Subjunctivitis - Seeing is Believing

In my ever-constant pursuit of Spanish fluency, I have come to notice like any struggling student the advantages and the pit-falls of the written versus the spoken word. There are certain things you can easily “get away with” saying to someone in a grammatically incorrect way,  that unfortunately stand out as glaringly wrong in written form. For example, when I’m speaking with my patients in Spanish, sometimes I’ll say something that, the split second I say it I know I should probably be using a verb conjugated in the subjunctive. But, I’ll get unsure of myself and nervous about changing a “puedo” to a “pueda” or a “va” to a “vaya” and instead I’ll just gloss over it, using the present indicative, and hoping the listener didn’t catch my mistake. And, it’s very possible they didn’t catch my mistake, if I say it fast enough or with a lilt of an accent. But when I’m writing something in Spanish, well, I can’t evade grammatical errors so easily. It’s right there, smack in front of the reader. In black and white. Yikes!

Throughout my med school and residency years, and now especially while in private practice, I have always done mini-translations from English to Spanish. These included simple explanations of eye diseases, instructions to patients on how to use their eye drops and consent forms for various procedures. While I feel I’ve done fairly well with these translations, I’ve never had any formal guidance as to whether or not I’m actually doing them correctly. I want my grammar to be correct. I want the end-product to look professional. So, I finally decided to enroll in a translation course to gauge just what I’ve been doing, and how to improve upon it.

The truth is, when something is written in a sloppy way, with many grammar and punctuation errors, it doesn’t give the reader much confidence in what he is reading. Now imagine a doctor’s office and a consent form for cataract surgery. If poorly written, with incorrect word choices and mistakes, it really will make the patient doubt the skills of his surgeon.  After all, if the surgeon doesn’t take the time to make sure his descriptions of the surgery are pristine, maybe he doesn’t take the time to focus on all the fine details of his surgery, as well? It may seem like I’m reaching too far with this analogy, but truly, the manner in which we present ourselves dictates our attention to detail, care, skill (or complete lack thereof).

My first item of business is to try and tackle the idea of the subjunctive. I’ve been looking for some online resources and found an interesting article from the language blog FluentU.  Nick, author of “How to Survive the Spanish Subjunctive”, describes subjunctive as, “... a mood. It is not a tense because it has nothing to do with time, rather it conveys a sense of uncertainty or conditionality.”He continues on to give word “triggers” that serve as little warning signs that the subjunctive conjugation should follow. For example:

Yo quiero que tú vayas al cine conmigo.   *     I want you to go to the movies with me.

Ella espera que él tenga un buen viaje.   *    She hopes/wishes he has a good trip.

Dudo que ella esté aquí.  *   I doubt that she is here.

No es cierto que hagamos el trabajo hoy.  *   It isn’t certain that we’re doing the job today.

Essentially, any sentence that starts off with words indicating uncertainty or a desire propels the rest of the sentence into the subjunctive. In Spanish, many times these phrases will use “que” or  “that” as in,

I hope that she is coming to the party.  *   Espero que ella venga a la fiesta.

The confusing part is, we don’t always use the word ‘that’ in English, but it is still subjunctive nevertheless:

I hope she’s coming to the party.    -- No ‘that’ in this sentence, but still a subjunctive clause.

The blog article concludes by saying that even if you neglect to use subjunctive in your speech, chances are “...Spanish speakers will understand what you’re trying to say.” This is true. If you make mistakes when conversing, you probably can get away with it.

But as for my Spanish languages goals, I want to do more than simply gloss over my mistakes. I want to speak and write in a polished way.  I want my patients to have confidence in what they are hearing and reading. I am hoping that this translation course helps me to reach these goals.  I suppose then the only ‘cure’ for my subjunctivitis is continued work and perseverance--a willingness to try and learn from my mistakes.

