I speak, therefore I am

To me, one of the great language-learning mysteries is how and when you reach a point in your non-native language when the words you speak pour forth from feeling, and not from thinking. You don’t have to translate in your head and check sentence structure before reacting to something. I have mentioned before in so many words that, in my native English, I don’t have to think about the words I want to use. I simply feel, and then I speak. But in Spanish, though I have improved immensely over the years, there is still a great deal of thinking associated with every feeling I want to convey.

So the question is, what gets you there? What allows you to achieve this level of fluency? I would imagine, immersion. Constant interaction. Constant listening and making sense of it all. And speaking. Hearing and answering. So you can imagine, here I am everyday in an exam room with the patient, and I’m trying desperately to immerse myself in his language, making it my own. I’m trying not only to hear and answer, but to feel, in Spanish. And at times I push myself to the point where I’m close, and then—I have to look at the computer screen in front of me. The patient’s chart. And it’s written in English. And I’ve got to document in English. And I find that my efforts to attain full submersion only leave me partially submerged. I’m bobbing at the surface between the two languages, never fully achieving either. And my notes end up reflecting that: a mix of the two. A confusion.

I can’t tell you how many of my chart notes over the years are inadvertently written as follows:

She stopped using plaquenil tres años atrás.

Ella sabe poco inglés, but prefers to speak in Spanish.

Historia personal: Él nunca fumaba, bebe casi two or three drinks a week.

Sometimes I just write the physician in-notes (those not transferrable to the medico-legal record) entirely in Spanish. The remainder of the chart stays in English, until I prescribe a medication and remember to write the instructions for the patient in Spanish.

It’s a lot of back and forth, a little of this and that. A constant interchange I imagine would be easy for a bilingual native speaker of the two. But for someone like me, native to one and only a frequent guest of the other, moving between the two languages can be difficult if not at times frustrating.

In the study of ophthalmology, when two eyes are properly aligned and the image of the object in sight falls on the same corresponding areas of retina in each eye, this is known as “retinal correspondence”.  If the eyes are misaligned, then the areas where the image focuses in each eye will not correspond and will result in a condition known as “visual confusion”. In the developing child, when the visual cortex is in its plastic period, visual confusion is not allowed because the image of the misaligned eye to the brain is suppressed. In adults, this suppression is not as active, and misalignment of the eyes leads to double vision.

Well, I was just thinking that, in many ways, when a non-native speaker is trying to juggle between his native and non-native language, I have found that, to a certain extent, there appears to be another type of confusion, a “verbal confusion”.  And the brain, being the excellent brain that it is, tends to suppress the non-native words.  I can say from experience that, years ago when my command of spoken Spanish was not as advanced as it is now, my “verbal confusion center” was active at suppressing those foreign words. It held them back, allowing the English to push through. Today, this suppression doesn’t appear as active. I can balance better, but there is still a stronger pull to the dominant English.

Does one reach a stage in language proficiency, where one can move fluidly between multiple languages, without much thought and with little to no confusion? Converse in one language with the patient, but write notes in another, without so much as a stammer? I don’t know. But the best I can hope for is that one day I will know the answer because I'll be living the answer.  For now, what I have is an eclectic, interesting mix of English and Spanish. If from that mix comes better patient-doctor communication, then the struggle for language harmony is certainly worth a little confusion.

Utah desert. Courtesy: D. Hromin

Un chin-chin of Spanish

¿De dónde es usted....es cubana?

No. Soy de aquí- los Estados Unidos.

¿Nació en los EE. UU.?

Sí, ¿por qué?

Su español es como lo que se hablan en las Islas Canarias, o como las islas del Caribe. ¿Ha viajado a España, o vivía allí por un rato?

No, desafortunadamente. Mi conocimiento de español – la mayoría de ello – es teórico. Aprendía español en la escuela.

Hmm, interesante. Bueno, ¡suena cubana!

I’ve heard this from patients frequently enough that my curiosity is officially piqued! When I speak to them in Spanish at the office, they assume I’m either Cuban or from Southern Spain-- the Canary Islands -- to be exact. They tell me that my Spanish is very similar to the dialect spoken in those locations. This is very interesting and highly unusual to me, since I’m an Italian-Polish-American born to an English-only speaking family in the suburbs of New York City. I decided to do a little investigating...

Incidentally, all Spanish spoken in the Caribbean shares the same basic dialect, and there is a historical reason behind this. In the 19^th and 20^th centuries, there was a large migration of people from the Canary Islands and Andalucía (southern Spain) to Cuba and the other Caribbean islands. The speech patterns in these areas were heavily influenced by these new settlers. Common language characteristics include:

1) the “debuccalization” of the end consonant “s” – in laymen’s terms, the weakening of or even complete dropping of the “s” sound at that end of a word. For ex:

Los niños no están aquí.   --> Lo’ niño’ no están aquí.

