Do as I say, and as I do

“¿Por qué Usted está aquí en la clinica hoy?”

“Hace seis meses ahora, tengo ojos rojos, ardor, particularmente cuando leo, tengo lagrimeo, no puedo ir afuera de la casa sin lagrimeo cuando sopla el viento. No sé lo que pasa, pero, los ojos están molestándome.”

(después del examen)

“Tal vez esto va a soñar poco extraño, pero Usted tiene ojos secos.”

“¿Cómo?”

“La manera en que el ojo mantiene una córnea lubricada es muy complicada, pero en su caso, las glándulas que normalmente producen bastante lágrimas para cubrir la córnea no están funcionando completamente. Las células de la córnea se vuelven secas, y  algo sucede que se llama en íngles “reflex tearing”o lagrimeo reflexivo.

“¿Qué es lo que tengo que hacer para curarlo?”

“No hay una cura. Tiene que mantener un régimen diariamente lo que se incluye lubricantes artificiales tres veces al día al menos, un limpiador para los párpados y una crema para usar cuando se acuesta por la noche.”

“¿Cúanto tiempo tengo que hacerlo?”

“Por siempre.”

<expresión abatida>

Patients are looking for a fast cure-all. It doesn’t matter what the problem is, or how long it’s been going on. I have found in my experience working with patients over the last 10 years, that if an easy fix isn’t provided, frustration results. For something like dry eye or glaucoma, which are chronic diseases, I work to present a doable treatment regimen that the patient can follow on a daily basis. Still, the fact that the regimen is not finite and requires a commitment over a lifetime is oftentimes not the resolve the patient is looking for.

Some might say, well, so what of it? You’ve presented the diagnosis and a treatment plan. You’ve explained the logic of it, based on their symptoms and signs, and what has to be done to alleviate the condition, temper it or control it. That should be enough to encourage compliance! Well, it isn’t. From those patients I cannot give a quick treatment fix, I detect a sense of frustration, disappointment, sometimes anger and/or sadness, and all of these associated emotions inevitably lead to a lack of compliance. Patients may start the treatment plan and stick with it for a while, but then their commitment wanes and not surprisingly, symptoms return full-fold.

There are and always will be certain personality types of patients that, despite every means of encouragement, will still fail to fully commit and comply. But one mechanism I have found to work for a majority of people falls under the “misery loves company” motif.

It is human nature, that in our suffering we look to others who are suffering similarly for support, hope and a camaraderie found only in a combined struggle. As doctors, we’re patients, too. Sufferers of the same afflictions. I personally use this to my advantage with my patients.

I have dry eyes. My symptoms started in my late twenties, when I was an ophthalmology resident. The end of a long day in the clinic used to leave my eyes stinging and burning, and I couldn’t understand why. I would run to the small sink in the back of the clinic and flush my eyes, for relief. It wasn’t until we started covering anterior segment pathology that I began to realize what all my signs and symptoms were pointing to: dry eye! ¡sequedad de los ojos! And then I began to understand the concept of evaporative tear loss, the function of the meibomian glands, or lack, thereof, in a person already suffering from acne rosacea.

Putting together my own daily treatment of dietary Omega-3, hot compresses and artificial tears helped my symptoms tremendously. Having gone through the not-so-pleasant experience of dry eye myself made me more exquisitely in-tune to the symptoms of my patients suffering from it. But again, when I identified these patients and told them that they need to follow a daily schedule of artificial tears, dietary changes and the like chronically, I was met with dissatisfaction and worry. I wondered, how can I encourage these patients? How can I try to make them dedicate themselves to a treatment plan?

The free dictionary of idioms on-line describes “misery loves company” as “fellow sufferers make unhappiness easier to bear”.  I decided to share my own story.

“¿¿Tengo que usar las lágrimas por siempre??”

“Sequedad de los ojos es, desafortunadamente, una enfermedad crónica, y que es más, tiene una tendencia empeorar con tiempo. Yo también tengo ojos secos.”

