Preferred language

Yesterday, before I called a patient into my office to begin the eye exam, I looked over the intake forms he filled out. Under the section where it said “preferred language”, he had checked “Spanish”. So, when I went to collect him from the waiting area, I greeted  him in Spanish. I brought him to the exam room and had him sit down. I started my usual Spanish dialogue of, “Está aquí por un examen completo de los ojos. La enfermera escribió aquí que necesita usted lentes nuevos, particularmente para leer, y también que tiene un diagnóstico de la diabetes, y necesita un examen de la retina,” and so on and so on. He answered me in English, “Yeah, my glasses are two years old and I need new ones. My doctor wanted an exam of the eyes because of the diabetes.”

His English was good and he continued speaking it, so I changed to English and onward the exam went. But I wondered, why did he start speaking English at all? Especially when he had checked off that his preferred language was Spanish? It’s not like he spoke in English to everyone else in the office. After I finished the exam and he brought the coding sheet out to the front desk to schedule his next appointment, I could hear him talking and joking in Spanish to the front office staff, who happen to be Latinas from the Dominican Republic.

This situation has been happening more often lately, and it just has me thinking, why? Is it because I’m a doctor, and these patients want to show someone who they perceive to be an authority figure that they are capable of conversing in either language?

Is it because they see me, a non-Latino person, speaking very good but not perfect Spanish, and would rather communicate with me in what they assume is my native English?

Is it due to the recent political climate--the random deportations of illegal immigrants--creating a fear in these patients that they feel the need to show that they do speak English well, and are a permanent part of American society?

Is it simply that they want to flex their English-speaking muscles, while I flex mine in Spanish?

I turned to a simple, but sometimes vacuous source for more information: Google. I searched, “Spanish-speaking patients who feel the need to speak English at the doctor’s office”, or something along those lines. Not many relevant hits came up.  The closest situation was one where a man, who was learning Spanish, described his frustration that every time he would try and practice his Spanish with Latino restaurant workers, they always answered him in English. Someone angrily answered his query, saying that it’s rude and racist to assume that just because someone is Latino, that he automatically should speak and be spoken to in Spanish. Well, I can just as quickly say, don’t assume just because someone is non-Latino that he doesn’t speak Spanish. You may find out quite readily that he does, if you give him a chance to speak.

I grew up in the 1980s. Back then, you could honestly and innocently do something or say something, without the observer or listener automatically assuming that you had racist or malintent.  What is so wrong with encountering a person, hearing that she has a heavy Spanish accent, and trying to converse in Spanish with that person? Is that racist?

 Nelson Mandela once said, “If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”

Therefore, can’t it simply be that you are trying to make a more personal connection with that individual, by speaking in his native language? In my particular situation, I work as an ophthalmologist in an office in the northeastern United States. It happens to be situated in a community of mostly Spanish-speaking people, many of whom who only emigrated to the US within the last few years. That being said, I do not go out into the waiting area and start speaking Spanish when I see a Latino patient. At the same time, there have been many Latino patients I approach greeting them in English, and they give me the look of any person who does not understand spoken English: one of confusion, dismay, even fear. I don’t want dismay and fear to be the first impressions that a patient has when coming to my office. I don’t want the patients to think that they will have a language barrier with their doctor, and therefore will not get the help they came to receive.

So, I look to the intake forms. If someone marks off Spanish as preferred language, I greet her in Spanish. I allow the patient to choose to either continue in Spanish or not. If she continues in English, then I will follow her lead. If I happen to greet a patient in English who indicates preferred language as English, but I see right away that he is having trouble understanding and/or communicating with me, I’ll ask,

“¿Qué es lo que prefiere usted—inglés o español?

and if he says,

“Prefiero español, gracias.”, then so be it, and onward the conversation takes place.

I’m very flexible as far as the way I run my practice. The goal of any doctor –patient dialogue is clear communication. The language choice is simply a means to an end, and shouldn’t mark the end of meaningful conversation.

