The Dissatisfied

The other day a patient of mine came back to the office for a “glass check”.  A “glass check” visit, for the uninitiated, is one where the patient who was recently prescribed glasses comes back to the office unhappy with her new pair. 

Sometimes this is due to a simple error of the optical lab: a wrong cylinder axis, a minus sphere used instead of a plus sphere or readers-only given when a progressive lens was expected. 

Sometimes it is because the patient has an underlying pathology: cataracts, keratoconus, corneal scar, diabetic retinal issues, or a fluctuating tear film, any of which may be contributing to less than perfect vision. In these cases, the patient is reminded that they have an underlying problem that is affecting the vision.

Sometimes it’s a mis-aligned visual axis. It could be induced prism, or distortion, or image jump or displacement. But if it’s not any of these things, then it is hard to know exactly why the patient just can’t “get used to” her new glasses. Then it can be difficult to reassure the patient and come to a mutual resolution to solve the problem.

Trying to address a dissatisfied or unhappy patient is a challenge in and of itself, regardless of the language in which the conversation takes place. However, when you have to be diplomatic, maintain a positive outlook and convey confidence that the problem will be resolved all in a language non-native to you, the experience can certainly feel overwhelming. 

For the ophthalmology exam in Spanish, I’ve memorized plenty of  “how are you's”, “what brings you here today's” and “look left and look right”, but surprisingly after 7 years of private practice and conducting general eye exams with my patients, I’ve rarely had to address an unhappy patient in Spanish. Given this situation,  I had to think first about what I would say in English and then mentally translate it. But somehow, it all just sounded, to me, unnatural and uncomfortable. Maybe it’s not so much saying it in another language that bothered me.  Maybe it’s simply the frustration and disappointment that comes with not making a patient 100% happy with his/her office experience.  Regardless of the etiology of the patient’s dissatisfaction, I think every doctor feels a certain sense of loss when the outcome isn’t what was expected. 

With this patient’s glasses, I tried to find the root of her problem and then give her reassurance:

D: ¿Qué es el problema con los lentes?

P: Bueno, cuando me los pongo, no puedo ver nada. Es incómodo. No puedo usarlos.

D: ¿Cuándo los compró?

P: Dos semanas atrás. Me los pongo una vez, inmediatamente me los quité y ya no he los usado.

D: Vamos a ver—(comprobando la visión)—bueno, puede ver 20/20 con cada ojo, en la distancia y para leer con los lentes. Y, el óptico hizo los lentes correctamente. A empezar, el poder de los lentes es mínimo. Es sólo a ayudarle funcionar por la noche, cuando maneja el coche, por ejemplo, o cuando quieres ver las letras escrito en la pantalla de la TV muy clara – eso es todo.

P: Sí, pero cuando me pongo los lentes, es borrosa la visión.  Cuando uso los lentes de mi amiga, son demasiado fuertes al princípio para mí, pero cuando estoy acostumbrada de ellos, puedo ver más claramente con ellos. 

D: (mirando la receta de los lentes de su amiga). Oh, no, estos lentes son demasiados fuertes para Usted. No es bueno para la salud de los ojos a poner anteojos con la receta incorrecta.

P: Lo sé, pero, veo mejor con ellos.

D: Bueno, Usted sólo se pusó los lentes una vez. No es bastante tiempo a acostumbrarlos. Pongaselos otra vez y uselos diario, por a menos dos semanas. Si no le los gustan todavía, llame la oficina otra vez.

P: Está bien. Es mi primera vez con lentes, entonces, no sé como debo sentir. Yo trataré...

D: Está bien. Pase un buen día.

P: Igual.

                                                                        *

D: What’s the problem with the glasses?

P: Well, when I put them on I can’t see anything. It’s uncomfortable. I can’t use them.

D: When did you buy them?

P: Two weeks ago. I put them on once and immediately took them off, since then I have not used them.

D: Let’s see (checking the vision), well, you can see 20/20 with each eye, at distance and near with the glasses. And, the optician made them correctly. To begin with, the power in the glasses is minimal. They’re only meant to help you function better at night, when you’re driving your car, for example, or when you want to see letters on your television screen more clearly—that’s all.

P: Yes, but when I put them on my vision is blurry.  When I use my friend’s glasses, however, they are too strong at first but then when I get used to them, I can see more clearly with them.

D: (Looking at the prescription of her friend’s glasses). Oh, no, these glasses are too strong for you.  It isn’t good for the health of your eyes to wear glasses with the wrong prescription.

P: I know, but, I see better with them.

D: Well, you only wore your glasses one time. That isn’t enough time to get used to them.  Wear them again and use them daily, for at least two weeks. If you don’t like them after that, call my office again.

P: Fine. It is my first time wearing glasses, so, I don’t know how I should feel. I will try...

D: Fine. Have a good day.

P: You as well.

Street Graffiti, Zadar, Croatia

Now You're Speaking My Language

Paciente: Su español es bueno. ¿Nació aquí? ¿Dónde nació?

Me: Aquí  - Nací en Nueva York. Gracias. Pero, no es perfecto. Tengo que practicar más...