“¿De veras?”

“Sí. Y yo también tengo que usar lubricantes, a veces tres o cuatro veces al día, particularmente por lo que miro la pantalla de una computadora todo el día diariamente. Esa actividad, le he explicado, tiene una tendencia a secar los ojos.”

“Pero Usted es joven.”

“Síntomas de ojos secos pueden empezar a cualquier edad. Especialmente hoy día, la edad de celulares y computadores, juegos de vídeo y cosas así, la gente más y más joven está sufriendo de sequedad de los ojos.”

“¿Sólo tengo que usar los lubricantes?”

“Bueno, Usted debe tratar de hacer el tratamiento de ojos secos una parte de su rutina diaria. Por ejemplo, por la mañana, cuando se levanta, y normalmente se lava la cara, use una toalla de agua tibio para frotar y limpiar los párpados – y puede repetirlo cuando se acuesta. Durante el día, debe usar una gota de <su marca favorita> de gotas artificiales, dos o tres veces, antes del trabajo, en el mediodía en la oficina, cuando regresa a la casa, y a veces, cuando mira la televisión por la noche. Trate comer comidas con el aceite del pescado, ‘Omega-3’, durante la semana, o puedo tomar el suplemento de la vitamina.”

“Está bien. Voy a tratar mantener el horario.”

“Hago una cita para Usted en 6-8 semanas, para reexaminar los síntomas y monitorear su progreso.”

“Está bien. Gracias, muy amable. Me ha explicado todo claramente.”

“De nada.”

Of course, providing some samples of artificial tears always helps, in addition to making an appointment in the near future to check on and encourage progress.

Mexican Hat, San Juan County, Utah

Lenguaje “Llano” – Common Words & Plain Language

I wanted to review a common list of terms I come across frequently when discussing eye problems/conditions with my Spanish-speaking patients. I have mentioned a few of these previously in my blog, notably in my October 2013 entry “A Rose by any other name...well, except for ischemia”.  As I have said before and as any physician knows (usually through personal experience), in any language, speaking to the patient only using medical terminology is not beneficial.  For anyone not medically trained, such words are foreign, scary and often misunderstood. People have common ways to refer to medical conditions, diseases, the human body and to fully know a language you need to be intimate with all of these manners of expression.

Now, Spanish language has the added issue of varying its dialect depending on country of origin. So, a Puerto Rican patient may have a different way of expressing an eye “floater” than someone from the Dominican Republic. I have not yet reached a level in my own Spanish knowledge and experience where I can differentiate terms based on national origin, or vice versa. What I do instead is repeat all the forms of the word that I know to the patient, until I reach one that the patient understands and identifies with. For example:

1 )  Mole, or any skin growth

You could try saying  nevo for nevus, but likely that won’t be understood, just as the word nevus usually isn’t! The equivalent Spanish word for mole is lunar. Now, what term to use for a generic growth of the skin is a different story.

Years ago I looked up the word growth in an on-line English-Spanish dictionary. The supposed equivalent Spanish word it gave me was protuberancia, apparently similar to the English word protuberance. So, I started using this word anytime someone had a growth I wanted to describe. Well, I can tell you I received many a strange look from the patients when I used this word! In fact, when I shared this experience with my Puerto Rican technician, she practically guffawed, and we had a hearty laugh at my expense!

The problem was resolved when a patient came in one day pointing to and describing what were actually small chalazia on his lower lids. He used the word bolita: ¿Qué es esta bolita?  Since then I have been using bolita for growth and the patients understand me, so it must be a valid and universal description.

2) Lazy eye

When I was studying Spanish during my high school days,  I learned the word for lazy to be perezoso. During my residency, it made sense, therefore, to refer to a lazy eye as an ojo perezoso.  No patient ever questioned it or seemed to misunderstand. Sometimes I will introduce the patient to the medical term, amblyopia, or ambliopía in Spanish.