References

FluentU “How to Survive the Spanish Subjunctive”  www.fluentu.com/spanish/blog/spanish-subjunctive

Mountain Goats, Zion National Park, Utah

Cuando el Médico no Habla Español

I had often wondered how my Spanish-speaking patients feel when they go to the doctor’s office and find out that their doctor doesn’t speak their language. I would imagine: fearful, worried that they’ll be able to express their concerns and that those concerns will be understood, worried that they’ll be able to understand the doctor and his instructions in return. Perhaps they will feel embarrassed, and even frustrated. Likely they will feel dissatisfied, knowing they didn’t say everything they wanted to, because they trimmed their conversation to the bare minimum – to what they thought the doctor would comprehend. And they wouldn’t ask questions, because they didn’t want to sound or look foolish.

Well, I don’t have to imagine this scenario, because I experienced it first-hand myself. It was when my husband and I went to Italy for our honeymoon. We spent numerous days in Capri, Cinque Terre – lounging along the sun-kissed shores. But all that lounging and strolling and shopping and sunbathing came to a halt when one day I got sick. Fortunately, the hotel we were staying in had a doctor who was on-call. I told the front office, “ Call the doctor immediately! I’m sick! “, and they readily obliged. This hotel was in a popular area – heavily visited by tourists, most if not all of which spoke English. The staff spoke English as if it were second nature to them, so I expected the same of the doctor.

I was lying on the bed in the hotel room. A knock sounded on the door and in walked an older gentleman with a black leather bag in one hand. His name was Dr. Buonocuore. Goodheart, in Italian. And he seemed to have a good heart. His hair was white and he was portly, and he had a grandfatherly air about him which was instantly calming. He gave me the sense that everything would be OK. I started talking to him immediately. Being a doctor myself, I wanted to give him all the pertinent information to make the diagnosis (I already knew my diagnosis, but being in a foreign country, I unfortunately could not write my own prescription there. Someone else had to do it).

I talked about where the pain was, when the symptoms began, how they evolved and over what period of time. I told him what I thought the diagnosis was – I told him of my medical background. Every now and again my husband chimed in with more details. And all this time Dr. Buonocuore looked at me intently, like he was really listening, like he was really taking it in.  I stopped talking and watched his lips part, and I waited with anticipation for what he would say.

“ You are...incinta? Incinta?”

My husband and I looked at each other. I don’t know what made me more frustrated: the fact that my husband studied Italian in high school and obviously didn’t remember a lick of it, or the fact that I just poured my heart out to this doctor and he hadn’t understood a word!

“I’m sorry, I don’t know what ‘incinta’ is.  ¿Usted habla español? Yo puedo hablar español con Usted.”

“No. <thinking pensively> “You are....with...the baby?”

And then I understood that he was asking me if I was pregnant or had the possibility of being pregnant, because this would help him in his antibiotic choice for me.

“Oh, no. No baby. No plans for baby.”

“OK.” <nervous laughter, writing something down on two slips of paper> “Take this to pharmacy. This pill, one a day. Finish. This other pill, only if you need.”

I looked at the prescriptions, one I didn’t recognize. The other was for “Levoxacin” which I could see was the equivalent of “Levofloxacin” available in the U.S.. I thanked him profusely and he left. My husband went to get the meds. Sure enough after one or two doses, I began to feel better. I was so grateful for this, and relieved. So much so, that after I made a full recovery days later, my husband and I brought a bottle of wine to Dr. Buonocuore’s office. I thanked him again, not entirely sure if he remembered me. Few words were spoken, but I think I got the point across.

Needless to say, after this experience I became especially sensitive to the issue of language barriers in healthcare. I have said many times before in this blog that medial lingo in and of itself is frightening and confusing for patients, never mind if another language is thrown into the mix. 

I recently found an intriguing article online entitled, “Si el Pediatra no Habla Español”, written by Carolina S. Clauss-Ehlers. In it, the author recounts true experiences of mothers who need to bring their children in for medical care, but cannot communicate with the doctor due to a language barrier. In one scenario, a mother woke up to find her child vomiting and with diarrhea and rushed him to a New York City emergency room. She was already frantic about her son’s health, but became doubly worried when she realized that she could not speak with the doctor. She found a bilingual Puerto Rican woman in the waiting area that agreed to help interpret for her and the doctor. She was so grateful to this woman for her help, but still felt a sense of dissatisfaction. As she put it, “It isn’t the same thing as speaking to the doctor in my own words – imagine if this woman had translated something incorrectly!”

