“The
limits of language mean the limits of my world.” – Ludwig Wittgenstein
El
paciente regresa a la oficina hoy para realizarse una visita de seguimiento
conmigo. Después de nuestra última
visita, le pide un examen con el cirujano de cataratas. Años atrás, el paciente perdió la visión en
el ojo derecho, tras de un accidente al ojo.
Sucedió una catarata traumática, pero, no sabía yo el alcance del daño
por la razón de él no vino con una copia de su médico historial. Sin esta
información, no sabía el estado de salud de la retina y, por eso, no sabía si fuera posible mejorar la visión
con cirugía para sacar la catarata.
Doctora (Dra.).: Leí el
informe del cirujano de cataratas. Se dice aquí que él ha decidido no hacer la
cirugía.
Paciente (P):Sí, lo sé.
Dra.: ¿Comprende usted la
razón para la decisión no hacer la cirugía para sacar la catarata?
P: Sí, pero pensé yo que, si
existe la posibilidad, no importa cuán remota, de que podamos mejorar la visión
con cirugía, entonces, me gustaría tomar el riesgo. ¿Me entiendes?
Dra.: Sí, pero quiero
explicarle la razón para la decisión.
P: Está bien.
Dra.: El cirujano recibió el
médico historial de su oftalmólogo en su país. Tengo el informe en frente de
mí. Se dice <leer las letras en la pantalla> ‘...sufrió el accidente de
un clavo dentro del ojo derecho, sucedió una ruptura del globo del ojo y un
desprendimiento de la retina’, él añade ‘...el paciente no tuvo cirugía para
reparar la retina..’
P: Sí, eso es lo que
sucedió.
Dra.: Aunque no hay una
agudeza visual escrita aquí, puedo decirle que, con un desprendimiento completo
de la retina años atrás, desafortunadamente, no existe la posibilidad de visión
viable en ese ojo.
P: ¿Cómo es eso?
Dra.: Dentro del ojo, las estructuras que son las
más importantes son el nervio óptico y la retina. Es por la razón de que ellos
transmiten información visual del ojo al cerebro. Si uno de ellos no funciona,
no importa lo que hagamos con las otras partes del ojo. Podemos reemplazar la
córnea, el cristalino natural (que es la catarata) –pero eso no va a cambiar la
visión, porque la línea de vida del ojo, la retina, no funciona.
P: Sí, la entiendo. Pero
tengo una pregunta. ¿Es posible, un trasplante de la retina?
Dra.: <pensar,
pensativo> Hmm. Bueno, hay experimentos ahora...los médicos están trabajando
a encontrar un proceso para crecer de nuevo o reemplazar la retina. Pero ahora,
desafortunadamente, son solo eso: experimentos, en las etapas tempranas. Tengo
la esperanza de que, en el futuro, vamos a ver la posibilidad muy real de un trasplante
de la retina.
P: Entonces, voy a continuar
a esperar, a tener esperanza. Mientras hay esperanza, hay también la posibilidad
de que, algún día, utilizaré el ojo otra vez.
Dra.: <sonreír> Sí,
hay siempre la esperanza, y el trabajo para realizarse los resultados de la
esperanza.
*
As you
have noticed, many times when I write my blog entries in Spanish, I leave them
in Spanish, sans translation in English. I choose to do this because it represents
my everyday experiences in the office. There is no interpreter when I talk to
patients. There is no translation for their words or my instructions. What
happens is very real, raw, and always represents a learning experience.
However,
I want to translate this particular conversation I had with a patient one day
to emphasize a point. I work with other doctors in the medical community at
large who do not share my same passion for learning to communicate in Spanish
with patients. Sadly, it’s easier for many of these monolingual
English-speaking physicians to examine Spanish-speaking patients because they
don’t talk to them (because they can’t, there’s a language barrier). This means
they can get through the exam faster and they don’t have to bother answering
patient questions because the patients can’t ask any – they won’t be understood.
Exams are completed in mere minutes and very sadly, many patient concerns go
unanswered and unaddressed because there is no communication. The patient may
feel embarrassed to push to be understood because they don’t know English or
have a rudimentary understanding of it. And there are some doctors who take
advantage of this. These doctors are not
only not providing the standard of
care for these patients, but at a very basic level, they are missing out on
truly hearing these people: what they
have to say, their thoughts and fears. This is a grave loss for everyone
involved in this patient’s care.