But many patients don’t really understand what constitutes making the eye “lazy”. In my experience, I have found that patients think that lazy eyes are eyes that drift, ie. a strabismic eye. Knowing this, I will sometimes refer to a lazy eye as ojo cruzado or crossed eye if I know that strabismus is the reason for the amblyopia.  Obviously I cannot use this term in all cases of amblyopia.

A description that a Puerto Rican patient may use to indicate lazy eye is ojo vago, but according a technician I work with, this is a very base way to describe a lazy eye. Per the Spanish-English translator, vago means slouch, lazybones or slacker. Can you imagine? “Hey, your eye is slacking off!” If you visit the website www.ojossanos.org, you will find the term ojo perezoso, which appears to be the acceptable way to express a lazy eye in Spanish.

3) Eyelid “crusts” and discharge

One complaint I hear about often from patients is that when they wake up in the morning, they have crust buildup on the eyelids/lashes. In English, they refer to this as crust, or flakes or “eye sleep”.  I’ve heard even more unflattering terms to describe it, but I won’t go into that right now.  But how does a patient refer to this in Spanish? Some common words are: legaña, lagaña or pinchas.  But I have asked, “¿Tiene algo como una costra en el ojo cuando se despierta?” and they do understand what I mean by costra = crust.

Incidentally, to ask about eye discharge, I often used the word descarga. “¿Tiene Usted una descarga del ojo?”, but I found I was stared at quizzically more often than not. Instead, now I use lagrimeo which is closer to the English for tearing. I do recall one patient describing her eye discharge as flujo, but I do not hear this word used too often.

4) Pterygium/ Pingueculum

Un pterigio or una pingüécula are words I will introduce to the patient just so they know the medical word for this lesion growing conspicuously over or near their cornea. However, Spanish-speaking patients have many colorful terms to describe these lesions: una carne, una carnosidad, and una uña, which are meat, fleshiness and fingernail, respectively.

I often start out: “Esta cosa que Usted tiene en el rincón del ojo, esta carnosidad/carne/uña, es algo se llama un pterigio.” English speakers typically refer to it as “this thing growing”, “this growth”or “lump”on the eye.

5) Blue Eyes

I remember when I was studying Spanish in college, my professor—wow, I just remembered her name now, just this moment! La Profesora Marques. I haven’t said it or thought it for years! Perhaps the old brain is still retaining and not simply leaking words, phrases and experiences like water through a sieve (as previously thought!).  

La Profesora Marques told my class one day that blue eyes are not referred to as blue eyes or ojos azules in Spanish. This is because, as she said, blue eyes are very rare among the Latino people. Instead, she said, that blue eyes are actually referred to as ojos blancos which literally translated means white eyes. I have never had the opportunity to use this expression with my patients.  The majority of them are from Central and South America, and the Caribbean islands. Their eyes are almost always a dark brown or marrón, rarely I will see even a hazel eye.

6) Flashes / Floaters

Patients coming in with potential PVD or retinal tear complain of destellos (flashes of light) or puntitas de luz (points of light). Sometimes they will describe the flashing lights as lightening or relámpago. Floaters I have heard called by different names:  manchitas (literally ‘little stains’), manchas (stains), pajaritos (little birds), moscas (flies) or líneas en la vista (lines in the vision).

I almost always will refer to the American Academy of Ophthalmology’s website www.ojossanos.org (an informational site for patients describing various eye conditions written in Spanish) to expand my vocabulary of medical ophthalmological Spanish. There, floaters are called flotantes.  However, I have used the word floaters / flotantes with my patients, and many do not know what I am referring to. It is easier to get across the following sentiment whether in English or Spanish: ¿Ve Usted puntitos negros que se mueven en su campo visual? Once people hear ‘black spots’or ‘moving spots’ and understand, then I introduce other ways to refer to them.