Other mothers in the article talked about how they try to get around the language barrier if no interpreter is available. They ask the doctor to speak slowly and to repeat the phrases that they do not understand. Sometimes they use body language – pressing on the ear of the child to localize the source of the pain. The author also interviewed doctors, asking those who only spoke English how they handled working with Spanish-speaking patients. Answers included employing interpreters, Spanish-speaking nurses, technicians and support staff and looking at the facial expressions of the parents to gauge degree of worry and severity of symptoms.

One mother described very plainly the dangers of lack of communication. She talked about how she would always bring her husband, who is bilingual in English and Spanish, with her when she had to take their child to the pediatrician. On one such occasion, her husband could not accompany her due to work-related issues. She tried speaking English with the doctor, but knew very little. What she really wanted was a prescription for a certain medication for her son, but the doctor didn’t understand and therefore didn’t give her the prescription. Ultimately she had to return to the office the next day with her husband to get the prescription. She felt badly about it, saying, “Imagine if it was something serious and I didn’t get the medication right away?”.

Health care is a field where it is of utmost importance to the patient’s well-being that the doctor understand exactly when & how the symptoms began and how they are evolving in order to properly examine, diagnose and treat a patient. If there is limited communication due to a language barrier, then a limited exam is performed and the patient suffers. It is the ideal scenario if the doctor can speak the language of his patients, but this isn’t always possible. Language learning is a lifetime of learning. We all find ourselves at different stages of that journey. Until language skill catches up to the medical demands at hand, doctors need to have appropriate staff, interpreters and translators present to ensure continuous and thorough communication with their patients, whose life and health depend upon it.

Reference

 http://www.parents.com/parents-magazine/si-el-pediatra-no-habla-espanol/

Devil's Garden, Arches Nat'l Park, Utah

Snowbirds

“Me alegro decirle que la presión del ojo es estable-“

“¡Qué rico!”

“Sí, la combinación de colirios está funcionando para Usted. Entonces, vamos a continuar con estas gotas. Recuerda, la botella con el tapón amarillo es dos veces al día en los dos ojos, y la botella con el tapón marrón es también dos veces al día.”

“Sí y voy a necesitar ‘refills’. Bastante para 6 meses.”

“Bueno, voy a verle otra vez para cita en tres meses para comprobar la presión..”

“No, no puedo. En un mes, más o menos, voy a irme a mi país, para ver mi familia y pasar el invierno allí. No me vuelvo hasta que abril o mayo del año que viene.”

“Oh, sí, olvidé que viaja Usted cada invierno afuera del país. Bueno, recuerda Usted que glaucoma es una enfermedad crónica, y tenemos que vigilar la presión con atención.”

“Sí – tengo oftalmólogo allí, un especialista quien puede examinarme.”

“Está bien. Entonces, voy a darle este papel, donde escribo la presión de los ojos de esta visita. Por favor, cuando esté en la oficina de su médico,  déle a él está información. Pregúntele a él comprobar la presión y pregúntele mandarme el resultado. Él puede utilizar este número de FAX.”

“¿Cuándo hago la cita para ver a mi otro médico?”

“Debe verle tres meses de ahora.”

“Está bien, entonces, le llamo a Usted cuando me vuelvo para una cita aquí.”

Let it be said: I am a member of the Cornell Lab of Ornithology. I love birds. I don’t think enough people pay attention to them, or realize how much beauty, in sound and appearance, they add to the world. I enjoy backyard bird watching, as well as learning about new and different species from around the world. Which is precisely why, when I was working with a patient of mine one day and introduced to a new kind of bird, my curiosity was piqued.

