The ER’s Narrative of Privilege

“Miss,” she said, as I bit my tongue (I was choking on the worst insult a female junior doctor can bear—miss), “I know that crystal meth is really my problem. I’m going to quit the meth.”

“Love,” I started, a reflex term of endearment for the wretched young woman in front of me, “What I need you to do is dry out your socks at night.”

She was tweaking in front of me, her eyes wild and her feet wet and macerated from her unwashed socks. She was earnest and somehow sweet despite the holes burned in her teeth and the scabs she had relentlessly picked on her face, arms, and legs. I was a bit afraid to touch her. Afraid, I guess, that I would become infected with whatever made her so diseased and broken. But when I looked into her huge, nearly-vacant eyes, I also wanted, badly, to give her a hug.

They tell me that I’ll get over that as I become more senior. With increasing experience in seeing patients who abuse substances, I will become inured to the pathetic faces they present to the emergency department. In time, I won’t care so much about the intoxicated guy in Room 9 who the nurses all hate; he comes in once a week, hurling abuses, and then leaves against medical advice when he needs his next fix. When I’ve seen more patients, I won’t waste my time on the tweaking addict who believes there are threads embedded deep inside his skin and shows me his abscessed track marks as proof. With experience, I won’t want to hug the addled young woman addicted to meth and covered in open sores, looking over her shoulder and telling me about how she really will get off meth tomorrow.

They tell me I shouldn’t care so much because the dirty, scabby woman in front of me made a choice to use drugs. Ultimately, we all deal with difficult life circumstances—admittedly, some more adverse than others—but most do not turn to a bottle or a crack pipe. I shouldn’t waste my time on those who are careless with their lives when there are so many responsible, upstanding individuals in the emergency department who “legitimately” need our care.

Amongst my colleagues, there is often a false narrative of choice. Smart and well-educated individuals construct a life story that reads as a series of decisions. The narratives they construct for others can be similarly linear. They reflect a perceived agency on the part of the protagonist, the main character who appears before us in the emergency department.

I know that as a successful young professional, I contribute to this narrative, especially because I come from a troubled background. In a sense, my story is evidence that overcoming adversity is a matter of personal fortitude. People like me are seen as proof that we create our own stories and are not bound by the haphazard circumstances into which we are born. But this narrative of personal agency we cleave to is not a narrative of choice; it is the narrative of privilege.

When I see patients who abuse substances in the emergency department, I imagine the hairstyle I wore when I was 16. I wore blunt bangs and a bob that nearly reached my shoulders. My hair was dyed pink, streaks of bleach blonde and deep black woven into the bright highlighter hue. I think about the clothes I chose when I was 16. I wore absurdly flared pants in bright colours, fastened to my hips with a seatbelt buckle and topped with a shirt held together by safety pins. I imagine how my choices changed as I matured; from pink hair to blonde, from blond to my natural brown with its streak of grey. From Geek Boutique pants and skirts from Ola, I have moved on to cotton dresses and scrubs. I imagine what it would be like to be trapped in the choices I made as a teenager, when my prefrontal cortex was still cooking and I couldn’t see beyond the five minutes ahead of me.

When people, often teenagers, make choices to use substances, they do so for a variety of reasons. Some choose substances because they seem fun or because they want to fit in. Others choose drugs to escape the deplorable circumstances of their own regrettable reality. Still others choose drugs because that is simply what is done in their circle; perhaps they have learned from parents, older siblings, or a peer group saturated with GHB or crystal meth. Regardless, without the neurological machinery to delay gratification or think of a future they are not sure will even exist for them, they make a choice that then excludes them from interacting with mainstream society for many years to come, perhaps for their whole lives. Some do get clean, and fewer still stay clean, but many remain trapped in choices they made when they were 16. It’s like being forced to wear the dyed hair and flared fleece pants you chose when you were in grade 11, only the consequences are much graver.

I was the recipient of immeasurable luck and privilege, and, if you are reading this, you were too. We were fortunate to be graced with intellect and the ability to make decisions based on our knowledge of the world. We were fortunate to have people interested in us —be they teachers, coaches, or parents—who provided opportunities. We may have chosen to accept or reject the opportunities presented to us, but rest assured that we were privileged even in the offering. We were lucky that circumstances allowed for us to make smart choices, to strive toward good lives. To fool ourselves into thinking that our successes are the result of our own agency is to subscribe blindly to a blatantly false narrative. It undermines both our understanding of our own stories and our understanding of the stories of others.

When I reflect on the journey that brought me to my current career in medicine, I see that I could not have arrived where I am without considerable luck. I am an agent in my own life, and I made important choices that brought me great success. I was also, however, fortunate to have been a smart kid with a flair for athletics and the arts. I was chosen for academic enrichment groups, and a music teacher provided me private lessons—for free!—during my lunch hour in grades 4 and 5. I sang in choirs and played sports. I was given the opportunity to go to summer school, play in bands, receive special development in my sport, and I was only able to make the choice to take advantage of these opportunities because they were offered. As I moved through the school system, I was encouraged to attend an alternative school, and then pushed to apply to university. When I reached university, mentors found me and pulled me through the hardest parts of my journey. I made choices and worked very, very hard, but none of these choices would have been available to make were it not for the considerable luck I experienced.

I made other choices, too, and they weren’t as positive. Yet, every step of the way, there was some interested party who intervened and helped me dig myself back out. I am acutely aware that it is only through luck that I am not a scabbed and scarred young woman tweaking in an emergency department at 2 a.m.

You, my colleagues and peers, are also fortunate. You are privileged if you were smart and born into a family that valued education and provided you with the opportunity to develop your intellect. You were lucky if you lived in a good school district with interested teachers and support staff. You were fortunate if someone enrolled you in sports or gave you the chance to go to summer camp. You were lucky many times over when circumstances conspired—in ways you cannot even imagine or fathom—to bring you the opportunity to make choices. You chose to work hard, but you also were given the opportunity to choose to work hard.

It is easy to construct personal narratives that pit us as protagonists. We imagine ourselves bravely making a series of decisions that bring us success, love, and money while those around us make the poor choices that condemn them to failure, loneliness, and destitution. It is gratifying to believe that we are the sole operating agents of our own lives. It is uplifting to believe in stories of redemption, wherein those with nothing make the independent choice to strive and turn their lives around. It is unsettling to imagine the great fortune we have in a confluence of circumstances that is entirely outside of our control. It undermines the distinction between us and those less fortunate. It is scary because it makes us just like the young woman with damaged feet, only luckier.
Maybe with time and experience I will lose the love and compassion I felt for that scarred young woman with macerated feet. Maybe I will forget her humanness. Maybe I will no longer be able to forgive the carelessness with which she treats her body and mind. But, if I do lose that part of me, if I lose my understanding of our false narrative of choice, I will be worse for it.

Image Credit: KOMUnews via flickr