7) Black Eye /ojo morado

Not everything can be literally translated from English to Spanish. If you describe someone as having an “ojo negro” literally ‘black eye’, it is interpreted as simply a dark brown eye in Spanish. It doesn’t have the same meaning as in English, where a black eye is an eye that is bruised as the result of a punch. Instead, you have to use the words ojo morado which literally means purple eye.

8) Blind Eye /ojo ciego

Any reference to blindness brings us to the word ciego in Spanish. Many patients, particularly those with eye problems like glaucoma or diabetic retinopathy, truly fear that they will lose the vision completely and go blind. Often I will hear, “Voy a ser ciego?” The answer is almost always no. So far in my >10 years in private practice, I have not heard of any slang (jerga) for a blind eye. Maybe the closest thing I have heard is bad eye (ojo malo) or weak eye (ojo debíl).

9) Prosthetic Eye

I have been using the most direct tranlation of these terms: prótesis ocular or ojo artificial.  Another description that is a little more basic would be ojo falso, or false eye.

10) Pink Eye – Viral Conjunctivitis

Pink eye is also another expression in English that is not necessarily literally translated into Spanish.In Central America, this condition is referred to as mal de ojo or ojos rojos, not rosados. You can also use the medical term conjunctivitis or conjuntivitis. However, conjunctivitis is a broad term and not always understood. If I use that word I preface it with: “La piel que cubre la frente del ojo se llama ‘conjuntiva’. Cuando esta piel se vuelve inflamada, se llama ‘conjuntivitis’”.

There are times, however, when I will interject the English words pink eye when explaining the diagnosis to a Spanish speaking patient. Why? Again, it takes me back to an earlier blog entry of mine “Spanglish” http://www.eyesayinspanish.blogspot.com/2013/10/spanglish.html when I talk about how Spanish in the Americas has been influenced by English. Because of this, sometimes the English slang equivalent is the jerga that Spanish speakers here will use and understand.

Universal Signs

La Jerga

Doctora: “Díme, ¿ qué son los síntomas Usted tiene?

Paciente: “Es como, veo un’ moca, un’ moca.”  

<me mira, con duda>

Paciente: “¿Sabes qué es, un’ moca?”

Doctora: “¿Usted ve ‘un moca’? No, no lo sé. ¿ Qué es un moca?”

Paciente: <mucha risa>

Later in the day long after the patients had gone home, I asked one of the ophthalmic technicians in the practice who is Puerto Rican and Spanish-speaking, what IS a ‘moca’? What was this patient talking about?

She laughed and told me he was saying “mosca” which right away I recognized as a fly. Because the patient left out the “s” sound when saying ‘mosca’, I had no idea what word he was trying to communicate. When people don’t fully pronounce words, or slur their speech, it can be very difficult to figure out what they’re saying. But, usually if this happens in English, I can figure it out. In a language non-native to me, however, I rely on every sound, every inflection, to get the meaning right. And if the sound I’m expecting isn’t there, then I feel very much like someone lost in the woods without a compass. I have no idea where I’m going. Or where the speaker is coming from.

Recently, I came across an interesting article on the American Translator Association website entitled, “La jerga de los médicos y de los pacientes” (Doctor and Patient Jargon). The article’s authors, Becky Katz and Rudy Heller, attended the Congress Division in Orlando during which physician Dr. Fernando Navarro presented euphemisms doctors and patients use to describe otherwise unpleasant or intimidating medical conditions and/or bodily functions. Dr. Navarro went on to describe vocabulary that doctors use with their patients that may be misinterpreted or misunderstood based on pronunciation alone or how the pronunciation is perceived. He goes on to give examples first in English:

Varicose veins = very close veins

Very high electrolytes = very high electric lights

Superficial phlebitis = superstitious fleabites     <hahaha, I can’t help but chuckle at that one!>

(I even remember one such misinterpretation from my medical school days:

Cystic fibrosis = sixty-five roses)!