I had just finished my examination and was trying to schedule a follow up appointment for one of my patients. He told me he wouldn’t be available in three months to see me, as, he and his wife are “snowbirds”. Snowbirds? After seeing the look of confusion on my face, he proceeded to explain that he and his wife don’t like spending the cold winter season at their home in the northeast. They prefer to fly (figuratively speaking- he liked to drive) down to Florida to spend November through March in their condo in the Keys. “But we come up once or twice to spend the holidays with the kids.”

And there it was, a new type of migratory species. And with this migratory pattern, brought new challenges to their eye care. Some of these patients have chronic eye diseases, like glaucoma, or dry eye, or iritis, ad infinitum, and they need consistent monitoring. So for these people, I had to set up a new system of care. This involved sharing their eye care with another ophthalmologist in their new winter habitat.  For these patients, at their very last visit with me before departure, I make sure to put together a short summary letter of their eye condition over the last few months. I send them on their journey with this information, and tell them when they should schedule their follow-up with their other doctor upon arrival to their wintering grounds. I always ask that the doctor they visit do me the same courtesy on their return. And I have and continue to successfully manage many patients this way.

Many of the Spanish-speaking patients in my office experience a similar migration, if somewhat farther. They return to their home countries come winter, to Peru or Ecuador or Bolivia – to a variety of South and Central American countries. I write a summary of their care, including their most recent visit with me, their visual acuity, eye pressure and general ophthalmologic status.  A separate challenge is worrying about their medication supply. Most of the time there is an equivalent eye drop (to what they are using from U.S. pharmacies) available in their home country. In situations where this is not the case, I will give them a supply of samples to cover their stay while out of the country. I make sure to reiterate that they need to arrange the appropriate follow-up with their other doctor. And of course, once their trip comes to an end, I look forward to continuing their care on their return.

“Bueno, nos vemos entonces, tenga un buen viaje.”

“Gracias-.”

“Y no olvide – lláme la oficina cuando vuelva. Quiero comprobar la salud del ojo en su retorno.”

“Claro que sí. Mucho gusto-“

"Dottie & Casper", Barn Owls. Courtesy: The Cornell Lab

Internet, M.D.

There was a time when the only access patients had to information regarding their health care or other medical problems was through their physician. And physicians, as the gatekeepers of this information, were viewed with a level of respect because of this unique knowledge that they possessed. I was a child of the 1980s and had one such family physician who was lauded in the community where I grew up. He was a good man, an intelligent one. I remember my mother bringing me into his office one night after school. I was coming down with some common school-age malady. As I was sitting in his waiting room near my mother’s side, sniffling, sneezing and wincing at the pain in my throat with every swallow, I looked around the room and watched as patients were called back, one by one, for their examination. I watched as people trudged toward the nurse at the call of their name, heavy with what seemed to be the weight of the world on their shoulders. But after a time, the door to the exam room opened and they would walk out, with more vigor and purpose, with a look of calm or even the hint of a smile on their face. And I thought to myself, my God, what kind of man is this? This doctor has the power to take a sick, unhappy, unhealthy patient-- and heal him – body and soul,  restoring him to his former self! I thought to myself, I would like to be like this man, to heal people—and make them well again. He has the answer for every problem, and patients seek him out, looking for the answers.

My childhood was also unique in that it spanned the growth and movement of computer technology into the private sector. I remember being taught in elementary school how to write program lines in DOS. As I continued to move through primary school,  high school and college, I watched as computers relied less and less on a user’s knowledge of programming to perform tasks and instead provided user-friendly interfaces so that anyone, even those without a technology background, could find them easy to use.  Then came the late 90s and the advent of the Internet which over the years grew and flourished to become a place where people anywhere at anytime can find out information – readily available at the tips of their fingers.

Some of the information people choose to seek is information regarding their health and medical problems.

Thus sprang forth WebMD, MedlinePlus, MedicineNet and a slew of other sites. Now, physicians are no longer the gatekeepers of medical information. Now, all a person needs is access to an internet provider to diagnose himself. Now, a person can forego years of medical education and sacrifice because he himself can do a review of systems, generate a differential, consider the appropriate studies, interpret the studies, diagnose and suggest treatment – because all of that information is available to him at the touch of a button. Right? Well, not exactly.

