Tuesday, January 28, 2014

The Art of Convincing



Me: ¿ Se dice aquí que no está usando las gotas para glaucoma?

Patient: Sí.

Me: ¿Y por qué?

Patient: Bueno, estaba usandola, pero se acabó, y no llamé la farmacia.

Me: Pero, ¿no sabe que las gotas son importantes para mantener la salud del ojo? Ellas controlan la presión del ojo, y así protegen el nervio óptico.

Patient: Entonces, ¿dice que tengo que continuar con la gota?

Me: ¡Sí!  Si no está tomando la gota, la presión en el ojo crece y va a dañar el nervio.

Patient: Bueno, si Ud. me dice que necesito la gota, voy a usar la gota.

Me: Aquí. Permítame enseñarle lo que está pasando con el “campo visual” de los ojos.   Aquí tenemos el campo visual que hizo en Octubre de 2010.  ¿Puede ver que tiene –es casi una sombra—que está creciendo en el campo visual del ojo derecho?  Ahora, compararé el resultado de 2012....así, puede ver, que esa sombra en el ojo derecho ha crecido mucho más.  Está acercandose su visión central. Y eso es peligroso, porque si lo afecta la visión central, entonces, Ud. va a perder la visión completamente.

Patient: Es porque, bueno, me siento bien. Veo bien


I want to stop here to focus on the last few words this patient said to me.  I had this conversation with a glaucoma patient of mine one day during his regular office visit. I had been trying to reiterate how important it is that he continue his glaucoma drops.  I know a picture is worth a thousand words, so I pulled out his visual fields to compare the results over the last 2 years. Despite this, and despite being told that he will lose his vision altogether if he does not take his drops daily, the patient still said to me, “But I feel OK.  I see well.”

This is so important to talk about, because it is a continuous theme in the medical field:  that if a patient doesn’t feel anything, ie pain, or notice any blurry vision, then he thinks that everything is “OK” and there is no need for medication.  There are a few concepts that must be taken into account:

1)      It is hard for patients to believe something is wrong when they feel no pain and see no vision change.
2)      It is hard to convince patients that a disease can affect their body and show no signs until it is too late.
3)      It is hard to get patients to accept the concept of prophylactic treatment—or treating a disease before it has caused damage.

Essentially, it is hard to get patients to spend money on a medication and to adjust their lifestyle to taking the medication -- when they feel well and see well -- for a disease they may or may not have...yet. 
And it is hard to do this in our primary language.  Compound this with having to explain and convince in a non-mother tongue, and it is twice as challenging.


Me:  Sí, Ud. ve bien—es verdad—ahora .  Pero, con glaucoma, desafortunadamente, en el momento cuando se da cuenta que tiene un problema visual, es demasiado tarde hacer algo. 

Patient: (escucha en silencio)

Me: Permítame darle un ejemplo. Es como, cuando una persona tiene presión alta de la sangre.  Ud. sabe que la presión alta daña el corazón. Bueno, la mayoría del tiempo cuando una persona tiene presión alta, él o ella no lo sabe, porque no hay dolor.  Eso es por qué es importante a tener exámenes regulares con su médico de familia. El médico toma la presión, él ve que es alta y él empieza una píldora a controlar y bajar la presión.  Usted no se siente nada, pero él está salvando el corazón...y la vida.

Patient: Entiendo. 

Me: ¿Tiene preguntas para mí?

Patient: Es que, el medicamento es caro, vivo con un ingreso fijo y es difícil a comprarlo. También, estoy ocupado durante el día—tengo que ir de compras, que visitar familia, que pasar el tiempo en el parque. A veces, olvido pocas gotas.

Me: Bueno, hay marcas diferentes de las gotas que usa—puedo ver si su seguro cubre una u otra—para bajar el precio.  Y sí, a tomar cualquier medicamento requiere un poco cambio en el estilo de la vida.  Pero, esta gota que usa ahora, por ejemplo, necesita que usarla dos veces al día. Entonces, para recordar cuando tomarla, puede asociar el uso de la gota con una actividad diaria. Cuando se desayuna, use la gota. Cuando come la cena, use la gota. 