Dr. Navarro then presented similar problems (referred to as ‘barbarismos’) in the Spanish language:

Otorrino = Doctor Rino

Cesárea = necesaria

Ataque de insulina = ataque de ursulina <chuckle>

And the list goes on and on...Something is being said, but is not necessarily heard as was intended. Inevitably, it leads to good-natured humor and a hearty laugh. From there continues a conversation of clarification, as I experienced during another patient conversation:

Doctora: “Bueno. Tengo que decirle, que Usted tiene ojos muy sanos.”

Paciente: <me mira confundido>  “¿’Sano’? ¿Qué es ‘sano’?”

Doctora: “Saludable. Usted tiene ojos saludables – sanos.”

Paciente: “Ahhh...(relajado)”

I’m still not quite sure why the patient didn’t understand me when I used the word ‘sano’for 'healthy'. No one else ever had a problem understanding me. But then again, maybe he heard something different. A little clarification was all that was needed to do the trick. Oh, and by the way, because of my experience confusing ‘moca’ and ‘mosca’, my mind is now keyed into that sound variation. Just yesterday a patient came to the office as an emergency visit, again with similar symptoms of floaters in the eye:

Doctora: "Se dice aquí que ¿Usted ve un cambio en la visión?"

Paciente: "No hay un cambio en la visión, es sólo que, ahora, en el ojo derecho, veo pajaritos – es como un’ moca."

Doctora: "Ajj, Usted ve moscas, ¿ o manchitas en su campo visual?"

Paciente: <muy profundo> "¡Sí! Sí, veo manchitas, hace más o menos tres días ahora..."

And the dialogue continued, unperturbed by a dropped syllable.

For more information on Becky Katz & Rudy Heller’s article, you can find it here at:

http://ataspd.org/2012/09/27/la-jerga-de-los-medicos-y-de-los-pacientes/

Bryce Canyon, Utah

"Tu español es muy bueno."

“Tu español es muy bueno. ¿Eres latina?”

“No. Nací aquí en los Estados Unidos. Soy una mezcla de nacionalidades: polaca y italiana.”

<me mira con duda>

“Bueno, las lenguas de italiana y español son semejantes. Entonces, ¿hablas italiana?”

“No.”

<más duda>

“Y no hablo polaco tampoco. Pero hablo y entiendo un poco de la lengua de mi esposo: croata.”

<ahora, confusión extrema>

***

This is a conversation I have with patients several times a week. I always feel complimented when my Spanish-speaking patients tell me that my Spanish is good, especially since I know I have much to learn, and I cringe sometimes at the thought of all the grammatical mistakes I must be making when I talk with them! But inevitably, after the compliment about my Spanish skills comes the question about how I know it so well. I must be Latina, right? Or at the very least, I must have travelled  outside the U.S. at some point and spent several years living in a Central or South American community of people. This is what my patients think! And truly, I am complimented they feel my Spanish is that good. 

But the simple answer is, no. I’m not Latina. I grew up in a two-family house with my parents and my mother’s parents. My grandparents were first generation Italian Americans who got married and raised a family during the WWII era. Based on their stories of what it was like living in the United States back then, everyone was fiercely patriotic. In their minds, to be American was to jump feet first into this ‘melting pot’ of a society. This meant learning the English language and adopting American customs, unfortunately, to the detriment of the mother tongue and traditions.  My grandparents spoke Italian as children growing up in Brooklyn, but that language was gradually lost during their years to adulthood. Eventually, when they had children of their own, there was no language to teach them but English and this, of course, carried on to my generation.