Some of my colleagues over the years have viewed the ease of access to medical information online in a negative light. They feel that there is a certain loss of respect for doctors that has occurred because doctors are no longer the only sources of medical information for their patients. As a doctor myself who examines and treats many patients every day in the office, I do understand on a very personal level why some physicians feel this way. I always have a few patients, few as they may be, who come in with a pre-conceived diagnosis who are unwilling to accept my explanation of their condition because they have read (or interpreted) something ‘different‘ online. (see my previous blog entry “ A Stye Caused My Presbyopia” ).

In the past, when I encountered these patients, I have to admit I would be disappointed because I felt that I could not overcome the wall they set up in order to educate them appropriately about their condition. However, I’m feeling less and less of that frustration these days. At some point I decided to take their faith in the Internet and make it work for me.

As an ophthalmologist, I truly love the American Academy of Ophthalmology’s website: www.geteyesmart.org which also has an equivalent Spanish-language version: www.ojossanos.org .  It is trusted and correct information regarding eye disease and treatment, because it comes directly from the Academy and is updated frequently to keep up with advances and changes in the field of ophthalmology. It is written in plain language, so people without a medical background can understand the topics with ease. Further, every eye disease is broken down into its definition, symptoms to look for, studies, exam, diagnosis and treatment. Patients can easily click on their topic of choice and share that topic with their friends or family through Facebook, Twitter, Google+ or any other number of social sites. Best of all, the articles instruct patients to review the information presented them, formulate questions and review their unanswered questions and concerns with their physician.

The reality is that today, we physicians are still the gatekeepers. We may no longer be the sole proprietors of the keys to medical information.  But, we’ll always be the master interpreters of this information. Data means nothing unless it can be analyzed and put to appropriate use.

“Quiero repasar todo la información de su examen. Los nervios ópticos son sospechosos para una condición se llama  ‘glaucoma de ángulo abierto’.”

“¿Qué significa eso?”

“Glaucoma es una enfermedad del nervio óptico que, poco a poco en tiempo, puede resultar en daño del nervio, y el paciente pierde la visión periférica.”

“¿Podemos curarlo?”

“No hay cura, pero podemos pararlo con tratamiento en la forma de colirio.”

<el médico le da al paciente un papel con escritura>

“Aquí puede encontrar el enlace para un sitio en la red “ojossanos” donde hay más información de esta enfermedad y tratamiento. Después de leerlo, si tenga preguntas, por favor, llámeme.”

“Está bien, gracias.”

Open Roads, Monument Valley, Utah

A Stye Caused My Presbyopia

Though there is no argument that culture influences a patient’s perceptions, fears, beliefs and concerns regarding her healthcare, patients, regardless of cultural origin, will be patients. We are all human, and with that comes the same human tendencies that stretch across cultural boundaries. In the following case, I highlight one such tendency – that is, for patients to make associations between symptoms that may not correct. My patient presented with a swollen eyelid, which was the immediate obvious reason for her coming to the office, but as you will soon see, it masked the real reason for her visit:

Doctor: So what brings you to the office today?

Patient: <pointing to eyelid> I have this lump on my lid.  It started two weeks ago.  I tried soaking it and it hasn’t helped.  I even tried over-the-counter allergy drops.

<after examining the eye>

D: What you have is a very common eyelid problem, it’s a hordeolum, better known as a stye.  It’s a blocked oil gland in the eyelid that has become infected.

P: Okay.

D: You have to continue doing the warm soaks with eyelid massage several times a day.  In addition, I’m going to give you a medicated eye drop that will help bring down the swelling and treat the infection.  Do you have any questions?

P: Yes, why can’t I read? I haven’t been able to read anything since this all started.

D: <looking at the patient’s age, and last chart note which was 10 months prior> It is not unusual for a person in her mid-forties to start experiencing ‘presbyopia’, or the problem with reading things in a near-range.  Have you tried using the over-the-counter reading glasses?