P: Sí, bueno, su español es bueno. Para mí, inglés es muy difícil.

M: Ajj, ahora sabe lo que digo yo, es difícil aprender un idioma - porque no quiero sonar estúpida, o como una tonta, cuando lo hablo.

P: Es muy difícil.

M: Le entiendo. Pero he aprendido que,  a aprender un idioma bien, tiene que usarlo a menudo.   Tiene que hablarlo.  Escucharlo.  Escribirlo.  Leerlo. Tiene que escuchar al radio en inglés, la televisión en inglés.  Tiene que leer libros en inglés.  Lo tiene que llegar a ser una parte de su horario al diario. 

P: Bueno, cuando trabajaba como pintor, sabía bastante inglés a hacer el trabajo, ¿me entiende? Yo sabía como decir: ‘Lift this up’, ‘Paint the wall’, ‘I need the brush’, pero eso es todo.  Ahora, hace muchos años desde trabajaba y olvidé mucho del idioma. Puedo entender más a escuchar inglés. Pero tengo miedo hablarlo.  No quiero sonar como tonto.  

M: Le entiendo.  Es un problema que todas personas quienes aprenden una lengua tienen que enfrentar y de que tienen que superar.

                                                                        *

Whenever I go through something difficult or challenging in my life, it has always been helpful to know that-

1) I am not alone in the struggle—someone else is going through it,too  &

2) that other people have risen above the same struggles and succeeded

Of the many years I have worked with the Spanish-speaking patient population, no one has ever talked about his personal struggle learning English.  Yes, the patients have expressed gratitude to me for trying to communicate with them in Spanish, but they’ve never shared their own personal challenges learning and communicating in another language themselves.

I really appreciate my patient taking the time recently to document his own struggle: learning English vocabulary, using it and then forgetting it. Forcing himself to listen and use it – when he had to. But especially, his fears of sounding foolish when speaking it.  This fear he admitted is so powerful that it has kept him from even trying to use English. Sometimes, I think, pushing past this fear is more difficult than the language learning itself.

I completely understand this, because I have felt this way many times myself. There have been many days in the course of my Spanish learning that I have felt tongue-tied and frustrated. There have been times when I felt embarrassed, not wanting to look or sound foolish when speaking to a patient. And then there have been moments when I even felt a twinge of anger knowing I would have to use Spanish with my next patient, because I knew that it would mean a longer exam time (due to my slow explanations in Spanish) and potentially a more awkward exam (not always understanding everything a patient says to me, and not communicating fully everything I want to say and could so easily say, if I was speaking in English).   

I visited my husband’s family in Croatia for the first time in 2011. In Croatia, not surprisingly, the people speak Croatian.  I bought some Berlitz books for myself before the trip and gave myself a crash-course in basic Croatian phrases.  When I finally got there, I did well communicating, yes, until I ran out of basic phrases. And when his family spoke to me, well, anything beyond the bare minimum was tough to comprehend. And this doesn’t even include regional accents or dialects, which took the difficulty of the language to a whole new level.

It is daunting to be different.  To be thinking in one language, and yet speaking another.  To sound different. To know that even if I use every word correctly, my accent and mannerisms expose something that I’m trying to conceal:

That I’m not a native speaker. That I will make mistakes. That I will sound strange, maybe even a bit foolish. But it’s helpful to know I’m not alone in this struggle. And I know that my struggle is not in vain. Knowing my patients go through the same challenges too, well, this reassures me.  It makes me want to try harder, and it makes me want to encourage others when learning a language to try harder, too.

Dare to be Different, Mohonk Mt., NY

En la mezcla otra vez - Vuelvo al mundo de lenguaje

I just completed my first week in a new ophthalmology practice. In addition to meeting new people, seeing new faces and remembering new names, I quickly discovered that I had three languages on which I needed to brush up:

 

1) Plain language – the ability to explain medical jargon in clear, concise, lay terms

 

2) Computer language – in order to qualify for certain incentives, more doctors’ practices are embracing the use of electronic medical records (EMR). Unfortunately, EMRs are not universal throughout the U.S. Working in a new office means learning new software. 

 

3) Spanish language – after 8 months away from a real, live Spanish-speaking patient, the task of falling back into unstrained fluency is upon me and is daunting.

 

My first two Spanish-speaking patients were booked for standard full eye exams, so, easy to perform and easy to explain in Spanish. Neither patient had any particular pathology and neither was very talkative, so I didn’t have to worry about too much small talk ‘la charla’ while typing up their medical reports.

 

But as the days progressed, patients came in with problems. Concerns. Questions, in Spanish. And they came in with their individual accents and colloquialisms. And what I thought would be easy was hard all over again.

 

One woman had a long history of accommodative esotropia, but she didn’t use bifocals. She felt “better” when she wore distance glasses, but felt a “pulling” sensation in her eyes sometimes.

 

She had mild amblyopia.  She wanted to know if surgery could be done to improve her vision.

 

One man couldn’t remember his medications or his primary care doctor’s name. He had 20/60, 20/70 vision, refused to wear glasses, and wondered why he felt dizzy most of the time.