2) the complete dropping of “s” at any position in the word. For ex.:

Disfrutar --> Difrutar  

  

Después --> Depue’ (de-pwe)

3) the dissimilation of the final “r”, particularly in infinitive words. For ex.:

Nadar --> Nada’

Although I have been known to make the pronunciation changes as described above – which could give the listener, potentially, a sense of my Spanish language origin – there are other characteristics of Cuban/Caribbean Spanish that I don’t follow. For ex.:

4) the use of “ico” or “ica” at the end of a word for the diminutive (instead of “ito/ita”), for ex, to indicate a small or quick moment, a Cuban speaker would say:

“un momentico, por favor” ,

whereas I was taught to say “un momentito, por favor”

Dominican Spanish, in addition to the southern Spain, Canary Island Spanish influence, also represents a combination of borrowed vocabulary from the Taíno language (the language of the original native inhabitants of that region) and the 17^th  and 18^th century Portuguese colonists.  In addition to the language characteristics I’ve listed above, it is also not uncommon to hear the following in Dominican Spanish:

5) Silencing of the “d” in words ending in “ado”. For ex.:

Él es casado ---> Él es casao.

Mire al lado --> Mire al lao.

6) the letters “l” and “r” are substituted for one another. For ex.:

Miguel  is pronounced Miguer

Arturo   is pronounced Alturo

7) the unique indigenous vocabulary of the region:

guagua – bus               (Castilian: autobús)

chin-chin – a little       (Castilian: un poco)

All of this research got me to thinking about my early introductions to Spanish language: who taught me, and where were they from? I was introduced to very basic Spanish (alphabet, vocabulary lists, etc) in the 7^th grade by a teacher who was French Canadian. In high school, my studies were conducted by a Peruvian teacher. It wasn’t until I reached college, and began taking advanced classes in Spanish literature and composition, that I had a Cuban professor. It was in college that I firmly dedicated myself to ‘getting the language right’, so to speak. I wanted to sound authentic, more like a native speaker, so I paid more attention to and practiced how words should be pronounced. Having a Cuban professor as my guide, it is not so unusual now to imagine how my Spanish began sounding more and more Caribbean in origin.

There is the standard, textbook language taught in school. And then there is the language spoken by the people. What they say and how they say it reflects who they are as a culture and from where they come historically. Speak the standard language with them and you open the channels of communication. But speak in their dialect, and you open the doors of trust, friendship and understanding.

“Language is the roadmap of a culture. It tells you where its people come from and where they are going.” –Rita Mae Brown

References

 “Cuban Spanish.” Wikipedia: The Free Encyclopedia. Wikimedia Foundation, Inc. 22 August 2016. Web. 26 August 2016.

“Dominican Spanish.”Wikipedia: The Free Encyclopedia. Wikimedia Foundation, Inc. 6 July 2016. Web. 26 August 2016.

Brod Fortress, Slavonski-Brod, Croatia

La Narración

A person can’t be a good translator unless she can express the same mood and sentiment of the source language in the target language. José Ortega y Gasset was a Spanish philosopher, writer and translator who lived from the late 19^th through early 20^th centuries. In his work, “Miseria y Esplendor de la Traducción”, he writes about the experience of the art of translation. He comments that,

“...La traducción no es un doble del texto original...por la  sencilla razón de que la traducción no es la obra, sino un camino hacia la obra.”

“Translation isn’t a carbon-copy of the original...for the simple reason that the translation itself is not the work, but a path toward the work.”

He goes on to say,

“Lo decisivo es que, al traducir, procuremos salir de nuestra lengua a las ajenas y no al revés, que es lo que suele hacerse.”

“The imperative thing is that, when translating, we need to leave our language behind to go to the other one and not the reverse, that is what needs to be done.”

So, in order to do a proper translation, one must know more than vocabulary and sentence structure in the target language – one must be able to express the same sentiments, the same feelings, as in the original, but within the expressive capabilities of the target language. How does one get to this level of understanding and knowledge in the target language? Well, if you were raised speaking that language, then those abilities of natural expression are innate.  If, however, you’re  like me: someone who started learning the target language later in life, then it requires years of reading, studying, conversing, interacting—and ultimately reaching a point where you can dream and ponder and be creative in that language. I don’t feel there is a time limit that can be set on this level of learning. We all march to the beat of our own drummer. With dedication, we can all achieve this degree of language proficiency.

I had mentioned in an earlier blog entry that I recently completed an English to Spanish translation class. Part of that class was dedicated to creative essay writing in Spanish. There is no better way to practice and hone expression in Spanish than writing a story documenting a personal experience in Spanish. I wrote this story based on my experiences and observations during a visit to Positano, Italy. Aside from a few grammar mistakes indicated by my professor (whoops! wrong preposition!  preterite vs imperfect!) which have since been corrected, I want to share with you the end result in its entirety. I am proud of it. At the risk of sounding pretentious (but with the hope of the most humble pretension) I consider myself a skillful creative writer in my native English. To be able to express myself in Spanish—not through translation, but through expression of the original sentiment in Spanish—felt quite freeing. I can tell the same story in two languages and from two perspectives. Not the same words, but the same meaning.