Patient: Sí, puedo hacer eso. Le entiendo.

Me: Está bien. OK—escribo una receta para esta gota—una marca diferente—pero la frecuencia es la misma, dos veces al día. 

Patient: Está bien.

Me: Regresará para una otra cita en cuatro a seis semanas para tomar la presión del ojo.

Patient: Gracias. 

Me: De nada. 

Constant reinforcement and reiteration of why a treatment is important are essential to improving patient compliance in any language. Incidentally, taking the extra time to explain the necessity of a treatment sometimes brings out other reasons why the patient let his treatment lapse.  In this case, the gentleman explains that the medication is costly and he admits to forgetting to use the drop during the day. Finding  less costly alternatives and a simpler dosing schedule help keep a patient compliant--and put him on the road to a lifetime of healthy eyes.

 
Courtesy: D. Hromin









Thursday, January 23, 2014

New Year New Vocabulary



Whenever I read Spanish, I always make a list of the words I don’t know when I come across them.  Despite this blog being medical-Spanish focused, I want to share a vocabulary list I recently created of everyday words, legal terms, descriptive vocabulary and colloquial phrases etc that I found reading newspapers and articles in Spanish.

Every little bit of information helps. Necesitará tiempo para memorizar todo pero, recuerda, ¡SÍ, Se Puede! 

Ponencia - paper (research paper)
Pitonisa - fortune teller
Tejemaneje - monkey business
Garapiñado - sugar coated
Columpio- swing (at a playground)
Entrometido - meddler
Nuera(o) - daughter in law(son in law)
 Estás de coño? - Are you kidding me?
Ejote/judía verde - greenbean
Ñame/batata/camote - yam
Carmelizada - candied
Cobijo - shelter
Estar de guardia - to be on duty
Carencia - lack
Estar de nuevo - to be again
Reemplazar - replace
Borrar - delete
Palo- branch                 
Rayar- to scratch                           
Desmenuzar - to shred
Rallador - grater
Portavoz- spokesperson
Rama - branch (tree branch)
Féretro - coffin
Rescatar- to rescue
Pateras- boats
Ahuyentar - to frighten
Enterarse - to find out
Cuero cabelludo - scalp
Remedio casero - home remedy
Vuelta de la esquina - around the corner
Rebasar - to exceed
Rebosar - to overflow
Enchufar - to plug in
Desconéctese - to disconnect
Arañar - to scratch
Machacar - to crush/grind
Lamer - to lick
Requiebro(requebrar) - compliment(to woo)
Piropo - compliment
Se niega a dimitir - refuses to resign
Dejar ir - to let go
Trastorno - disorder
Reto - challenge
Atemorizar - to terrify
Enfurecer -to enrage
Proyectar - to project
Agudeza - (visual) acuity
En polvo - powdered
pestañas postizas - false eyelashes
adelgazar - to thin
hojuela - flake
vínculo - link; tie
cacahuetes - peanuts
nitidez - sharpness
tuitear - to tweet
bloquear - to block                               
haquear - to hack
etapa - stage
reposo - repose/state of rest
influjo - influence
grosor - thickness
al fin y al cabo - when all is said and done
colirio - eyedrops/eyewash
lupa - magnifying glass
encandilar - to dazzle
amenza - threat (n)
truco - trick (n)
pleonasmo - pleonasm
adelgazar - to thin
zarpar-to sail   
dejar a alguien plantado - to stand someone up
marfil - ivory
abultamiento - bulge (ie orzuelo/chalazión)
Quitarse a alguien de encima- to get rid of somebody

Courtesy: D. Hromin

Monday, January 13, 2014

No lo olvides



I had mentioned early on in this blog that I started my Spanish studies at a relatively young age—10 or 11 or so—in school.  Over the years, from elementary to high school to college to graduate school, I experienced a slow but steady increase in my Spanish vocabulary.  I say “slow” because Spanish was something that I encountered in the educational setting and nowhere else.  I didn’t hear it or speak it at home. I didn’t listen to it on the radio. I didn’t watch it on TV. I didn’t speak it among friends.  I didn’t read it in the newspapers.   So, perhaps it’s not so surprising that, when I had to really start using it—as a tool for communication with patients—the words didn’t come out so smoothly.  And there was definitely some brain-ear-mouth disconnect which I had to fight to get past, when trying to listen to the patient speaking Spanish, trying to understand, trying to formulate a response and trying to make that response intelligible enough to be understood.