 

Another man asked why his eyes were always tearing. He thought it was because of his cataracts. He looked at me with an expression that indicated to me that he may not be taking me seriously. 

 

As I sputtered on and tripped over my explanations,  the patients listened to me, but not fully understanding what I was saying. I realized three main points:

 

1) When faced with giving an explanation in a second language, know what you’re saying in English first.  If you don’t know that, you won’t be able to say what you want in Spanish, either.

 

            Case in point: the White Dot Syndromes. How do you explain MEWDS to a young, healthy 22-year-old? Imagine what you’d say in English first. Think about it. Think about what makes sense. Then give your most concise interpretation in Spanish.

 

2) Familiarize yourself with the right vocabulary, and say it often enough so you’ll remember it.

 

            There are many disease states in ophthalmology that we just don’t come across often enough, for example, Susac disease, or Posterior Polymorphous Dystrophy. If we learn the vocabulary to use with one patient and never use it again, we will forget it. When you come across a less common eye problem and make the effort to explain it in Spanish, it’s worth writing down and keeping for future reference. It helps to use as a refresher when another patient with Sympathetic Ophthalmia walks through your door.

 

3) Always employ the approachable “plain language”.  ‘Side vision’ is more easily understood than ‘vision in the periphery’.

 

            Every time I see a glaucoma suspect patient, I want so badly to say, “your nerves look suspicious for glaucoma..”in Spanish, but I always forget the word for “suspicious” (sospechoso, incidentally, but after this I’ll forget if I don't use it), I lose confidence in my pronunciation of the word for ‘look’ (which translated would be the word “appear” or “aparece”). In the end, I find myself breaking the sentence down to the simplest explanation: “One optic nerve looks bigger than the other. This could be normal. This could be glaucoma.”   So choppy. So not me linguistically, at least in English. But just as the poet John Stone so eloquently put in his poem “He Makes a House Call”, medicine is what works. And so dialogue in a patient’s first language and a doctor’s second must do the same thing: what works. 

 

These are many concepts I’ve wanted to explain in Spanish, but struggled to do so clearly and concisely:

 

“It’s difficult to explain this, but the fact that your vision isn’t “crystal clear” is not all related to strabismus or the fact that you are hyperopic.  Since you have a fair amount of far-sightedness and astigmatism, and you had to start wearing glasses since 5 years of age and you admit that you did not wear them consistently, only “once in a while”, I suspect you have a level of amblyopia.  Amblyopia means that during the formative years, the visual part of the brain did not receive a clear image from each eye. This part of the brain stops forming when we are around 10 years of age.  After that, there is no surgery or eyeglass that can “force” the brain to see 20/20, when the best it can see is 20/30 or 20/40.  But  you are fortunate, because your amblyopia is mild. To be able to see 20/30 is great. Some patients with amblyopia can’t even see 20/400, which is equivalent to the big “E” on the chart.”

 

Is this plain language? Actually, no, it isn't. So why am I tripping myself up making it more difficult for myself and the patient? Maybe I should have thought about saying:

 

“Surgery cannot make your eyes see better. You did not wear your eyeglasses regularly as a child, and now the eye is lazy- it cannot see 20/20. But, your vision is still very good with your glasses. We can make the glasses a little bit stronger.”

 

“Cirugía no va a corregir la visión.  No se vestía los lentes regularmente cuando era niña, y por eso el ojo es un poco ‘perezoso’- Usted no ve 20/20. Pero, la visión es todavía muy buena con los lentes que tiene.  Podemos hacer los lentes un poco más fuerte.”

 

 

Or how about when I tried explaining why a patient’s eyes were tearing? I wanted to say:

 

“Your eyes are tearing because they are dry. I know this sounds strange (I know this is an oxymoron), but eyes tear as a reflex response to not having enough basal tears to cover and protect the cornea. I have to examine your tear film first to see for sure, but if this is the case, then likely you will need to use artificial tears regularly.”

 

But maybe I should have simply said:

 

“Your eyes are dry. They tear because they are irritated, but this is not normal tearing. You have to start using artificial tears regularly.  If you put a drop in each eye 2-3 x a day regularly, especially when you are reading, watching TV, using the computer, sewing, then the tearing will stop.”

 

“Los ojos son secos.  Están lagrimeando porque tienen molestia, pero no es lagrimeo normal.  Tiene que usar lágrimas artificiales regularmente.  Si ponga una gota en cada ojo 2-3 veces al día regularmente, especialmente cuando lee, mira la television, usa la computadora, cose, el lagrimeo va a parar.”

 

Better. I still want to use the word ‘oxymoron’ (el oxímoron, incidentally.  That can’t be too difficult to remember!)

 

Of course, the International Classification of Disease, Ninth Revision, prefers doctors speak in this type of language:

 

“You have 375.15, 365.0 and a touch of 368.03.” 

 

Statistical. Universal. Alas, impersonal.

The bottom line is that practicing medicine today is about more than simply practicing medicine.  It's about being fluent in, at minimum, three languages: the language of your patient, plain language and the software language to document the visit.  Maintaining fluency requires constant use. Language growth requires the patient encounter.

Adirondacks, NY