I was a child in the 1980s and back then, television programming was not like it is today. It did not introduce children to any languages other than English. Even Sesame Street, which I probably watched for the majority of my young childhood, introduced me only to the basics of ‘gracias’, ‘hola’ and numbers up to ten in Spanish. I remember hearing once when I was growing up, I’m not sure if I heard it on the news or in school or elsewhere, but I remember hearing someone saying, “What do you call a person who speaks two languages? Bilingual. What do you all a person who speaks three languages? Trilingual. What do you call a person who speaks one language? American.” And when I heard this joke, it bothered me. I would have loved to have learned something other than English as a young child. That opportunity wasn’t given to me.  My grandparents touted many times how proud they were to be of Italian origin. Then why did they give up on the Italian language? 

Fast forward to my junior high years of 7^th and 8^th grade and my school finally introduced me to another language: Spanish. I loved it! It was fun to learn, but something that unfortunately could only be learned in the confines of a classroom. At home, my family – namingly my grandparents- flip-flopped between being proud of me for being such a good student, and being angry at me for speaking a language they didn’t understand and didn’t want to understand. It was a tough situation. But I continued my Spanish studies through high school and college and eventually got real practice using it in my medical school and residency years. It took many many years to accustom my ears to the different sounds of Spanish, enough to understand someone speaking it. I still struggle at times with that today, especially if someone’s using slang or speaking with a heavy accent or dropping syllables from the words. But I have come a long way. And I am proud of what I’ve accomplished.

Because I speak Spanish, and because I can understand Spanish, windows into patients’ lives have been opened to me that I would never have been able to peer through before.   It’s a real gift, this gift of communication, and one that I work hard to maintain everyday.

***

In this same vein, I came across an article title recently that caught my attention: “Non-Spanish Fluent Latinas: ‘Don’t Judge Us.’” written by Tracy López for the website NewLatina. The article mentions that, though it is predicted that the United States will be home to the largest population of Spanish speakers in the world forty years from now, many Latinos born and raised in the U.S. do not speak Spanish. It goes on to talk about the history of Spanish language in this country, which most interestingly parallels my time-line of Americans’ attitude toward foreign language learning from the 1930’s to present –this time seen from the perspective of the Spanish-speaking immigrant. Those whose mother tongue was Spanish during the WW II era here did not dare speak the language outside the home because they received discrimination if they did. And often times that translated to them not even using the language in the home for fear their children would not be able to learn English properly enough to “blend in” with American society. Hence, a generation of Latinos was born that, upon reaching adulthood, could not teach the Spanish language to their children even if they wanted to because they themselves had no exposure to it.

Ms. López goes on to say that for these non-Spanish fluent Latinos, there is a sense of judgment from other Latinos in the community who do speak the language. They are regarded as “fake Latinos” because not speaking Spanish is viewed as shameful. Several Latina women are quoted remarking on their experiences with this in the U.S., all of which have the common thread of feeling less-than or left out because they do not know Spanish fluently. These even include stories of famous Latinas such as Jennifer Lopez and the late Selena Quintanilla who struggled with having a strong Latin identity and yet weak Spanish-language skills.

The article ends on a positive note, saying that among the Latina community, people should embrace each other for their similarities and differences.  Latinos come from a rich variety of countries of origin, cultures and backgrounds, and therefore should not be held to a standard that says they should all act and sound the same way. There is certainly a lesson we can all learn from this.

...Which brings me back to the conversation I had with my patient.  I speak Spanish, but I am not Latina. There are many Latinas out there, proud of their heritage, who don’t speak Spanish. 

Because I am not Latina, should it be assumed that I don’t speak or understand Spanish?

Because  a woman is Latina, should it be assumed that she does speak Spanish and if she doesn’t, she is ‘fake’?

No and no to both counts. Preposterous!

How about this: We live in a country of which we are proud to be a part. We come from various origins we are proud make us who we are, and we respect and embrace each other for our similarities and our differences.

***

“¿Dónde aprendiste español?”

“En la escuela.”

“¿En los Estados Unidos?”

“Sí. Desde mi escuela primeria.”

“Ohh.”

“Tengo mucho más que aprender.”

“Bueno, está bien. Lo hablas bien.”

