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

My Chief Complaint: When Communication is One-Sided

Me: “Hola, Soy Dra. Hromin, vamos a empezar el examen.”

Patient: “ Hi. How are you? I’m fine.” (spoken with little to no accent)

Me. “You can have a seat right there. So, I see you’re here today for a general eye exam and follow up from the last visit. Do you have any particular concerns you’d like to tell me about?”

Patient: (looking confused) “Sorry, not much English”.

Me: “Oh, está bien – puedo hablar en español – Usted habló inglés tanto bien antés, pensé que Usted querría conducir el examen en inglés. Pero está bien, ¡sólo tiene que decirme!”

Patient: (looking serious and somewhat angry) “Bueno estoy aquí por lentes nuevos.”

For anyone who’s been reading my blog and following my blog, you know that the purpose of my entries is primarily to educate and to share. You know that I’m a practicing ophthalmologist who grew up speaking only English in my family’s household. You already know it wasn’t until I started the 7^th grade that I was given an introduction to basic Spanish in school and that over the years as I grew, my Spanish grew with me. I took Spanish learning to every level of my education, high school, college, medical school. I’ve documented for you that just as conversation English and English medical terminology are two very different elements, so too are medical and conversational Spanish. You know that I want to help other physicians who learned Spanish secondarily to use it proficiently in their communications with Spanish speaking patients. My opinion of language learning is that it is fun—though it requires work and dedication – at the core it is fun, cool even!, to be able to converse with someone who you otherwise wouldn’t be able to if you didn’t speak their language.

There is on-going controversy here in the U.S. regarding whether it should be a requirement of doctors to learn Spanish to communicate with their patients. My feeling is that, though it shouldn’t be a requirement, doctors should attempt to communicate (or find services that can) in their patient’s language while patients too should take responsibility for their U.S. health care and attempt to learn some English. 

Over my last 10 years of ophthalmology practice, my overall experience with my Spanish speaking patients is that they have been nothing but grateful at my communication skills with them. There is relief, gratitude, happiness and a true sharing and learning that has taken place between doctor and patient. However, every now and again during that time period, I do come across a patient who is not grateful and friendly, but rather has a very arrogant attitude about Spanish language use in this country. Fortunately, I have had so few of these encounters I can count them on one hand, but negative experiences stand out most in our minds, unfortunately. And though these experiences were so few, they will not be forgotten.

The earlier conversation in this entry documents one of these interactions. I return to it now:

Me: “Se dice aquí que la última vez, cuando estaba aquí, el oftalmólogo empezó un tratamiento nuevo para Usted. ¿Por qué no lo ha continuado?

Patient: (somewhat heated) “El otro medico no me dijo lo que tenía yo, o que tuve que continuar con el tratamiento.”

Me: “Ok, está bien, bueno, voy a examinar sus ojos hoy, y despues podemos discutir lo que tiene que hacer.”

After the exam, having explained the patient’s diagnosis and treatment, I turned to the computer to print out his new eyeglass prescription:

Me: “Déme un momentito a escribir su receta por lentes-“

Patient: (talking to me, as I’m typing out his prescription) “Es bueno que habla español,--debe hablar español. Hay veintiseis milliones de personas quien habla español en este país. Usted debe tener la abilidad hablar con ellos.Yo vine aquí demasiado viejo a aprender inglés. No puedo aprenderlo. Mis hijas, aunque, son bilingues.”

Me: “Oh.” 

There were so many things I felt like saying, but I realized any retort would be provocation for an argument and to be honest, I wanted to finish up my prescription and get the patient on his way. His presence and words made me uncomfortable.

For the first time ever, at that moment I regretted knowing Spanish. If I didn’t know it, then I wouldn’t have understood his arrogant remarks. He felt that I “should” know how to speak and understand Spanish, to make up for his (and anyone else’s) choice not to learn enough English to at least interact with the larger community living outside his family/friends. 

I didn’t learn Spanish to satisfy this man or to make up for his short-comings. I learned Spanish because I like to learn, I love language, and because I recognize that the United States is an immigrant nation, the largest immigrant group of which happens to be Spanish speakers (the latest census of which documents 45 million Hispanophones). I knew that in my medical career there would be a very good chance I would be interacting and caring for these patients, and I wanted a personal way of communicating, more personal than a telephone line or interpreter service.