Imagine un lugar completamente tallado en la roca. Una ciudad, esculpida de una montaña cerca del borde del mar. Un lugar finito, lo que se experimenta desde la base a niveles superiores. En la base, se camina por la arena de la orilla. Hay un hombre, un pintor, quien trabaja para capturar la escena: el mar, la arena, los visitantes, una fuente antigua que existe ahora solo de decoración. Las tiendas donde se venden baratijas y recuerdos. Por el lado, la boca de una calle con el cuerpo de una serpiente. Apresuradamente, se desliza y se desaparece arriba de la montaña. 

Me encontré aquí un verano. Yo quería ver este lugar secreto, el lugar del que todos hablaban. Fue el último verano de libertad, de juventud. Antes de que todas las cosas se volverían rutinarias. Tuve que escoger. Yo podía ir por la calle, seguir la serpiente misteriosa y luchar por espacio entre turistas y autobuses de turistas. Yo podía escalar las escaleras de piedra, directamente a la montaña. Allí, más sereno, pero más difícil. Pero creo ahora lo que siempre creía:  la vida le recompensa a quien toma el camino menos transitado.  Y por eso, fui yo, arriba de las escaleras.

Los escalones de piedra cortan a través de jardines cultivados en niveles diferentes hacia la cima. Los jardines de verduras, aceitunas, frutos secos y uvas, cultivados por los habitantes allí.  De vez en cuando, entre  respiraciones fuertes, vi a una persona, cubierta con un sombrero de paja, que se ocupaba del jardín. Paré para beber de una botella de agua, mientras él esquilaba las ramas de las plantas, levantó la cosecha y fue a la casa. “Verduras para cenar”, pensé yo. Sequé el sudor de mi frente y continué adelante, cada pisada más pesada que la anterior.

Después de una hora y media, llegué a la cumbre. A la cúspide había un pueblo pintoresco, enteramente hecho de piedra. Yo pasaba por una iglesia, una tienda, un café. Cada hogar, diminuto pero fuerte, rendía homenaje a la Virgen María.   Me paré frente a un hogar. Un letrero decía: “Ristorante”. Tuve hambre y curiosidad. Entré. Seguí a una mujer a una mesa, cerca de una ventana con vista a todo: la montaña, los jardines, la ciudad, el mar. La mujer era la camarera y la hija del cocinero. Ella nació en ese pueblo. Vivía allí. Trabajaba allí. Se había ido para asistir a la universidad, pero regresó. Esa fue la vida que conocía. “Me gustaría espaguetis de aceite y ajo”. Ella desapareció a la cocina con mi pedido.

Mientras me sentaba, a esperar por la cena, pensaba de no solo la camarera en el restaurante, pero todos los ciudadanos de este lugar;  turistas, como yo, llegarían y se irían, pero los habitantes se quedarían. Estables y firmes, como la montaña así. Literalmente, vidas talladas en la roca y piedra. Ellos aprendían a vivir con el mar y el viento. Se ajustaban a su entorno, no al revés.  Pensaba en mi vida, en mi ciudad de origen.  Dondequiera que vaya, estoy llamada a volver a casa. “¿Quiere queso con eso?”, la camarera esperaba la respuesta.  Sacudí mi cabeza y sonreí.

*

Narration translated:

Imagine a place completely carved in stone.  A city, sculpted in a mountain near the edge of the sea.  A place with boundaries, which one experiences from the base level to great heights.  At the bottom, one walks in the sand along the shore.  There is a man, a painter, who works to capture the scene: the sea, the sand, the visitors, an ancient fountain that exists now only for decoration.  The stores were they sell trinkets and souvenirs.  On the side, the mouth of a street with the body of a serpent.  Quickly, it slithers and disappears up the mountainside.

I found myself here one summer.  I wanted to see this secret place, the place that everyone talks about.  It was the final summer of freedom, of youth.  Before all things would become routine.  I had to choose.  I could go by the street, following the mysterious serpent and fight for space between the tourists and the buses of tourists.  I could climb the stone steps, directly up the mountain.  There, more serene, but more difficult.  But I believe now what I always believed: that life rewards he who takes the road less traveled.  And as a result, I went, up the steps.

The stairs of stone cut through  gardens grown at various levels up to the summit. The gardens of vegetables, olives, nuts and grapes, cultivated by the inhabitants there.  Once in a while, between heavy breaths, I saw a person, covered in a straw hat, that busied himself in the garden.  I stopped to drink from a bottle of water, while he dodged the branches of plants, he picked up the harvest and went into the house.  “Vegetables for dinner,” I thought to myself.  I dried the sweat from my forehead and continued forward, each step more heavy than the last.