P: Yes, that’s what I’ve been doing, but my vision wasn’t like this before I had this stye on my eyelid.

D: It’s not unusual to make associations like that: when something is actively going on in our eyes, like a stye or infection, we focus on our eyes more, and may start to notice things we previously overlooked.  But it is very normal to start to need readers in your early forties.

P:<getting increasingly more agitated and frustrated> This problem did not start until I got this stye! My stye caused this! What are we going to do about my vision? I was fine the last time I was examined!

D: <looking at the last note’s date> Yes, but that exam was almost a year ago now, it is common to have vision changes in this time period, I assure you.  Please, try these +1.25 magnifiers on now, and see if you can read this pamphlet.

P: <looking at the pamphlet with the readers on> Yes, I can see everything, but it wasn’t like this before—I know the stye did this.

D: A stye is a blocked oil gland in the eyelid, it doesn’t affect the vision.  Here is some reading material on ‘presbyopia’ or the need for reading glasses.  Reading this information will help you understand more about the natural visual progression of the eyes over time.  We can recheck your stye in approximately 1-2 weeks from now after you’ve started treatment.

P: <doubtful> Humph, ok.<walks out, still disbelieving the doctor>

This is a classic case of a patient coming into the office with a pre-conceived idea of her medical condition and not being able to come to grips with the fact that she may be wrong in her self-diagnosis. Maybe this particular patient equates trouble reading with getting older, and doesn’t want to accept that she is getting older. It is easier to project blame onto a stye rather than aging. Maybe her difficulties with  reading remind her of a family member who lost vision and she fears she could be going down the same path. Maybe this patient truly believes an eyelid infection can cause loss of vision and simply needs to read more on the topic to understand the pathogenesis. It is hard to know exactly what factors were at play in her mind, but encounters like this are frustrating, for both doctor and patient. Both stand on different platforms of a dialogue that never truly reach a level plane of understanding. The following is another example with a Spanish-speaking patient of mine:

D: ¿Por qué Usted está aquí en la oficina hoy? Se dice aquí que Usted necesita un examen completo de los ojos.

P: Sí, necesito una examinación, y lentes nuevos, pero, tengo problema. Todos los días los ojos me arden, son rojos, y tengo lagrimeo – especialmente cuando voy afuera de la casa.

D: <después del examen> Bueno, Usted tiene sequedad de los ojos – especialmente cuando está afuera, cuando el viento sopla, o cuando está concentrando en la pantalla de la computadora todo el día en el trabajo, las lágrimas naturales en la córnea se evaporan- y el ojo se vuelve seco.

P: ¿Y por qué tengo este problema?

D: Sequedad de los ojos es muy común con el envejecimiento. Particularmente hoy día, con vídeos, móviles, computadores y todo, nuestras lágrimas se evaporan, y hay mucho más sequedad para personas de todas edades.

P: Sí pero, yo trabajaba por una fábrica que hacía aislante para hogares y, el cuarto donde me estaba estacionado era muy polvoso y sucio. Los síntomas que tengo empezaron allí.

D: Es posible cuando hay contaminantes en el ambiente medio donde trabajaba, que los puedan causar más molestía de los ojos – sí – particularmente si una persona tiene sequedad u otro problema de la superficie del ojo, pero los contaminantes no causan sequedad.

P: Bueno, pienso que el trabajo causó los problemas que tengo ahora, porque nunca en el pasado antes tenía los síntomas de ojos rojos, picazón o ardor.

D: Sí, pero tiene que recordar que sequedad de los ojos es una enfermedad que es una parte del envejecimiento. Entonces, los síntomas podrían empezado, no importa si trabajaba por esa fábrica o no.

P: <mascullando> Sí, es de la fábrica. Sí, los síntomas empezaron allí.