The United States has no official language. English is primarily spoken, followed by Spanish, followed by Chinese, Tagalog, Vietnamese and French, followed by an even smaller array of Slavic, European, Middle Eastern and Indian languages. With so many languages, unless one is a gifted polyglot, it is impossible to know them all fluently, let alone medical vocabulary in all of them. So, we have to find a way to work together to communicate with each other. For me, it makes sense to know the business language of the world, English, primarily but then to learn secondarily the language of the community of people I interact most often with. For anything else, I need the services of an interpreter. But I think if everyone made an attempt at learning something beyond their native tongue, this would work toward better communication and a stronger bond between one another. After all, we are citizens of a beautiful, culturally diverse nation. We should embrace that – not use it to make more divisions.

In the end, I actually felt sorry for my patient. I hope I never reach a stage in my life when I deem myself “too old” to learn something. And I hope when faced with a choice, I choose the path that unites, not divides.

Political Opinions, Preko, Croatia

Child as Translator

The following encounter is a very common one. I call Juana Sanchez* into my room to begin her eye exam. Juana smiles and nods, shyly says ‘hi’, and is followed closely behind by Maria, her daughter, who I estimate can’t be more than 8 or 9 years of age. After the initial greeting, Juana hasn’t shown me any indication that she does not understand me when I speak, so I continue to converse in English during the beginning of the exam. I ask her to sit down, directing her toward the exam chair, and usher her daughter to the chairs on the side.

Me: “ I understand you’re here today for a complete eye exam. My technician was mentioning you lost your reading glasses and would like another prescription.”

Juana (tensing up and turning quickly to Maria): “Díle a ella que no hablo íngles.”

Before the child turns to me, I say to her,

“No, está bien. Hablo español. Podemos hacer el examen en español.”

Juana smiles and Maria goes back to her chair, appearing relieved. And I’m happy to know that, at least during the time that they spend in my office, I can relieve Maria of her translator duties.

Parents using children as translators has become more of a commonplace issue in the United States- and  it’s not something only found in the doctor’s office. These children will help their parents with banking, legal documents, and licensing exams. They negotiate rent with the landlord. They fill out mortgage applications. They interpret job applications.   From 1980 to 2000, the country’s “limited-English” proficiency population doubled from 6 to 12 percent. (1) A 2013 census report found the number of people speaking a language other than English in the household rose 153% over the last two decades. As a result, it is projected by 2022, employment of translators and interpreters is projected to grow 46 percent. (2)

In Cara Nissan’s article regarding the use of children as interpreters, “Innocence lost in Translation”, she asks the question, are these children, “..learning valuable life skills, or shouldering too much family responsibility?”. Many children of immigrant parents, when asked if they mind translating for mom and dad, say they don’t mind. (1) However, one has to ask if exposing a child to highly personal information, such as that found during a medical exam, is potentially harming the child.

I have mentioned previously in my blog that I grew up a third generation Italian/Polish American. By the third generation, all foreign language was lost and only English was spoken in my household growing up. My husband, on the other hand, is a first generation Croatian American. His parents moved here in the 1970s and while they were learning the English language, my husband- of elementary school age at the time- had to interpret and translate for them in Croatian. This included, among other things, translating the household bills and negotiating with their renters. I remember when he first told me about this, I was shocked that as a child he shouldered this kind of responsibility and pressure. But to my husband, it was all matter-of-fact, nothing unusual. Still, just because something can be done doesn’t mean it should be. I feel children should be allowed to be simply that-- children.

Sabriya Rice makes an interesting point in her article for Modernhealthcare.com, “Hospitals often ignore policies on using qualified medical interpreters”, that even hospitals with an interpreter services program in place still have problems making those services available to those who need it. Many times, the busy setting and sheer volume of patients in an emergency room make taking the time to access an interpreter unpalatable to the hurried physician/nursing staff. In this scenario, they often will use their own limited language abilities or a family member to do the translating. (2)

