When I first met a young woman named Rani*, I saw her sitting alone at a domestic violence shelter in rural India. She wore a simple, white salwar-kameez (a traditional Indian dress), with her dupatta (shawl) dangling solemnly from her shoulder. Yet, despite her modest attire, she stood out. Small grooves and scars from a blade were painted onto her cheeks, and the white stain of skin that had been set on fire remained etched into her arms and neck. These were silent tattoos that depicted her past relationship for the world to see.
Rani was one of many women I met at the domestic violence shelter. As a trained dancer, I visited the shelter to teach the women dance. With time, while most of the women opened up to me, letting go of their inhibitions and taking part in lessons, Rani remained detached. She would watch the other women perform at times, but mostly would peer out of the window of the shelter introspectively.
At the end of our dance classes, I sometimes would hear her humming the same song over and over again. “Rani, what song are you singing?” I once asked. She looked back at me in surprise, because no one had ever asked her this question. The song was a lullaby that she used to sing to her children each night – children who she longed to see again, who had been torn from her arms by her husband. While I listened more to Rani's story, it became clear to me that Rani’s emotional wounds penetrated much deeper than her physical wounds.
When applying to medical school, I hoped to attend a school that would give me the chance to continue to work with women, to listen to their stories, and to be there for them in their toughest times. I ended up choosing Boston University School of Medicine aware of the opportunities I would have to work in a community health clinic focused on women’s health, and to train at one of Boston’s major safety net hospitals for the poor. On our first day of classes, a professor noted that I need only to look outside of my window to see issues of infant mortality and violence that parallel the developing world. But, I remained skeptical as to the degree of the issues in Boston. I wondered if things could be as severe as they were in India, and if my previous encounters would translate in a healthcare context.
My perspective changed after I interviewed one of my first patients at the community health center; here, the realities of violence in the United States and the role of physicians in empowering and detecting victims of violence came into greater focus.
The first patient interview was with a 35 year old woman named Anna*. After walking in, she sat in a chair which was placed in the very corner of the room. I asked if she would like to pull her seat closer, to which she quietly replied, “No, I am okay.” I noticed the way her toes curled as she spoke to me and how she seemed to keep her arms and legs close to her body, almost in a protective, defensive fashion. When I asked her about her social history, she told me how she had moved from Puerto Rico to the United States with her three children and had lived in New York for almost 20 years before coming to Boston. “So, do you ever go back to visit New York?” I asked.
There was a pause in the conversation; a heavy, uncomfortable silence.
“No… I can’t,” she finally replied.
From that moment, my work in India slowly began to come to life. Like Rani’s song that had never before been uncovered, I found that Anna had much more to share. As a victim of domestic violence, she had been stripped from the women’s shelters in New York, the state where most of her family and mother lived, to Boston, a new place where she knew no one. Each day she lived with the gripping fear of retribution from her spouse. She took 5 to 6 antidepressants as a means to cope with the lingering emotional damage she had experienced, and battled multiple physical illnesses with raising her three children. As Anna opened up to me, I found that the issues I had seen in India were right in front of me in Boston in a way I had not imagined.
At the end of the interview, my classmates and the supervising community health physician commended me for empathizing with Anna and bringing her out of her shell. However, the supervising physician also explained that while I was sympathetic and served as a good listener, I could have done more. “You also had the opportunity congratulate her – for being brave enough to walk away from her relationship or for single-handedly raising a large family,” he noted.
And I realized he was right. As future physicians, it is true that we have critical roles as listeners. We must pick up on silent cues and delicate body language, understanding that issues of violence and abuse can sometimes be uncovered in a healthcare setting. We must ask questions that often go unasked, and serve as patient listeners. However, just as importantly, we must encourage, congratulate, and empower our patients in any way we can; whether that might be by simply recognizing the beauty of a song our patients are humming or commending them for the strength of their spirit.
*Names have been changed to protect patients.