A Thousand Words is Worth a Thousand Words

Blefaritis

1-Tenga que limpiar los párpados cada mañana y noche con una toalla tibia.

2-Tome 1,000mg de Omega-3 (dos píldoras con la comida).

3-Ponga dos gotas de lágrimas artificiales en cada ojo dos veces al día.

One of the topics that I repeat ad infinitum in this blog is that, no matter the language or the culture, people are people.  We are all subject to the same concerns, fears, questions, hopes. We all have the same goals as patients—we want to stay healthy, be well and are willing to do what we must to keep things that way.  Ophthalmology patients want the best for their most important sense: they want to see the sharpest, maintain their vision, and continue with their daily routines sans eye irritation or discomfort. They of course have concerns, having an understanding of what conditions like ‘macular degeneration’and ‘retinal detachment’are-- they want to make sure such vision-threatening diseases are preventable or at the very least, caught early and treated.

It’s alot to think about, and as a patient in a doctor’s office (a place where many people have a low-lying level of nervousness to begin with), sometimes it is difficult for the patient to A) remember all the questions he want to ask his doctor and B) listen to and remember all the doctor is telling him regarding his diagnosis and instructions for treatment. And this is assuming that the doctor is explaining things in plain language.  If technical medical jargon is being used, then this adds an extra element of confusion to the mix for patients.

I have found time and again since my third-year medical school clerkship days, that even when I explain in my native English a patient’s diagnosis and treatment to a native English-speaking patient, many times in the end my patient will still have difficulty remembering everything I’ve said, let alone the steps to take to treat the condition. I make every effort to use plain language and not medical terminology. I take as much time as necessary to explain everything and answer all questions to my ability. Yet, when I ask the patient to repeat back to me what her understanding of her eye condition is and how I want her to proceed with the treatment regimen, many times she can’t do it! She nods her head in understanding, but in the end she still does not fully remember everything I’ve said. As I mentioned earlier in this post, most of this has to do with a certain level of anxiety the patient may be experiencing, in addition to having to take in a large amount of new information which, honestly, takes time to digest.

Think about it—if this happens, and it does frequently happen, in my native English language, imagine how much more convoluted and confusing the story gets when I am attempting to explain the same diagnosis in my secondary language of Spanish! Sure I have a professional fluency, but it is not native level, and the native Spanish-speaking patient is therefore subject to my personal interpretation, my accent, and my linguistic angle of his language. –Eso es decir, hablo el idioma bien, pero no soy un hablante nativo de Español, y estoy segura que hay veces cuando mis frases suenan extrañas. –>Maybe even this sentence!  When speaking or listening in a non-native language, there will always exist misinterpretations or confusing elements. Add to this scenario the usual time crunch in a busy clinical setting, and we have the perfect storm which can result in a patient leaving the office frustrated and not fully understanding his/her diagnosis and what to do about it.

To make life a little easier and clearer, what I like to do is have written material available in Spanish which I can give to the patient at the end of his visit.  This serves as a take-home reminder of what we discussed in the office. The American Academy of Ophthalmology is one of several sources that offers  brochures on their website which thoroughly cover a variety of eye diseases in Spanish (see below for link).  However, I find that sometimes, such information is a little bit too lengthy.  Even written information, when given in too large a quantity, becomes a giant ocean where the main points are lost.

During my residency, when the time crunch really really mattered, I became master of writing out instructions on small pieces of paper or index cards of the most common eye maladies I treated: dry eye, blepharitis, corneal abrasion, bacterial keratitis, open-angle glaucoma, metallic corneal foreign body removal, the list goes on and on. I would photocopy them and hand them out at every opportunity.  I did this in both Spanish and English, and I opened this particular blog entry with an example of my “Blefaritis” treatment information card.  A little extra work to prepare these went a long way in driving home understanding of the disease and/or treatment. It meant the difference between seeing a patient at follow-up who was fully recovered versus the patient who was still suffering because he/she couldn’t remember how many times a day to use the drops.

Of course, some patients returned the next visit having lost my cards, but I would hand them another copy and we’d start all over again!  In the end, it’s about doing all you can to make sure there is an understanding between doctor and patient, regardless of the language in which you communicate.

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American Academy of Ophthalmology Patient Education Brochure link:

http://www.aao.org/practice_mgmt/patient_ed/brochures.cfm

The Adirondacks, NY

 

Más que Enfermedad ~ parte de una familia y una comunidad

Doctor: (después del examen de los ojos) Ud. tiene algo se llama “ojos secos” . Es por eso tiene ojos rojos, que le pican y le molestan, especialmente cuando está afuera en el viento. No tiene infección.  Parte del problema es que su glándula lacrimal—la glándula que produce las lágrimas—no está produciendo bastante lágrimas para mantener la tela de lágrimas en la cornea. Es por eso está parpadeando a menudo. Pero, la otra parte del problema es que, los medicamentos que usa para el glaucoma, bueno, algunas de esas gotas tienen preservativos y es el preservativo que está contribuyendo a su molestía.

Paciente: Recuerdo cuando era niña, mi mamá tenía, un ungüento que ella se lo pondría en mis ojos cuando yo tenía ojos rojos. No sé lo que tenía yo, pero el ungüento funcionaba cada vez.