I remember well my own experiences during my residency days at NYU. I worked at Bellevue Hospital and commonly encountered Farsi, Russian, Hindi, Cantonese, Mandarin, Spanish and Creole on a daily basis. I felt a giddy sense of relief when my patients were Spanish-speaking, because my own language skills allowed me to avoid using the hospital’s Languagelines services. I could get my eye exams with them done faster, more efficiently, and frankly, more personably.  For any other language, Languagelines was an excellent service, but it took time. I’d call in, get an operator and then I was told to wait while an interpreter was found. Depending on how remote the language was, this waiting could last anywhere from 3 to 10 minutes or more.  I remember one patient of mine who spoke a remote Chinese dialect called Fuzhou. I had to go through a Mandarin and Cantonese interpreter to discover that she spoke neither, and then had to wait longer until a Fuzhou interpreter was found. All in all this took 15-20 minutes, and this did not yet include exam time which would be another 10-15 min of back and forth talking between doctor – translator – patient. Twenty minutes may not seem like a lot of time, but when you are seeing 40-50 patients within a span of 4 hours, these minutes do add up. This is why I can empathize and understand with the health care professional who desires to create an ideal interpreter situation with her patient, but in the end chooses the faster route of having a family member, be it a child, step in for that role.

I am not a polyglot and will never be one. I know Spanish well and fortunately, I work in a community of patients where my language encounters are either in English or Spanish. I’m not advising that every doctor should attain fluency in every language of every one of his patients. That would be impossible and unreasonable. But I do feel that a doctor should look at the community she serves and the language(s) spoken, and work on becoming professionally fluent in them. Language translation/interpretation services are wonderful, but they are costly and they do take time. They also make an exam encounter less personal by introducing a third party communicator. When this is the only option you have, by all means it should be employed. Patients need to understand their health status to make informed decisions about it. But if you take the time to know the language and can speak it yourself, you save time, you save money and by far, foster a bond with that patient beyond what can be obtained over a phone or through a video. It’s not easy. It takes work. For me, it is taking a lifetime of learning. But for me in the end, the rewards far outweigh the trials and efforts to get there.

Returning to the conversation I had with Juana and Maria at the beginning of this entry:

Me: OK. Usted tiene ojos sanos, pero para contestar su pregunta, ‘¿Por qué no puedo leer sin lentes?’, es porque tiene una cosa muy común después de la edad de más o menos 40 años, “presbicia”. Significa que, el cristalino dentro del ojo no tiene la abilidad a cambiar en configuración a permitir una persona leer como facilmente que en el pasado. Es normal, una parte de vida, y ahora, para ver todas cosas cercanas claramente, va a necesitar lentes. Escribo la receta ahora para Usted.

Juana: Gracias. ¿Dondé los compro?

Me: Traiga la receta a un óptico- tenemos un óptico en nuestra otra oficina.

Juana: Está bien. Gracias- muy amable.

Me: Un placer conocerle, pase un buen día.

Maria: Wow. You speak Spanish well.

Me: Thank you – it can always use improvement, but thank you. Have a good day-

Maria & Juana: ‘Bye.

*patients' names changed to respect privacy

References

(1) Nissman, Cara. “Innocence lost in translation”. http://www.salon.com/2004/08/04/interpreters/ Aug. 4, 2004.

(2) Rice, Sabriya. “Hospitals often ignore policies on using qualified medical interpreters”. http://www.modernhealthcare.com/article/20140830/MAGAZINE/308309945  Aug. 30, 2014.

Zadar Square, Croatia

"To avoid criticism, say nothing, do nothing, be nothing." -Aristotle

The following is a recent submission I made to the 2015 Medical Economics Physician Writing Contest. It is a medley of concepts that I addressed in previous blog entries, regarding my personal experiences learning and using Spanish language with my patients. I personally believe that physicians in the U.S. are very divided on this topic - whether or not they should learn a non-native language to communicate with patients. The fact remains that while doctors debate what language they should be speaking in, a large and growing faction of patients need medical care now, and only have their language to communicate in. That being said, efforts need to be made by medical professionals to work with patients to meet this need. In my opinion, nothing achieves this more effectively and personally than conversing with and treating a patient in his native tongue. 

“I can talk to you.  You understand me.  For me, this is the most important thing.”

There is the old adage, that when making a first impression we should put our best foot forward.  As a physician, I want to put my best words forward as well.  How we speak and communicate with patients makes all the difference in their understanding of their diagnosis and treatment.  It encourages compliance with the treatment because good communication inspires patient confidence, both in the plan of action and importantly, in the doctor.