In the
above scenario, I had referred my patient to a cataract surgeon, not yet
knowing the historical details of the accident the patient had in his eye years
ago. I thought, if there is a possibility of vision improvement by removing the
traumatic cataract, then I wanted the patient to have the opportunity to
explore this option. By the time the patient’s appointment with this cataract
surgeon (who does not speak Spanish) came to be, the ocular records were
finally received from the patient’s ophthalmologist in his home country. The cataract surgeon learned that the patient’s
eye trauma included a completely detached retina in the right eye, which was
never repaired. Knowing there was no chance for visual potential in that eye,
the surgeon opted not to perform surgery. This is entirely acceptable, but what
bothered me was the extreme brevity and detachment in this surgeon’s note:
(of importance, the following lines are me
paraphrasing the gist of the note, I am not transcribing verbatim here the
actual patient note!):
A/P: h/o ruptured globe right eye, with complete retinal
detachment, unrepaired, and traumatic
cataract.
No visual potential. Not amenable
to surgery.
Interpreter explained to patient.
The
surgeon didn’t take patient questions, there was no explanation to the patient
why such a retinal detachment can’t be repaired now, so many years later, and
the surgeon didn’t have to break the bad news himself at all- an interpreter
did. A quick 3 minute exam, 5 minutes tops, but all the patient’s hopes were
riding on this exam.
After
speaking myself with the patient, I could see he didn’t understand why this
type of trauma could not be repaired and I explained this to him in Spanish.
The patient was then able to pose well thought-out questions to me such as, whether or not
retinal transplants exist and if that would be an option for him. You can read
my continued explanations to him in my translation, but my point is simply that
this patient deserved more attention from the surgeon. Now, it is possible that this surgeon is short
and gruff with all his patients, English-speaking, Spanish-speaking or
otherwise.
However, I have seen this many times before, particularly when a
doctor does not speak the patient’s language, it is easier for the exam to be
done in minutes and pass any explanations off to an interpreter.
In my
opinion, you, as a doctor, can’t avoid the tough questions by claiming not to
understand the questions. If you are treating a patient population that speaks
a language other than your own, then you are obligated to understand and be
understood, and to take whatever extra time is needed to ensure that.
*
The patient returns to the office
today for a follow-up exam with me. After our last visit, I had requested for
him an exam with a cataract surgeon.
Years ago, the patient lost the vision in his right eye after sustaining
an accident to the eye. A traumatic
cataract resulted, but, I didn’t know the extent of the damage because the
patient did not come with copies of his medical ocular history. Without this information, I didn’t know the
state of health of the retina, and as a result, I didn’t know if it was
possible to improve the vision in that eye with cataract surgery.
Doctor
(D): I read the cataract surgeon’s report. It says here that he has decided not
to do the surgery.
Patient
(P): Yes, I know.
D: Do
you understand the reason for this decision not to do surgery to remove the
cataract?
P: Yes,
but I thought that, if there is the possibility, no matter how remote it may
be, that we can improve the vision with surgery, then, I would like to take
that risk. You understand me?
D: Yes,
but I want to explain to you the reason for this decision.
P:
Fine.
D: The
surgeon received your medical record from your ophthalmologist back in your
home country. I have the report in front
of me. It says <reading from the
screen> ‘...he suffered an accident of a nail to the right eye, resulting in
a ruptured globe and a retinal detachment’,
he adds, ‘...the patient did not have surgery to repair the retina...’.
P: Yes,
that is what occurred.
D:
Although there is no visual acuity written here, I can tell you that, with a
complete retinal
detachment so many years ago, unfortunately, there is no
possibility of viable vision in that eye.
P: Why
is that?
D:
Inside the eye, the structures that are the most important are the optic nerve
and the retina. It’s because they
transmit visual information from the eye to the brain. If one of them doesn’t function, it doesn’t
matter what we do with the other parts of the eye. We can replace the cornea, the natural
crystalline lens (which is the cataract) –but we are not going to change the
vision because the lifeline of the eye, the retina, isn’t functioning.
P: Yes,
I understand. But I have a question. Is
a retinal transplant possible?
D:
<thinking, pensively> Hmm. Well, there are experiments now...doctors are
working to find a process to grow a new retina or replace the retina. But for now, unfortunately, they are only
that: experiments, in the early stages.
I have hope that, in the future, we are going to see the very real possibility
of a retinal transplant.
P:
Then, I am going to continue to hope, to have hope. While there is hope, there is also the
possibility that, one day, I will use the eye again.
Dr:
<smiling> Yes, there is always hope, and the work to bring about the results
of that hope.
 |
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