Communication eventually became easier, and once I added medical vocabulary to the mix, I achieved what I call a professional fluency in Spanish.  But I’m thinking about this now, because currently and for a temporary period, I am not working clinically. My exposure to Spanish speaking patients, at least for the time being, has stopped. I worry about this because –without taking into account the formal studies of how a person acquires a language secondarily or how one’s age affects that acquisition—I can honestly say from experience learning Spanish over the years, that less exposure leads to less ability in the language over time.

People have differing opinions on this, and I can only give my opinion based on my life experience. The reality is that for me, English is written on more than just the mind. I don’t think about it when I speak. It’s something I feel, it’s at the very core of me.  Words aren’t really words, but feelings.   Spanish comes in at a close second, but “close” is not close enough. If I don’t maintain a relationship with the Spanish words, whether visually or orally, then I forget them.  And it’s not something that happens all at once.  At first it’ll be words I rarely use, like the words for certain foods or colloquial phrases. Then it will be problems remembering placement of accent marks or the spellings of Spanish text. Next medical vocabulary in Spanish will become more difficult. Last, even the sentence structure of very basic conversational phrases will be affected.    I do not want to let this happen, after so many years of hard work to make this language a part of my life!  But I know it can happen if I let it, because there were times I can remember, particularly after college and before medical school, that I let my Spanish exposure slip a little, and when I had to start working with patients, it was like starting all over in the language again.

Fortunately, with 38 million people in the United States that speak Spanish – according to the recent US Census – there is no shortage of resources for me in an effort to keep my knowledge alive.  It really is just a matter of making the initiative to review and read every day. I want to provide you with some resources I find particularly helpful in keeping myself and my Spanish, up to date. 

I enjoy online newspapers, particularly: 

http://www.elmundo.es/   for global news

http://msnlatino.telemundo.com/  for mostly entertainment news
Online newspapers are great and so easy to access—I just read the pages on my computer or my Ipad during my down time.

If you’re looking specifically for ophthalmology related sites, the following are excellent for plain language based explanations for patients regarding various eye conditions :

http://www.sao.org.ar/index.php/informacion-para-pacientes/patologias-y-afecciones/alergia-ocular  patient-focused information (de la Sociedad Argentina de Oftalmología) on various eye diseases

http://www.geteyesmart.org/eyesmart/espanol/  available from the American Academy of Ophthalmology, a patient-focused website on various eye problems

For non-ophthalmology, general medical and health care information, I use:

http://www.howto.gov/web-content/multilingual/spanish-guide/health-care-terms  a great site for Spanish health care terminology

http://www.healthinfotranslations.org/  In 18 languages, including Spanish, this site was put together through a collaboration of Ohio State University, Mount Carmel, Ohio Health, Central Ohio Hospital Council and Nationwide Children’s Hospital. It offers various topics that enable you to talk to your patient in his/her language. For example, one topic is Home Care. Under this tab, you can find numerous instruction pamphlets including How to Care for a Foley Catheter. You get side by side translation of the materials in English and your language of choice.

Finally, I want to remind everyone reading this that for practice in any language, you can find someone anywhere around the globe via www.mylanguageexchange.com    You can exchange emails together, or Skype or both. Not to mention, you can make friends from different parts of the world with the same goal you have: to learn a language and bridge the linguistic gaps.  

To keep a non-native language alive and well in your mind takes a little consistency and initiative, but to have that ability to communicate with the extended world around you is well worth the effort!