D: Bueno, no puedo decir lo que tenía durante ese tiempo pero, puedo decirle que en este caso una crema no va a ayudarle. Necesitamos cambiar sus medicamentos para el glaucoma.  Va a necesitar gotas que no tienen preservativos.  Entonces, debes empezar con una gota artificial—es un lubricante--dos o tres veces al día en cada ojo. Hablando de su glaucoma, la presión de los ojos es alta hoy.  ¿Por qué? 

P: Acabé la gota.

D: ¿Acabó que? ¿--su medicamento para glaucoma? ¿Cúando?

P: Sí. Hace tres meses ahora.

D: ¿Por qué no llamó para la recarga?

P: No sabía que—que necesitaba continuarlo.  Es muy difícil para mí, tengo sólo una hija, y ella no vive lejos de mí, pero, nunca me ayuda con nada. Necesito ir de compras para la comida, pero ella nunca es disponible para ayudarme. Es muy difícil. Vivo solo, es muy difícil.

Just to quickly summarize this interaction I had one day with a patient, I was explaining to her that her eyes are red because they are dry, partially due to age and partially due to the preservatives in the glaucoma drops she was using. Many patients with red eye think they have an infection, and this woman was no exception. She recalled a “salve” her mother used to give her as a child which she remembered as a “cure-all” for any eye problem she had. The way she spoke about it showed she had real confidence in it as a treatment.  

Later in the conversation, I came to discover that she was not taking her glaucoma medications as prescribed. She used them until she finished them, and then did not get refills.  When I ask her why, she began talking about the relationship she has with her daughter and how disappointed she is with it.  Her daughter lives nearby, but according to my patient, never seems to make the time to go spend with her mother.  

Medicine is never simply about medicine. It’s about the whole person.  It is important to take into account a patient’s strong beliefs concerning home remedies because it’s less about the remedy itself and more about the fact that it’s tied into the patient’s past— in this case, her mother.  I never try to immediately dismiss the use of home or folk remedies, which may give the patient the sense that I don’t feel her personal experiences are important.  However, that being said, if the “treatment” is outright dangerous or potentially damaging (case in point: I had a patient once state that she believed in using diluted Boric acid to clean her eyes!) I will indicate my concerns to the patient.    Many patients share this common trait: the belief that family-taught treatments have great value, and the Latino patient is no exception to this.

From my experience working with the Spanish-speaking Latino community, the family unit and multiple family units which comprise the community at large, are central to every person’s well-being. In other words, I have worked with patients who, even though they are medically well and/or stable, do not perceive their status as “good” if all is not right with the relationships they have with family and community.  Conversely,  a patient who is not doing well health-wise is still empowered by the love and support of his family.

The article “Caring for the Latino Patient” from the January 2013 issue of American Family Physician, reiterates the importance of recognizing certain aspects of the Latino culture in the clincal health care setting.  These include personalismo (friendliness), respeto (respect) and simpatía (kindness). Personalismo relates to the importance of family and closeness of society in the  Latino culture.  Respeto refers to the respect that is given to people based on their age or  status within the family and/or community.  Simpatía refers to treating one  another kindly and considerately, essentially, treating our neighbor as we would wish to be treated ourselves.  Understanding and recognizing the importance a patient places on this qualities is crucial to us as physicians because incorporating them into our daily practice results in successful treatment of the patient. 

Going back to my patient above, if I chose to ignore my patient’s concerns about her relationship with her daughter because that has no bearing on glaucoma treatment, I am actually doing a disservice to myself and the patient. If I instead provide a listening ear, I begin to realize that to her, ‘wellness’ has more to do with stability and happiness in her family life, and less to do with an eyedrop schedule.  Sharing a little bit about my own family also goes a long way in relating my understanding, my own personalismo, to my patient:

D: Entiendo lo que dice. Mi madre vive cerca de mí, y estoy preocupada de ella porque ella tiene problemas médicos, pero ella no le gusta ir a su doctor.  Ella tiene—de hecho—siempre tenía, un temor  del “mundo de medicina”, y por eso, ella elige quedarse en casa y no busca la ayuda de médicos. Tal vez, no estoy de acuerdo con su elección a continuar sin el consejo de médicos, pero la amo a ella. Estoy aquí a soportarla y ofrezco ir al médico con ella si un día ella decide hacer una cita.

P: Sí, es muy difícil cuando se preocupa de un otro.

D: Sí. Comprendo que probablemente está frustrada con su hija. Usted quiere que ella pueda hacer más tiempo para Ud. en su vida. Y, pienso que vale la pena a hablar con ella una otra vez en el futuro. Pero, no importa lo que pasa, no es un pretexto a  no cuidarle a su propia persona—su salud o su visión.

P: Le entiendo.

D:  Y, imagino estaría difícil a mantener un horario de gotas, medicamentos, cuando tiene preocupaciones de otras cosas. Le prometo que podemos trabajar, juntos, a encontrar una manera en que es un poco más fácil a recordar el horario de gotas.  Entonces puede continuar con su vida diaria sin problema.

References

Juckett G MD. Caring for Latino patients. Am Fam Physician. 2013;87(1):48-51.

                                                                    

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