In one of my earlier blog entries, “The Art of Convincing”, I touch on a very similar topic, how it is difficult at times to convince a patient to be compliant with a treatment regimen, especially if the medical problem he has is virtually symptomless and not affecting the vision. When there is no pain or vision loss, it is hard for a patient to accept there is something wrong that needs daily, long-term medical care. That entry shares a common point with today’s topic: that the key to getting past these misunderstandings and incorrect associations is education. Regardless of a patient’s language, culture or medical problem, it is our duty as physicians to provide the facts to the patient through whatever means necessary to allow the patient to come to the most informed conclusion as possible. We can achieve this through thorough conversations, informational pamphlets, medical website references and second opinions with other professionals. Some patients may still come to the wrong conclusion, but through education I believe we plant a seed in their minds that they can further reflect on and question in their own time.  

 

Broken Castle, Sv. Mihovil, Hrvatska

Am I Part of the Problem?

In my October 2014 blog entry, “Now You’re Speaking My Language”, I presented a dialogue I had with a patient of mine. The patient talked to me about how he tried learning English when he first came to the U.S., and confessed he knew more of the language then than he does now. He said that he used English only at work, but when he got home at the end of the day, he surrounded himself with his family and friends—with whom he spoke only in Spanish. Since being retired, his exposure to English has dwindled to almost zero, and as a result he lost any previous knowledge in English that he had.  He stated he would be too embarrassed to speak it now, fearing he would sound foolish at best.

I was reminded of this particular conversation during a very similar encounter I just had with another patient of mine yesterday. She told me she’s been living in the U.S. for 29+ years, but doesn’t have any English language skills because she made it a point to isolate herself only with Spanish-speakers in her community. She works for a friend’s family-owned business where she only speaks Spanish. Her family and acquaintances only speak Spanish. Her education ceased back in her home country, and not exposing herself to any classes here in the U.S. keeps her speaking, reading, writing, watching T.V. and listening to the radio in Spanish. But she told me that despite all this time that has passed, she still has a hope and desire to learn English because she doesn’t want to be limited to interactions only in her small community. And she told me all this in Spanish, with me listening and responding, of course, in Spanish.

This patient’s frankness about the difficulties she’s been having made me start to think, when does a service that we provide for people become less a help to them and more a hindrance? There is an immediate need now for health care for Latino immigrants fresh to this country that are functionally illiterate in English. For these people, I can do the entire ophthalmologic exam and assessment, greet them and explain to them, diagnose, treat and provide follow-up, all in Spanish. And this is a good thing – for doctor and patient! However, for the Spanish-speaker who has been living in the U.S. for several years, who may be earnestly trying to become more proficient in English, he is greeted everywhere he goes (his community, the doctor’s office, signs in department stores) in his native language.  How does that help and encourage him to accomplish his goal of learning English? From my own personal experience with language learning, I can say that the less practice a person has in a language, the less likely he is to try and push himself to communicate in it, for fears of sounding and looking foolish. Some people are confident enough to push past this fear, but many people are not, and will just continue to communicate in what is comfortable for them-their default, native language.

As a result, I personally think it is important to communicate in both languages when possible. If I’m speaking with a patient, and I notice she seems to know a few words or phrases in English, I will interject some English when speaking with her. Or I will introduce the word for whatever we’re talking about in both languages. “Bueno, Usted necesita usar una toalla con agua tibio – a towel with warm water – para limpiar los párpados.” “Usted tiene un rasguño de la córnea – a corneal scratch – donde el palo le golpeó.” “Una catarata ocurre cuando el cristalino natural del ojo- the eye’s natural lens – se vuelve nuboso-cloudy.”

I have said before that, just as English in the U.S. has been influenced by the Spanish language, Spanish in America, too, is influenced by English. There’s no rule in the book that says that our conversations can’t reflect that- a little bit of both –un poco de los dos idiomas – to encourage learning and understanding. Let’s build a bridge across linguistic barriers and foster growth in both languages.