After an hour and a half, I arrived at the top.  At the summit was a picturesque town, entirely made of stone.  I passed by a church, a store, a café.  Each home, small but strong, paid homage to the Virgin Mary.  I stopped in front of a home.  A sign said, “Restaurant”.  I was hungry and curious.  I entered.  I followed a woman to a table near a window with a view of everything: the mountain, the gardens, the city, the sea.  The woman was the waitress and daughter of the cook.  She was born in that town.  She lived there.  She worked there.  She had left to go to college, but she returned.  That was the life she knew.  “I would like oil and garlic spaghetti.” She disappeared into the kitchen with my order.

While I was seated there, waiting for dinner, I thought not only of the waitress in the restaurant, but of all the inhabitants of that place; tourists, like me, would come and go, but the townspeople would remain.  Stable and firm, just like the mountain.  Literally, lives carved in rock and stone.  They learned to live with the sea and the wind.  They conformed to their environment, and not the reverse.  I thought about my life, my city of origin. Wherever I go, I am called to return home.  “Do you want cheese with that?”,the waitress waited for my response.  I nodded my head and smiled. 

Vernazza, Italy. Courtesy: D. Hromin 

Difficulty is in the Eye (and Ear and Mouth) of the Beholder

“Usted habla español bien. ¿Dónde lo aprendió?”

“Gracias. Aquí...en las escuelas aquí en los EE.UU.”

“Es bueno tener un médico que habla mi lengua, porque no hablo ni entiendo inglés.”

(el examen continúa)

“Pienso que inglés sea mucho más difícil que español.”

“¿De veras?—¿En qué manera?”

“Bueno, las palabras – no se dicen  como se escriben. En español, se dice una palabra exactamente como la se escribe. Y también, la ortografía es bien diferente. Pero, me gustaría saber el idioma, un día.”

“Sí, es bueno saber más que una lengua- especialmente en este mundo global.”

It surprised me when my patient said she thought English is a more difficult language to learn than Spanish. It made me think back to a quick search I did once a while back-- it was one of those days I had some down time and for interest’s sake decided to compare languages.  I looked up “most difficult languages to learn” (from an English speaker’s perspective) and what I saw didn’t shock me. In no particular order: the Asian languages: Chinese, Japanese, Korean etc, Hungarian, Icelandic (can you pronounce: Reykjavík?), Native American languages such as Apache, Cherokee, Choctaw and Navajo (incidentally, the Navajo language, due to its varying inflections, the existence of few native speakers and, at the time, the fact that it was an entirely oral and unwritten language, was used as a method of communication between US Marines during WWII, in an effort to hide military plans from the Japanese. The most skilled of Japanese decoders couldn’t break the Navajo communications during WWII).   Other languages making the difficult list include Polish, Russian and German followed by the romance languages.

But grammar rules and pronunciations aside, I personally feel a language is difficult to learn if it is significantly different in its rules, sound and structure to the one you grew up learning. Then again, anything different from what we know and are familiar with would seem daunting, minus any practice or experience.

In an effort to research more about language difficulty, specifically related to English and Spanish, I located an interesting article on the web: “The Differences Between English and Spanish,” which begins by stating that written English in and of itself is not problematic for the native Spanish speaker. However, the pronunciation, or phonology, causes several problems for a Spanish speaker learning English.   The length of the vowel, when pronounced in English, is very important to discerning the meaning of the word. Examples include:

sheep/ship

cat/cut/cart

fool/full

One personal example of this that I encountered in the office one time when asking a patient what pharmacy he uses:

“Quiero mandar la receta a la farmacia. ¿Cuál farmacia utiliza usted?”

“La una aquí en Garnerville...Drew-car. Pienso que sí. ‘Drew-car’.”

“Perdón, pero no conozco ‘drew-car’.  ¿Tenemos CVS...o Rite Aid...tal vez Walgreens?”

“No, no...hmmmm. Está ubicada cerca de la estación de gasolina. Ahí, en la carretera <202>. Drew-car.”

“<al pensar> ¡¡¡O!!! Usted quiere decir ‘True-Care’....True-Care Pharmacy!”

“<al reír> Sí, sí. Drew-car.”

This is particularly interesting to me, because there are several aspects of the English language that I take for granted as a native English speaker. But, if one can’t pronounce the subtle difference between the ‘tr’ of true and ‘dr’of drew, then he will not be understood by the listener.