***

To read more of Tracy López’s article “Non-Spanish Fluent Latinas: ‘Don’t Judge Us.’”, you can find it with this link http://newlatina.net/non-fluent-latinas-dont-judge-us/ 

Arches Nat'l Park, Utah. "As far as the eye can see..."

 

La Primera Visita

Me: Hola. Soy Dra. Hromin. Un placer conocerle (extiende la mano)

Paciente: Mucho gusto.

M: Bueno, déme un momentito, como leo su información en la pantalla aquí – Veo que Usted estaba aquí en dos mil trece, con el Dr.—

P: Sí

M: ¿Cambiaron los lentes durante esa visita?

P: No, tengo estos lentes por, bueno, hace un año y medio ahora.

M: ¿Y qué piensa de la visión? ¿Está esforzando la visión? ¿Ve Usted con claridad? ¿Qué?

P: No, con los lentes, veo bien.  Pero sin los lentes (ella mira un dibujo en la pared) no puedo ver las letras ahí.

M: Entiendo, pero si los lentes son más o menos un año y medio y todavía Usted ve bien, significa que la visión es estable y los ojos son estables.

P: Sí. Bien.

M: ¿Usa Usted gotas, para lubricar el ojo?

P: Tenía un médico en mi país, él me daba gotas.  Él me decía que tengo glaucoma.  Pero en la otra oficina donde yo fuí aquí en los Estados Unidos, me dijeron que no, no tengo glaucoma y no necesito las gotas.

M: Bueno, depende en la situación.  A veces un medico empieza gotas para glaucoma no sólo para tratar glaucoma, pero para prevenir glaucoma.

P: Le entiendo.

M: Depende an la apariencia de los nervios.  Pero, vamos a ver—empiezo el examen ahora.

...(después de un rato)...

M: Está bien.  Siéntese atrás, le explico todo.  Usted tiene ojos sanos, pero entiendo por qué el médico en su país empezaba gotas para glaucoma.  Basado en el tamaño de los nervios, son sospechosos de glaucoma.  Entonces, tenemos que hacer otro examen – un campo visual – para determinar si ha perdido la visión periférica que resulta en el glaucoma.

P: Sí, recuerdo ese examen – el campo visual.

M: También, es normal después de la edad de más o menos cincuenta años desarrollar cataratas.  Usted tiene una catarata pequeña en cada ojo – son la razón por la que su agudeza visual cambia poca a poco con el tiempo.

P: ¿Y esto es la razón por la que tengo lagrimeo del ojo izquierdo?

M: No. Lagrimeo resulta cuando la córnea se vuelve seca.  Los estudios nos han enseñado cuando concentramos en algo (p.e. un libro, la televisión, la carretera) por un rato, parpadeamos menos y la córnea pierde lágrimas.

P: Entonce, ¿cómo lo podemos tratar?

M: Tiene que usar un lubricante: gotas artificiales, una gota en cada ojo dos o tres veces al día diario. Esto va a disminuir los síntomas que tiene. (le doy a ella dos muestras).

¿Usted tiene algunas preguntas para mí?

P: Pues, pienso que no.

M: Está bien. Entonces, voy a hacer una cita para Usted para el campo visual en dos o tres semanas. También va a tener una cita de seguimiento conmigo cuando discutimos el resultado de los exámenes. Cuando regresa, puede decirme si las gotas artificiales están ayudandole.

P: Está bien. Gracias por su ayuda. Pase un buen día y Dios le bendiga.

M: De nada, es un placer conocerle. Igual.

Ute Indian Petroglyphs, Moab, Utah

Un Diálogo

“Dialogue is a therapeutic intervention.” – Dr. Robert Alexander Buckman, M.D.

Me: “Veo aquí en su otra oficina, el medico allí hizo un procedimiento de los ojos, algo que se llama “iridotomía láser”.”

Paciente: “Sí.”