Death Valley National Park 2016

  

Una conversación con un paciente

Doctora: (al mostrar a la paciente y a su hijo al cuarto) Por favor, siéntese ahí, (mira el hijo) y hay una silla para usted en el lado.

Paciente+hijo: gracias.

D: Ok, leí la información que trayó – sus antecedentes medicos – esta información me ayuda saber la historia de sus ojos y el cuidado –lo que proveía su medico en Puerto Rico.

P: De nada.

D: Veo aquí que usted recibió un diagnóstico de glaucoma hace algunos años ahora, y que está utilizando la gota latanoprost – una gota cada ojo por la noche.

P: Sí. One drop in each eye at night.

D: Bueno, la presión hoy es alta- 25,26-necesito revisar la presión con esta máquina, la lámpara de hendidura- es el estándar dorado para revisar la presión del globo del ojo.

Hijo a la madre: Ella quiere revisar la presión con—

P al hijo: Sí, la entiendo. I understand.

D (hace el examen, revisa la presión y el nervio óptico, acaba el examen y da vuelta para afrontarlos)

El tamaño de nervio óptico es pequeño, no es sospechoso para glaucoma, pero sí, la presión es alta mediados de los veinte. No pienso que funcione para usted este medicamento.

Quiero—

P: I also feel pressure in the eyes – como una presión adentro de los ojos – when I move down or look down.

Hijo: Ella te dice que la presión es tan alta-

P: Sí.. I understand.

D: It is possible with the pressure this high that you might feel uncomfortable or have head /eye pain with a change in body position. Es posible que tenga el dolor adentro de los ojos porque la presión es elevada.

Entonces quiero cambiar los medicamentos. I want to start different eye drops.

P: (asiente con la cabeza) Yes I agree. What should we do?

D: Tengo aquí muestras de dos otras marcas de gota para el glaucoma. En vez de latanoprost, la que tiene ahora- va a utilizar esta marca (le muestra a ella la otra) una gota por la noche, cada ojo. Y esta marca en el boxeo colorado rojo, una gota cada ojo dos veces al día. (le da los medicamentos a la paciente)

P: So I put this one at night, and this one morning and night, both eyes?

D: Yes. Then we’ll make an appointent for you to return, I’ll check the pressure on the new drops, and we’ll do another visual field test and photo of the optic nerve, to compare with those taken at your other doctor’s office.

Hijo: Ella quiere hacer una cita para revisar la presión después de utiliza estas gotas nuevas y para hacer examénes del nervio.

D: Sí para hacer un campo visual y sacar una foto del nervio óptico.

P: Yes, I understand what you’re saying.

D: (al dar a la paciente los boxeos de gotas y hoja de códigos) OK, puede entregar este papel en el frente para hacer la cita para la próxima vez. Hand in this sheet up front to make the appointment.

P + hijo: Gracias, doctora, dios le bendiga-

D: Igual, pasen ustedes un buen día.

Of note, this conversation took place with a Puerto Rican patient – she had just moved up to the U.S. and was in the process of switching over her medical care to local doctors. You can see the dialogue was a mix of English and Spanish. This type and level of mixed conversation never happens when I see patients from other Spanish-speaking regions of the world. I tend to see it more with the Puerto Rican patient population. I did some research online in this regard and found some interesting information regarding the reasons for this, mainly due to Puerto Rico’s political history. The island was initially claimed by Spain in 1493 and the language of the conquistadors prevailed. However, after the Spanish-American war, Puerto Rico joined the U.S. in 1898 and was granted citizenship in 1917. English began having a dominant influence.