The article continues by addressing the consonant sounds--which in general are not problematic for Spanish-speakers--except when used in particular instances, and other tricky nuances to the language:

a. Not pronouncing the end consonant hard enough:

            ie. “saying brish for bridge or cart for card ...”

b. Trouble deciphering phonetically similar sounding words like see/she or jeep/cheap/sheep..”

c. Problems with auxiliary verbs. Remember, in English the auxiliary, or helping, verb works with the main verb of the sentence to add clarity to the phrase. Auxiliary verbs, though used in Spanish, are not used as commonly in oral conversation. For example, in English:

            ie. Did he remember to put the garbage out?  Main verb: remember, auxiliary: did

            A Spanish speaker commonly makes this error when trying to say the same thing:

            ie. He remember to put the garbage out? The auxiliary is left out, and the sentence sounds wrong. There are only three auxiliary verbs in English: to be, to have, and to do, but using them appropriately is important to providing clarity to communication in English.

d. Inability to infer the spelling of a word in English from its pronunciation:

            In Spanish the sound of a word is strongly correlated to its spelling. As any native English speaker knows, this is not the case at all in the English language. For example:

            won, one  They’re pronounced the same, but the spelling and meaning are different

            their, there, they’re  Same concept

            And what of heteronyms? Words in English that are spelled the same, but when pronounced differently have different meanings, for example:

            bow  if said BAU: the front of a ship or to lower one’s head; if said BOH: a device for shooting arrows or a decoration for one’s hair

            contest  if said kahn-TEST: to argue;  if said KAHN-test: a competition

And the list goes on and on....

Researching more into my native English makes me appreciate more the difficulty that my Spanish-speaking patients encounter when in the process of learning the English language.  It gives me new insight into my own native tongue, and why certain concepts of my own Spanish learning come more easily than others.  I’m either aided or, conversely, tripped up by preconceived grammar and pronunciation rules molded and shaped by years of English education. Though there are some tools from our native tongues that we can take with us when embarking on new language learning, we invariably have to leave other concepts behind. Letting go of a lifetime of foundation can be scary, but it is precisely in the letting go that we evolve to something more unique and beautiful.

References

“Auxiliary (or helping) Verbs.” Ginger Grammar Rules. http://www.gingersoftware.com/content/grammar-rules/verbs/auxiliary-or-helping-verbs/ (Accessed August 6, 2016).

Ellis, J. “Welcome to the Heteronym Homepage!” 6/1/96

http://www-personal.umich.edu/~cellis/heteronym.html (Accessed August 6, 2016).

Shoebottom, Paul. “The Differences Between Spanish and English.” Frankfurt International School. http://esl.fis.edu/grammar/langdiff/spanish.htm (Accessed July 31, 2016)

Wilsont, William R. “World War II: Navajo Code Talkers.” HistoryNet. 6/12/06 http://www.historynet.com/world-war-ii-navajo-code-talkers.htm (Accessed August 6, 2016).

Barn Owl. Courtesy: Rogers Wildlife Rehabilitation Center

When Translation is Law

“The single biggest problem in communication is the illusion that it has taken place.”George Bernard Shaw.

As a follow up to Intro to Translation, I would like to review exactly what types of documents physicians are required by law to translate for their practices.

If a physician has a practice which provides care to a substantial number of non-English speaking, or LEP (limited English proficiency) patients, then providing these patients with translated documents has a number of benefits. The United States federal government defines LEP as a patient’s own self-assessment of his or her ability to speak and understand English as less than very well.

Patient satisfaction surveys have consistently shown that LEP patients have 36% lower satisfaction rates than English speaking patients and 47% --almost HALF of them – are more likely not to return for future care as a result. Although there are 6 types of medical documents that must be translated in order to remain compliant with federal law, it may be worthwhile to consider including other practice materials, such as patient education materials or patient survey forms, in an effort to improve the LEP patient experience.

Under the Civil Rights Act of 1964, Title IV, patients cannot be discriminated against because of national origin by any institution that receives federal funding. When documentation is not provided in a language the patient can understand, this too is considered discriminatory under this act. The specific requirements for translation were further elucidated upon in 1997 by the Critical Access Hospital Program which focused on hospitals in areas of the U.S. that have a higher percentage of LEP patients. The six types of documents that must be translated are:

1 – notices of free language assistance

2  - eligibility for services of language assistance

3 – patient intake forms

4 – informed consents

5 – patient complaint forms

6 – discharge instructions

The Office of Civil Rights (which is part of the Department of Health and Human Services) requires that these documents be translated when “the LEP language group constitutes 5% or 1000 persons – whichever is less – of the population served.”

State government interpretations of this law may be more strict, as in the case of New York State, where the requirement given by the Office of Civil Rights has been expanded to “1% of the hospital service area.”

It is further important to note that the Affordable Care Act (ACA) has shifted incentives for doctors and hospitals to offer better quality, not quantity, of care. In essence, there are financial repercussions to providing care that does not result in patient satisfaction. Medicare provides higher rates of reimbursement with more readmissions. Doctors receive bonuses or penalties if they receive high or, conversely, low scores on patient satisfaction surveys.

Therefore, it is in the doctor’s best interest, aside from satisfying the legal translation requirements for providing care to LEP patients, to try to overall improve the LEP patient’s entire office experience by offering as much patient material as possible in the language the LEP patient can understand. These include as mentioned earlier in this blog entry: patient education pamphlets, surveys, and marketing materials.