Blog Reference Links:

“Now You’re Speaking My Language” http://www.eyesayinspanish.blogspot.com/2014/10/now-youre-speaking-my-language.html

“Spanglish”http://www.eyesayinspanish.blogspot.com/2013/10/spanglish.html

“The Only Foolish Question is the One That Isn’t Asked” http://www.eyesayinspanish.blogspot.com/2013/12/the-only-foolish-question-is-one-that.html

Hopi Tribe wall engravings, 300-1300 AD, Utah

Letters & Numbers

When I was a resident working at Bellevue Hospital in Manhattan, the majority of my patients were immigrants freshly arrived to the U.S. from all parts of the world. Most did not know English, and required the intervention of a third party interpreter for the completion of their health care exams. Of course, it was always easier for me to communicate on a one-on-one basis with those patients from Spanish-speaking countries, because I had a fair command of the language and didn’t need to use the LanguageLines telephone interpreter otherwise provided. 

During my time there, one experience that I would come across time and again was a patient who would struggle to read the letters I put up on the screen. I would look at their age and think to myself, ‘it’s probably nuclear sclerosis, or perhaps some macular chorioretinal scarring, or corneal scarring or astigmatism, that is contributing to their difficulty’. And I would proceed to do the refraction and find no improvement. And then I would do the exam which revealed no cataracts or corneal or retinal scarring, and I would wonder why I was not getting a better visual acuity measurement. Was it amblyopia?

Many times the patient didn’t say anything to me. He would just struggle through the lines. Or he would  ask me if he could say the letters to me in Spanish, but still struggle through. One or two letters would come in loud and clear on the 20/80 line, but not much else. Just for good measure, I would put numbers on the screen.  All of a sudden, a break-through occurred. The 20/80 line plunged down to 20/30, as the patient quickly read the numbers on the wall. 

There were patients who would even struggle with the numbers, and for those I would use the tumbling E’s which, when the patient pointed out all the line directions correctly, would confirm my suspicion. That is, that I was dealing with a literacy issue and not a visual one. 

According to Wikipedia, the definition of functional illiteracy is “ having inadequate reading or writing skills in a language, as would be required for daily living and employment tasks that require reading beyond a basic level”. The article goes on to say that a foreigner living in a country with a language non-native to his own which he cannot read or write is considered functionally illiterate.

My blog has been born from the fact  that the majority of patients in the community where I work are functionally illiterate. Outside their very insular Latino community within the borders of their town, they cannot communicate with the English-speaking world. But, the majority are literate in their own native language of Spanish.

However, there are still some patients that I come across who, unfortunately, may not have had access to education in their home country. Although they can communicate easily orally in Spanish, which does not give any indication of a deficit, when confronted with reading tasks such as visual acuity taking, the problem emerges. If a doctor is not thinking about the possibility of illiteracy, then it is very easy to assume that the problem is solely visual.

A literacy chart provided by the United States CIA Factbook from 2003 looks at the literacy rates of various Central & South American countries and compares them to those of the U.S. at that time. ‘Literacy’ was defined as ‘age 15 and older that can read & write’.  In 2003, the literacy rate in the U.S. was 99% of the total population. By comparison, Puerto Rico was 94.1%. The highest rates behind the U.S. came from Uruguay 98% and Argentina 97%. The lowest were Nicaragua 67.5%, Guatemala 70.6%, Honduras 76.2%, El Salvador  80.2% and Peru at 87.7%. More recent estimates from 2012-2015 show an increase for all said countries, but still trailing behind the U.S.: Uruguay 98.5%, Argentina 97.9%, Nicaragua 82.8%, Guatemala 83.4%, Honduras 88.5%, El Salvador 88% and Peru 94.5%. 

With better access to education for all citizens, literacy rates will continue to improve world-wide. This is still an ongoing work-in-progress. Until literacy is achieved for all, doctors working with an immigrant population need to think about not only functional literacy in their multicultural practices, but also the general literacy of their patients. This issue needs to be considered, particularly if the eye exam points to a 20/20 eye, but the visual acuity result says otherwise.

References

http://latinostories.com/Latin_America_Resources/Latin_American_Literacy_Rate.htm

https://en.wikipedia.org/wiki/List_of_countries_by_literacy_rate

https://en.wikipedia.org/wiki/Functional_illiteracy

 

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