Examples of Spanglish commonly encountered in the U.S. which have also infiltrated the island include:

el roofo = the roof (instead of azotea or techo)

parkear= to park (instead of estacionar)

la carpeta= the carpet (instead of alfombra; a confusing mistake, because carpeta in Spanish means folder)

el lonche= the lunch (instead of el almuerzo)

and a personal favorite of mine which I encountered as a doctor:

checkear= to check/toexamine (instead of revisar) – This one I caught myself using incorrectly for a long time based on what I heard patients say, until I looked up the true Spanish way of expressing “a check up” and found “una revisa” from “revisar”. Now I make it a point of saying it correctly.

Voynich Manuscript

BE the Interpreter

One day I was getting ready to call a patient from the waiting area  to begin his eye exam. He had marked “Spanish” as his preferred language on the intake forms, so I walked out to greet him.

He was sitting in the waiting area with a woman who looked about his age, and a younger man.  I called his name:

“Sr. Vasquez*, podemos empezar el examen ahora. Por favor, venga conmigo.”

*(names changed to protect patient privacy)

He got up and followed me, and the woman he was with stayed seated. But the young man stood up and trailed behind us toward the exam room.

I had just motioned for the patient to sit in the exam chair, when the patient’s ?friend ?family member reached the door.

“I’ve come to do the translation.”

I felt a twinge of irritation, but kept my composure,

“Oh, no es necesario – yo hablo español. Why? Is my Spanish that bad?”

The young man said “No!” and started laughing, and then I laughed, and then he turned and went back to the waiting area.

I shut the door and proceeded with the eye exam.

The truth is, if this man wanted to come into the room, or if the patient himself had insisted, I certainly would have allowed him to keep the patient company while I did the exam. It’s just, as I’ve said before many times in this blog, my attitude toward the use of Spanish during a medical exam runs a sinusoidal gamut of emotions, changing on any given day and even throughout the course of one day.

I go from feeling confident in my second language abilities, to being unsure. I feel frustration, at having to work harder, at having to think to communicate, and then there are the days when it’s easier and I’m more relaxed in my speech. At times I’m resentful, that out of the group of doctors where I work, I’m assigned all the Spanish –speaking patients while the other docs get to work comfortably in their native English. But almost simultaneously, I feel personal pride and a bit superior to these doctors, knowing I provide care in two languages. Knowing I am growing an ability and a talent that they lack, and it’s an ability that is not confined only to the exam room. Being able to communicate in Spanish – or, really, any language beyond our native one- widens our scope of interaction with the people around us. It broadens horizons. It enlarges our world. The other docs I work with live in a fish bowl. I’m sailing the high seas.

They say you have to push yourself outside your comfort zone to grow. Growth and change are uncomfortable. I have to remind myself of this constantly – when I get frustrated from forgetting a vocabulary word or from having to ask the patient to repeat himself more slowly so I can understand.  I have to remind myself that if I keep pushing ahead, what feels foreign will become second nature. Second nature means I can work more quickly and efficiently in Spanish.  And it really is to my advantage and to the advantage of my patient if I put in this extra effort.

There’s a poignant scene in an old Jim Carrey movie that I like, Bruce Almighty, that I’m reminded of at this time.  Morgan Freeman, aka God, endows his protégé Bruce (Jim Carrey) with all his powers.  Bruce takes the use of those powers to an extreme and to his advantage: walking on water, changing his beat-up old car into a sports car, dragging the moon closer to his house for a romantic evening, etc etc. But in the end, Freeman tells Bruce that all of his antics amount to nothing more than magic tricks. He tells Bruce, “You want a miracle? Be the Miracle!” After this Bruce, aka Jim Carrey, stops self-serving with these magical acts and instead simply reaches out and helps other people.

Similarly, I say, “You want an interpreter? Be the Interpreter!”  You want to communicate directly with your patient? You do the communication! So when my patient’s ?friend ?family member approached me and said,

“I’ve come to do the translation.” (he meant interpretation, but who’s mincing words?)

I just wanted to cut out the third party. Communication is clearer, faster and to-the-point when there is no middle man.

“No es necesario. Soy la traductora. Yo soy, la intérprete.”

2016 Adirondack Balloon Festival, Queensbury, NY