The consent forms I have been referring to in this article apply to procedural consents provided to patients. In my office, they would include cataract surgery, laser iridotomy, chalazion/eyelid lesion excision, selective laser trabeculoplasty and YAG capsulotomy consent forms- to name a few. However, it is important to note that research-related consent forms are also included in this category.

The Institutional Review Board (IRB) requires that consents for research must be written in the language in which the patient interview is conducted. Further, according to information provided on the Language Scientific website regarding IRB-specific consent forms, there are 4 specific scenarios to consider when deciding if consent forms have to be translated from English:

1 – If the patient/participant has the ability to read and understand sixth-grade level English, then no translation is necessary. Forms may be provided in English.

2 – If the patient/participant cannot read but understands spoken English, then it is possible to have someone read the consent form to them with a witness present. Understanding by the patient must be documented and the patient, witness and reader of the consent must all supply signatures at completion.

3 – If the patient/participant cannot read or understand spoken English, but is fully literate in another language, then the consent and all related materials may be translated into the language the patient understands.

4 – If the patient/participant cannot read or understand spoken English, nor is literate in another language but can understand another language when spoken, then the consent must be translated into the other language and another person must read the translated consent to the patient with a witness present, documenting that the patient understands all that is being said. In the end, the patient, the reader of the consent and the witness will provide their signatures to this effect.

Further, the IRB “.. must review and approve all translated versions of an informed consent form before the form is used in a study.” If the study itself is complicated or carries with it significant clinical risk, then an added safety measure for quality assurance of a proper translation must be provided to the IRB via a back translation. A back translation is one where the translated document is translated back into the original English by a separate translator, to ensure that everything written in the language correctly reflects that which was written in the original English.

References

duMont-Perez, Suzy .“The 6 Medical Documents You Must Translate to Remain Compliant.” LanguageLine Solutions. http://blog.languageline.com/6-medical-documents-must-translate-to-remain-compliant (Accessed July 22, 2016).

Markert, Cory. “Medical Translation: Is Translation of Vital Documents Enough?” LanguageLine Solutions. http://blog.languageline.com/medical-translation-is-translation-of-vital-documents-enough (Accessed July 22, 2016).

“Office Guide to Communicating with Limited English Proficiency Patients.” American Medical Association. https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=what+is+the+definition+of+an+LEP+patient (Accessed July 23, 2016).

“6 Things to Know About Translating Informed Consent Forms.” Language Scientific. http://www.languagescientific.com/6-things-to-know-about-translating-informed-consent-forms-2/ (Accessed July 24, 2016).

Dubrovnik, Croatia. Courtesy: D. Hromin

Intro to Translation

“Translation is that which transforms everything so that nothing changes.” –Gunter Grass

I recently completed an 8-month long translation course focusing on English to Spanish translation. My initial intent was to focus solely on medical translation: consent forms, patient information pamphlets and the like. However, this course offered a variety of material: legal, business, economic, and fictional narratives to be translated from the English source material to Spanish. It definitely was a demanding class, requiring much reading, researching, writing and editing, but it helped me improve my written Spanish communication immensely. Reading and writing a language is also a superb way to increase vocabulary and grammar knowledge. It’s easy to graze over grammatical errors when we speak, but writing hides nothing. There it is, in black and white, for the reader to see: spelling mistakes, run-on sentences, incorrect punctuation, missing accent marks and all.

I plan on shifting my blog focus for several future entries on written Spanish. This is because working as a physician demands not only the ability to dialogue with patients, but to also provide them with various forms of reading material in Spanish. You cannot orally describe a surgical procedure to a patient in Spanish, only to hand them the consent form written in English. Because Spanish is the second most popular language spoken in U.S. homes, there is a wealth of reading material available in the various areas of medical specialty that physicians can obtain for their patients.

However, there are always office-specific procedural forms, consents and materials, research study descriptions and consents, that need to be translated. Take, for example, a study design on cytomegalovirus-induced uveitis in immune-compromised patients below. This was one of my class assignments for translation.

While comparing the translation to the original, take note that there are several factors to consider when translating a document. A few to consider are: Who will the reading public be? Should certain names and/or abbreviations be left in the original English? Are numbers and measuring units written the same way in the target language as in the source? Do you keep the same formatting? Answering these questions first helps to create a successful and cohesive translation.

Methods

Patients
Patients with AIDS and newly diagnosed, active cytomegalovirus retinitis were enrolled at 18 clinical sites in the United States. Eligible patients had to be at least 18 years old, and their best corrected visual acuity had to be 20/200 or better in at least one affected eye. Exclusion criteria included opacities that would prevent visualization of the fundus, contraindications to intraocular surgery or to therapy with intravenous ganciclovir, the presence of overt signs or symptoms of extraocular cytomegalovirus infection, an absolute neutrophil count below 500 cells per cubic millimeter, a platelet count below 25,000 cells per cubic millimeter, a serum creatinine concentration above 1.5 mg per deciliter (133 µmol per liter), and a Karnofsky score below 60. Informed consent was obtained from all patients.

