The Code-Switch

She sat in front of me in the clinic room along with her husbands, hands in her lap. She was one of the Muslim Aunties from my South Asian community, poised and proper in her lavender cotton salwar kameez. As a physician fluent in Hindi, Urdu, and English, I have had the privilege of caring for many Indian and Pakistani patients. Despite being born and raised in the United States, I pride myself on my ability to navigate different languages, cultures, and faith-based traditions. I can have a nuanced conversation about fasting for Karwa-Chauth (the Hindu tradition of the one-day fast) as easily as I can about Ramadan (the Muslim 30-day fast from sunrise to sunset).

I will refer to her as Aunty, as this is the term we use to respectfully address all older ladies in our community. Aunty is in her 60s, an authentic product of her conservative upbringing. She didn’t talk much. She was always put together and well-groomed. Under the surface, however, she suffered bouts of depression and anxiety, having lost her son in his 20s in a motorcycle accident. I proceeded to check in about her Diabetes, heart disease, high cholesterol, and bipolar disorder medications. She reported adherence to them all. I didn’t doubt this one bit. This Aunty is a rule follower. She isn’t like my grandmother, who collected all her pills in one bottle and then got confused. She did not self-diagnose.

So, when she presented with a new complaint of “ghabrahat”, I honed in.

Ghabrahat is directly translated as a feeling of worry or nervousness. When asked about specific symptom presentations, healthcare providers associated ghabrahat” with anxiety, nervousness, palpitations, and restlessness (JAPI, Aug 2025). I was aware of the direct translation of “worry” or “nervousness”. However, not being raised in South Asia, I was NOT aware of its connotation with palpitations.

Her husband chimed in that he felt her anxiety had been worse lately. I latched onto the mental health definition of the word and proceeded down a path focused on depression, anxiety, sleep, and symptoms of panic. She did not endorse any such symptoms. She also didn’t endorse chest pain or shortness of breath. I moved on to the next topic, assuring her that perhaps this indeed was anxiety-related. She dutifully complied, without pushing back or adding more information. I completed the visit, ordering lithium levels to make sure that they were therapeutic, and moved on to my next patient.

One month later, I ran into my Pakistani Cardiologist colleague. She informed me that Aunty was admitted to the hospital.

“What happened?” I asked, my self-doubt rising in my throat.

“Acute coronary syndrome,” she replied.

Aunty had suffered a heart attack.

“Fortunately, her heart is healthy, and she was given a second stent to open the blockage. Glad we caught it quickly.”

I was shocked. She had just seen me and didn’t endorse any cardiac symptoms.

 

“What was her presenting complaint?” I asked.

“Ghabrahat, especially when walking up hills,”

I felt numb. It felt as if the floor had been removed from underneath my feet. I had made a grave mistake that could have cost Aunty her life.

As I processed my clinical failure, I was slowly able to reflect on what happened. I surmised that this might be a linguistic issue. Urdu is a rich and layered language. One word can have multiple definitions. For example, there are eleven Urdu words that translate to the English word “desire.” As someone not raised in India or Pakistan, I had limited knowledge of all the connotations of the word “ghabrahat”. I called my mother, who understood the complexities of Urdu like no other. She had instilled in me a love of the language since childhood, teaching me about the famous poets Ghalib, Allama Iqbal, and Maqdoom. She understood linguistic nuance in a way that few did. She reminded me that Urdu is a multilayered, rich language developed over 800 years and that it is an amalgam of three major world languages: Hindi, Farsi, and Arabic. She pushed me to read more.

I was intrigued to learn that this one word, “ghabrahat,” wasn’t just a problem for American-born South Asians. It had no direct equivalent in medical terminology. It can also be used to describe “discomfort.” I had always understood it to solely mean anxiety. The term’s ambiguity can lead to overtesting or, in my case, misdiagnosis. The strong associations with both the cardiovascular and psychological systems (86% and 73.8%, respectively) suggest that “ghabrahat” may represent a complex psychosomatic manifestation that requires a multidisciplinary approach to diagnosis and treatment. This clinical challenge has been published in the South Asian medical literature. This piece of information provided me with some comfort.

I took away three lessons from Aunty’s condition. First, I should keep learning and reading- not just about medicine, but about culture and linguistics and anything else that I love that can also help patients. Second, that my knowledge of language (or anything for that matter) need not turn into over-confidence. Third, I can always care a bit harder and listen a bit closer. It matters.

 

(Or: Third, great leaders are not free of mistakes, but they also do no repeat them.)