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The shoulders of giants

I regretfully told my 65-year-old patient in the preoperative area, “I’m going to have to cancel your case.” We both knew this was coming. He suffered from a large inguinoscrotal hernia that was symptomatic but not dangerous, a condition that had threatened his welfare for the past several months. Given his education level and social issues, his career prospects were limited to manual labor. I sensed his desperation to return to work from the moment I met him in the office; he was eager to tell me how long Calviva had taken to process his referral, and I was just as eager to help him put the hernia behind him.

There was one small wrinkle in our plan: his methamphetamine addiction. I’ve always believed that a good surgeon knows when not to operate. I carefully decided that while I would not operate on an active meth user, I would give him as many chances as needed to show up for the surgery with a negative urine drug test. No shame, no judgment, no dismissal from my practice – just patience and faith.

This was a skill I had been practicing for a while, so it came somewhat naturally in situations like these. As a mother of three, I am accustomed to people needing second (and third, and fourth) chances in a safe space to make good choices. This is a treasured skill born of a string of many, many parenting failures.

But the real roots of believing in my patients and investing in them as human beings started far earlier in my life. As many do, I had a tumultuous transition from high school to college. On all outward accounts, it would seem that things were going according to plan: I was the privileged daughter of wealthy physician parents, recruited to UC Berkeley to play Division 1 tennis on a (then) PAC-10 team. I was living on campus independently and performing well in all my classes. However, I had, up to this point, been adept at pretending to be normal.

In reality, I had already been struggling with anorexia for several years in my young life, and the stressors of college only exacerbated my eating disorder. Unable to keep up with the demands of college sports, I took a leave of absence on two separate occasions. In place of any meaningful direction or life ambition, I found crystal meth through an old acquaintance. After using it daily for a month, I realized that I had become something incompatible with life – unable to eat, sleep, or even think rationally. Thankfully, I had a family who would only let me fall so far before intervening, and so began a long road back from a deep abyss at the ripe age of 20. I recall my path to recovery as more of a discovery; I never truly knew myself before the Berkeley student-athlete façade of myself shattered into pieces. But here I was, now forced to pick those pieces up and put them back together into some sort of identity that had nothing to do with my accomplishments or my appearance. I had to find my authentic self, and no one else had the answers. With nothing else to do – indeed, I was too sick to do much of anything else – I threw myself into this recovery-discovery and plumbed depths at the time I wished I hadn’t needed to, but would be grateful I did for decades to come.

Through the course of my recovery, I came to appreciate the immense privilege of my existence, not only because I was born into a family that afforded private coaches and Kumon but also because they refused to relinquish me to my downward spiral. I stood in awe of the physicians who helped me and my family climb out of the abyss of my eating disorder and all it represented. Towards the end of the tunnel, I recall marveling that anything good that came of my life moving forward, anyone I helped in the future, would have only been possible because of their excellent care and faith in my potential – what a powerful legacy.

As the physicians who helped me in my darkest moments 20 years ago, I was drawn to medicine to serve others in their own darkest moments. Truly, needing health care is one of the most vulnerable positions we can find ourselves in. Mental health is particularly challenging, as stigma and fear of repercussions often block the path to help. While my interests in medicine led me into a field with very concrete, tangible ailments rather than psychiatric ones, I am always reminded of how powerful the mind is in the healing process, and connecting with patients on that level is a precious tool in my physician toolbox that I may never have cultivated without my own suffering. As Abraham Verghese writes in The Covenant of Water, “Before we treat the flesh, we must acknowledge the greater wound, the one to the spirit.”

I am particularly reminded of my own privilege when I see patients in our community struggling to navigate their own mental health battles. The current meth user in and out of prison with congenital adrenal hyperplasia and adrenal tumors the size of twin infants. The recovered addict whose severe cardiomyopathy and palpitations were chalked up to his drug habit rather than the pheochromocytoma he had with 40 times the normal level of metanephrines. In my practice and within our community, I believe in making an extra effort to connect with and support the neediest, many of whom are suffering mental health crises, battling addiction, incarceration, and poverty with absolutely no social support. There I would be, but for the grace of God, and so there I continue to go, trying to lift them up in whatever small way I can. Empathy for the effects of mental health on patients’ lives leads to deeper connections with patients from all walks of life and enriches my own experience as a physician as well.

To become a physician requires extremely hard work and dedication, as well as many fortuitous events – good health, access to resources, and social support. My path was extraordinarily fortuitous: I had a dedicated family with bottomless resources to navigate my illness, and every ambition I had upon recovery was met with even more support and abundant finances. Not every former meth user or mental health sufferer who falls as far as I did has the resources to obtain an MD/MPH, complete a surgery residency, and travel the world, carrying on as if nothing ever happened. But the fact remains that the path to recovery cannot be bought; it begins with nothing but the hope and faith of an individual and their support system. I recall vividly that the physicians who cared for me at my worst always treated me like the person they knew I could become, rather than the person I was at that moment. I stand on the shoulders of giants who had such hope and faith in me; I now have the privilege of being those shoulders for others.

As for my patient, he recently finally showed up to the operating room proudly with a negative urine drug screen, having decided to quit meth for good. He underwent a successful surgery and to date, sees this as a turning point after 30 years of addiction. I don’t presume to know his future, but I do know the power of someone choosing to invest in your humanity, rather than dismissing you for your circumstances; I hope that this, if nothing else, will be my legacy.

Farah Karipineni is a general surgeon.

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