Base-Line Evaluation and Randomization
Before randomization, patients underwent a complete base-line examination, which included nine-field fundus photography. The randomization was stratified so as to distribute patients with unilateral and bilateral cytomegalovirus retinitis equally among the three treatment groups, and blocking was used to assign patients equally to the treatment groups over time.

Treatment and Follow-Up
Eligible patients were assigned with equal probability to receive one of three treatments: an intraocular implant (Vitrasert, Chiron Vision, Irvine, Calif.) with a release rate of 1 µg of ganciclovir (Cytovene, Roche Laboratories, Nutley, N.J.) per hour, an intraocular implant with a release rate of 2 µg of ganciclovir per hour, or intravenous ganciclovir. A 2-µg-per-hour implant was included to determine whether a release rate higher than that used in a previous study³⁷ (1 µg per hour) would have greater efficacy. Investigators and patients were unaware of the release rate of the ganciclovir implant. The surgical procedure to insert the implant has been described elsewhere.^35,36 Patients assigned to receive intravenous ganciclovir received an induction dose of 5 mg per kilogram of body weight twice daily (total daily dose, 10 mg per kilogram) for at least 14 days, followed by maintenance therapy at a dose of 5 mg per kilogram once daily.
For patients in the implant groups, ophthalmic examinations were performed on postoperative days 1, 3, 4, 5, and 7. Patients in all three groups were examined at weeks 2, 4, 6, and 8 and then monthly until there had been eight months of progression-free follow-up or until progression of cytomegalovirus retinitis, death, or another event specified as leading to the termination of follow-up occurred. At follow-up visits from week 2 on, a complete ophthalmic examination was conducted, including measurement of visual acuity with modified Bailey–Lovie charts,⁴⁴ slit-lamp examination, indirect ophthalmoscopy with the eyes dilated, and bilateral, nine-field photography of the fundus.

[ Source http://content.nejm.org/cgi/content/full/337/2/83, New England Journal of Medicine]

Métodos

Pacientes

Los pacientes con el síndrome de inmunodeficiencia adquirida (SIDA) y la retinitis activa por citomegalovirus (CMV) de diagnóstico reciente se inscribieron en dieciocho sitios clínicos en los Estados Unidos. Los pacientes elegibles tenían que tener por lo menos dieciocho años, y la agudeza visual mejor corregida tenía que ser 20/200  o mejor en al menos un ojo afectado. Los criterios de exclusión  incluyeron: opacidades que impedirían la visualización del fondo del ojo, contraindicaciones de la cirugía intraocular o la terapia con el ganciclovir intravenoso, la presencia de signos o síntomas evidentes de la infección por citomegalovirus extraocular, un recuento absoluto de los neutrófilos debajo de 500 células por milímetro cúbico, un recuento de plaqueta debajo de 25.000 células  por milímetro cúbico,  una concentración de creatinina sérica arriba de 1,5mg por decilitro (133 µmol por litro) y índice de Karnofsky debajo de 60. El consentimiento informado se obtuvo de todos los pacientes.

Evaluación inicial y  randomización

Antes de la randomización, los pacientes tuvieron una evaluación inicial  que incluyó la fotografía de nueve campos del fondo del ojo. La randomización se estratificó para distribuir de manera equilibrada los pacientes con la retinitis por citomegalovirus unilateral o bilateral entre los tres grupos de tratamiento, y el bloqueo de los datos se utilizó para asignar a los pacientes por igual a los grupos de tratamiento a través del tiempo.

Tratamiento y  seguimiento

Los pacientes elegibles se asignaron con probabilidad igual para recibir uno de tres tratamientos: un implante intraocular (Vitrasert, Chiron Vision, Irvine, Calif.) con una tasa de liberación de 1 µg de ganciclovir (Cytovene, Roche Laboratories, Nutley, NJ) por hora, un implante intraocular con una tasa de liberación de 2 µg de ganciclovir por hora, o ganciclovir intravenoso.  Un implante de 2µg por hora se incluyó para determinar si una tasa de liberación superior a la utilizada en un estudio previo³⁷ (1µg por hora) tendría mayor eficacia. Los investigadores y los pacientes no estaban al tanto de la velocidad de liberación del implante de ganciclovir. El procedimiento quirúrgico para insertar el implante se ha descrito en otra parte^35,36. Los pacientes asignados a recibir el ganciclovir intravenoso recibieron la dosis de inducción de 5mg por kilogramo de peso corporal dos veces al día. (la dosis diaria total, 10mg por kilogramo) por a menos 14 días, seguido por el tratamiento de mantenimiento con las dosis de 5mg por kilogramo cada día.