Me: “¿Le dijo por qué lo necesitaba? ... ¿Le dijo él que Usted tiene ‘ángulos estrechos’?”

P: Bueno, no.

Me: Entonces, hoy, vamos a empezar con lo que Usted entendía y entiende del procedimiento.

P: Bueno, es que, me dijeron si no tenía el radioláser, perdería la visión. Duraba menos de un minuto en cada ojo.

Me: (After examining the patient) Sí, veo el resultado del láser – ¿Está bien si le explico la razón necesitaba el láser?

P: Sí.

Me: Bueno, una iridotomía láser se le hecho cuando tiene ‘ángulos estrechos’. Este significa que el espacio entre del iris (la parte colorada del ojo) y la córnea es mínimo. Es decir que, la zona que actúa como filtro para el fluido dentro del ojo es muy estrecho. El fluido no puede escapar, y la presión dentro del ojo se incrementa. Esta es una forma de glaucoma se llama “ángulo estrecho” o “ángulo cerrado” y puede resultar en ceguera.

P: Le entiendo.

Me: Su medico ha prevenido esta forma de glaucoma con el procedimiento.

In order to renew one of my state medical licenses recently, I was required to take a certain number of hours of an online course on end-of-life care. My immediate thought was, end-of-life care? But I’m an ophthalmologist! I never see patients at end-of-life. And as a general ophthalmologist,  the worst news I have to deliver is a diagnosis of glaucoma or macular degeneration, not terminal illness.  Even with these diagnoses, there are treatment options and/or lifestyle changes I can recommend that help. And give hope.

When searching for such an online course, I came across the University of Texas’ MD Anderson Cancer Center website and found several end-of-life continuing medical education programs, created and conducted by the late oncologist Dr. Robert Buckman. The purpose of these videos is to teach physicians how to effectively and respectfully deal with all the emotions and fears of their patients dealing with terminal illness. It is no easy or pleasant task to tell someone his chemotherapy regimen failed, or her cancer has come back and is now at end-stage.

In these doctor-patient scenarios involving Dr. Buckman himself and a patient-actor, one particular theme is emphasized repeatedly.  It is that of the importance of dialogue. Instead of starting the patient interview with a monologue of explanations and assuming he knows what the patient is thinking, Dr. Buckman always begins by asking the patient her own understanding of  her illness – its course, progression and treatment – up to the present point in time.  In this way, he can pick up where the patient leaves off and fill in any gaps in understanding.

After watching several of these videos, I began to realize that what I do everyday in my practice of ophthalmology is very similar. Particularly for patients who transfer to me from other practices where they’ve received previous treatments and/or surgeries, I always like to start with their own understanding of their eye condition. I do this before I provide them with information from my exam. In this way I can be sure that true continuity of care is provided. And as I always say, if I’m doing this in English for my English-speaking patients, then I do this in Spanish for my Spanish-speaking patients as well.

Starting the patient dialogue this way helps me be a better doctor for my patient. If I pick up where their comprehension of their eye condition leaves off, then I am more likely to get my points across clearly and concisely. The patient feels heard, has any lingering questions addressed and is therefore more likely to be compliant with continued care by me.

A patient told me recently,

Paciente: Me gusta lo que dices.

Me: ¿Cómo?

P: Me oyes a mí. Me siento que tú tienes un entendimiento de lo que digo yo.

Me: Bueno, gracias. Está bien, hago aquí una cita en un més, para ver si las gotas funcionan para Usted.

P: Está bien, (con la tarjeta de visita de regreso) pase un buen día.

Me: Igual.

In memory of Dr. Robert A. Buckman, MD 1948-2011

Link to MD Anderson Cancer Center CME/Dr. Buckman presentations on end-of-life care:

http://www.mdanderson.org/education-and-research/education-and-training/schools-and-programs/cme-conference-management/online-cme/md-anderson-online-cme-activities.html

Even in the desert, Life. Moab, Utah