Food & Wine Festival, Zadar, Croatia 2011




Wednesday, January 1, 2014

Auld Lang Syne



Me: Hola. Soy Dra—Puede sentarse en esa silla azul.

Patient: ¡Oh!  ¡Hablas español—qué bueno!  Dios te bendiga---ohh, tengo muchos problemas mi’jita, me hicieron cirugía en la rodilla, estuve en el hospital por una semana, después, una facilidad para terapía...ahora puedo caminar,pero, ves aquí (motioning toward her knee and leg)no puedo doblar muy fácilmente, y camino lentemente...no tengo nadie para ayudarme en casa.  No puedo ir de compras, no puedo salir de mi apartamento, ¡ojalá que Dios me de la fuerza para continuar!!!

Me:  Lo siento oír esto, espero que Usted esté bien, pero una pregunta, ¿cómo están los ojos? 

I remember during one particular class in medical school, an instructor brought a patient actress into the classroom.  He and the actress were simulating a patient visit for us.  He asked her the reason for her visit, in an effort to elicit the chief complaint.  But, this woman never answered him directly. She never really told him why she was there, why she had scheduled an appointment. Her throat wasn’t sore.  She had no headache.  No backache.  She wasn’t  gaining weight or losing it.  She seemed perfectly fine and content, just to sit right there on the examining table and went on and on about personal goings-on in her life. She talked about anything and everything else: her family, how she keeps busy, friends who have visited, an old surgery she had years ago. She said how wonderful it was to be married for 63 years, to her high school sweetheart, and how she doesn’t really travel anymore, since she lost her beloved more than two years ago now. 

When the demonstration was complete, the instructor turned to us, the students, and asked the real purpose of this ‘patient’s’ visit. I answered that there was no purpose. There was no chief complaint. She was there for attention, for company, for friendship—whatever, but she wasn’t there for anything that could be treated with anything other than a listening ear and a concern for her as a human being.

I went to Pennsylvania State University College of Medicine and at the time of my attendance Penn State was among the few pioneering schools that used patient-actors in an effort to simulate real-life patient encounters for the medical students.  I didn’t realize the great value of this particular demonstration at the time.  I wouldn’t recognize the value—and the truth—of this scenario until years later, when I myself was seeing and treating patients. 

I remember being a busy resident in NYC along with one, maybe two other residents, and having to race through 60+ morning patients before rushing off to the midtown clinics in the afternoon where another 60 would be waiting for us. In order to get through each exam in a timely fashion—and get to the afternoon session on time—I  had to focus on the physical exam and little else. Very little room was left for conversation.  You can imagine what a monkey wrench in the works it would be, to have a patient come in and contentedly review his life story, when asked why he came to the clinic that day. I would try to redirect the patient, but a patient who’s there for company and conversation doesn’t leave the normal pauses between the sentences of speech.  Pauses mean a chance for redirection to the task at hand, and a patient who is there for company doesn’t want to let that happen!  As a novice doctor and overworked resident, frustration was a theme regularly experienced.

That was over ten years ago. Now, I get it. I know that there are patients who come for more than just a diagnosis and medication. I know that some, many, come for caring. For attending to. For concern. For an ear to listen and not much more. And the English speakers do this, y personas quiénes hablan español.  And it’s OK, because we as human beings are social beings who must share our concerns every now and again, not all of which can be contained in a ten minute examination. 

Patient: Mis ojos son sanos. Aunque, están lagrimeando cuando miro la televisión, o cuando voy afuera de mi casa. Pero es difícil ir afuera, como te dije antes, con mi rodilla así, y, bueno, cuando no tengo nadie en mi familia quién vive cerca de mí, es casi imposible encontrar la ayuda que necesito.  También yo le cuido a mi nieto de vez en cuando, pero ahora no puedo porque no puedo mover la pierna fácilmente.. y él estuvo enfermo, tiene cinco años ahora,-- ¿Te dije ya cómo él se enfermó?—le pasó a él en la escuela....

I always take a few extra minutes to listen because sometimes, the listening is the most effective treatment of all. 
 
Optika u Zadru