paternalistic, patient- and culture-centred era of medicine: First, do no harm. Next, listen. You’ll be amazed what you might hear.

The Unexpected Patient: True Kiwi stories of life, death and unforgettable clinical cases by Dr Himali McInnes (HarperCollins, $37) is available in bookstores nationwide.