Sometimes, we take this communication ability and the importance of it for granted, until we’re faced with having to speak and examine a patient in a language non-native to our own.  Today I can say that I am bilingual, but this wasn’t always the case.  I grew up in an English-speaking household and did not begin studying my second language of Spanish until my early high school years.  This journey, from basic conversational vocabulary to medical terminology and ultimately, conducting full ophthalmology exams in Spanish, has not come without great effort and difficulty, satisfaction and frustration, on my part.  In my own experience I have found that it is not enough to simply know the medical words and translations.  It’s not always what you say, but how you say it.  In Spanish, I can get my point across to the patient, but exactly how am I doing it?  Is my word choice poor? Is my sentence structure sloppy?  Am I speaking more like an automaton and less like a human being? It is this finesse, this articulation, that makes confidence exude from our words, and we take this for granted in our primary language.  In Spanish, how do I know with certainty that I’m “saying it right” and how do I know for sure that the patient hears what I say?

I recently examined a patient in my office whose chief complaint was irritation in both eyes.  The exam revealed an aqueous deficient dry eye, the diagnosis and treatment of which I thoroughly explained to him, in Spanish.  He asked questions, I answered.  Then he said:

Patient: “Your Spanish is good. Were you born here?”

Me: “Yes, here, I was born in New York. Thank you.  But it’s not perfect,  I have to practice more.” 

Patient: “Yes, well, your Spanish is good. For me, English is very difficult.”

Me: “It can be difficult, learning another language. Particularly because the true learning comes from using the language regularly, every day, as part of your daily life.”

Patient: “There was a time, when I was working as a painter, when I knew more English than I do now. But at home I never used it, and now, so many years after retirement, I have forgotten most of it. I am almost afraid to speak it, because I don’t want to sound foolish. It is this fear that really holds me back.”

Our conversation had me thinking that, whenever I go through something difficult or challenging in my life, it has always been helpful to know these facts:

1) I am not alone in the struggle—someone else is going through it as well and 

2) other people have risen above the same challenges and succeeded.

I really appreciate my patient taking the time to tell me about his own struggle: learning English vocabulary, using it and then forgetting it. Learning the language as it pertained to his work. But especially, his fears of sounding foolish when speaking it.  This fear he admitted is so powerful that it has kept him from even trying to use English. Sometimes, I think, pushing past this fear is more difficult than the language learning itself.

I completely understand this, because I have felt this way many times. There have been many days in the course of my Spanish learning that I have felt tongue-tied and frustrated. There have been times when I felt embarrassed, not wanting to look or sound foolish when speaking to a patient. As a physician, my personal challenge every day is mustering up the confidence to speak in a language when I know I will make grammatical mistakes. To know I can’t wear my words like I do my crisp white and neatly pressed coat. My words will expose flaws, and the fear that my patient may equate flaws in speech with flaws in my knowledge and therefore, treatment of her disease looms always present in my mind.  It is daunting to be different.  To be thinking in one language, and yet speaking another.  To sound different. To know that even if I use every word correctly, my accent and mannerisms expose something that I’d rather not:

That I’m not a native speaker. That I will make mistakes. That I will sound strange, maybe even a bit foolish. But it’s helpful to know I’m not alone in this struggle. And I know that my effort is not in vain. Knowing my patients go through the same challenges too, well, this reassures me.  It makes me want to try harder, and it makes me want to encourage others when learning a language to try harder, too.

These sentiments remind me of a conversation I had with a patient years ago in practice: 

 

Patient: “I came here for an eye exam because my friend – she’s a patient here – she told me she had a good experience during her exam with you.  She told me, ‘you will like this doctor’. After meeting you, I now understand what she was saying.” 

 

Me: “Thank you, and how is that?”

 

Patient: “Well, she told me you speak Spanish. That is very important to me. I like being able to talk about my medical problems in my language, and know that you’ll understand me.”

 

Me: “That’s fine.  I know that my Spanish isn’t perfect. I am not a native speaker...”

 

Patient: “It doesn’t matter. I can talk to you.  You understand me.  For me, this is the most important thing. I am glad that you are here.”

And with that, all of my fears about expressing myself appropriately in Spanish- how I sound, the words I use, the way in which I speak, the literary pomp- it all simply melted away. Understanding—in any language, there is more than one way to convey it. For all of us, it is the most important thing.

 

Wooded trail, Adirondacks, NY