Para los pacientes de los grupos con implantes, se realizaron exámenes oftalmológicos en los días postoperatorios 1, 3, 4, 5, y 7.  Los pacientes en los tres grupos se examinaron en semanas 2, 4, 6, y 8 y luego mensualmente hasta que había pasado ocho meses del seguimiento sin progresión o hasta que la progresión de la retinitis por citomegalovirus, la muerte, o cualquier otro evento especificado como la causa de la terminación del seguimiento. En las visitas de seguimiento de la semana 2 y demás, un examen oftalmológico completo se realizó y se incluyó la medida de la agudeza visual con los gráficos  modificados de Bailey-Lovie⁴⁴,  el examen por la lámpara de hendidura, la oftalmoscopia indirecta con ojos dilatados, y  la fotografía de nueve campos del fondo de nueve campos del fondo del ojo bilateral.

Joan of Arc, Jules Bastien-LePage

All the better to Hear you with, my dear

When you talk, you are only repeating what you already know. But if you listen, you may learn something new. –Dalai Lama

I have been using Spanish daily in my work for at least 15 years now, and I’ve been studying it for 28+. I have what I like to call a professional fluency. I know vocabulary, phrases, questions, answers and conversation centered on the ophthalmologic exam.  I can converse outside this, but I have many more years to go before considering myself at near-native level. I have found during this time period that my reading and writing skills in the language from very early on far surpassed my listening and speaking ability. I could never understand why. I looked at studies that analyzed how people learn in general, and then at studies that focused on the mechanisms that go into language learning in particular. I looked at articles that documented the neurophysiology of language acquisition, the best brain periods of a person’s life to absorb a language. The best conclusion – scientific conclusion – that made sense to me was that neurologically, we are wired to become accustomed to the sounds (language sounds) we hear as an infant and child growing up, and our brains “prune away” neurologic connections for foreign sounds. I suppose for survival purposes, this adaptation increases survival ability. It allows a person to hone in on conversations and communications he can understand and respond to, and keeps “foreign” and confusing sounds that would lead to a break down in communication, out.

But then there’s the argument, what do you say about the people who pick up languages easily later in life? People that can be thrown into a crowd of individuals speaking another tongue and, given some time, they begin to verbally communicate and understand, having never seen one written word. Or what about those individuals who learn multiple languages? How do their brains get accustomed to hearing, accepting and analyzing varied sounds? How do their brains reconcile the differences in those sounds? How do they not confuse the languages when they speak? Is this just an extra “gift” that a person has? A talent? Like being a concert violinist or a world-renowned sculptor? Can the average individual re-teach his brain? Can he force his brain to accept that to which it is not accustomed?  

In pondering these questions, I turned to the first open source of information available: the Internet. I searched: “How to improve my listening skills in a language?”.  A multitude of hits came up, which I eagerly perused hoping for the answer. The one that piqued my interest the most is an article written by a guest blogger on Benny the Irish Polyglot’s website Fluent in Three Months.

In his article, How to Improve Your Listening Skills in a New Language, author Andrew Barr talks about the need for something he calls ‘high stakes active listening’. What he is referring to is the fact that many language programs today encourage passive listening as a way to learn a language. An example of passive listening is listening to a CD of native speakers while on your drive to work: you’re hearing them, but you’re not actively engaging in conversation. You have no impetus to have to understand everything they’re saying. Instead, Mr. Barr encourages active listening:  listening because you have to hear and understand the answer in order to accomplish something. He gives an example of when he experienced this type of listening for the first time during his trip to Spain. He had parked his car in a public garage and needed to find out if he would be able to get access to the garage after hours, otherwise, he would have been stranded without a car in the city that night. He had a reason, a true need, to communicate with the parking attendant and figure out what the man was saying in order to get his car later.

After reading this, a light bulb went off! I realized that the reason my communication skills in Spanish have increased tremendously over the last ten years in medical practice is because I, too, have experienced this type of high stakes active listening. In my case, there is a very important need to find out crucial information related to my patients’ medical history. I need to know symptoms, duration, medication, and allergies to ultimately correctly diagnose and treat the patient. When a patient tells me something in Spanish and I don’t understand completely, I ask them to repeat it. Even though I don’t want to appear foolish - even though I want to look like I understand everything easily and readily, the need for accurate information outweighs my linguistic ego. The need to know increases the stakes of learning. I have to know this information, and that gives me the drive to really listen and make sense of what I’m hearing. 

So, to go back to my earlier question: how does someone improve her listening skills in a language? Is there a specific technique, or must you be born with a talent for languages?

The answer is: you don’t need to be born with a special linguistic talent. Anyone can improve his skills in any language, but in order to do so he must take an active role interacting in that language. You can’t build muscle simply staring at equipment in the gym. You must use the equipment. The next time someone speaks to you in Spanish, don’t just listen to words spoken, really listen. Hear the words. Then, make sure to respond to them.

References

Barr, Andrew. “How to Improve Your Listening Skills in a New Language.” Fuent in Three Months  Web.  http://www.fluentin3months.com/listening-skills/

Salt Flats, Death Valley, CA