Two tongues

It’s not unusual to have multiple family members in the room when I’m examining a patient.  Sometimes a grandmother will be accompanied by her daughter and grandchild.  Sometimes a husband brings his wife.  Sometimes, a mother comes with her child and her sister.  But multiple family can be multilingual.  Some may speak Spanish while others know only English or are fluent in both languages.  This can present a special challenge to the health care worker—who to address? –and how?

A woman brought her 10 year old daughter in to see me at the advice of her daughter’s pediatrician.  The young girl had been rubbing her eyes at night when watching TV.  In addition, evaluation of her vision at the pediatrician’s office revealed poorer vision right eye vs. left.

I could hear the technician getting the patient’s medical history and checking her vision in the next room and she was talking to the mother in Spanish and the daughter in English.  I find these situations sometimes awkward, because I am not always sure how I should introduce myself and address the patient and family for the entirety of the exam. 

Do I walk in speaking Spanish?   “Hola, Soy Dra. --. Voy a examinar su hija hoy.”

Do I then conduct the whole exam, including diagnosis and explanation, in Spanish?

Do I walk in speaking English?  “Hi, I’m Dr. --, I’m going to examine your daughter today.”

Do I then conduct the whole exam in English?

Do I address the daughter and the mother in two languages, English for daughter, Spanish for mother?

I use the word “awkward” because my goal is always to make the patient and family feel comfortable.  People feel comfortable with their doctor when they can understand their doctor, and when they know their concerns are being heard (and understood) as well.

In this particular case involving a minor, even if one doesn’t factor in languages, I prefer to address the parent/guardian involved, at least initially.  Usually the child will know the parent’s tongue and be able to follow along, but this is not always the case. Here, when I addressed both of them in Spanish, I could tell there was some vocabulary the daughter didn’t understand, and further, she did not know the letters on the Snellen chart in Spanish.  So I actually used a little bit of both:

Me: Hi, I’m Dr.--, (smiling at child and mother), which is better for you—English or Spanish?

Mother: Para mi, español, pero para ella, inglés o español. Ella sabe las letras en inglés.

Me: Está bien. (addressing both child and parent) ¿Entiendo Uds. están aquí porque el pediatra les dijo la visión es borrosa?

Mother: ¿Borrosa? No—por la noche cuando ella mira la televisión, está frotando los ojos constantemente.

Me: Ahh, (turning to the daughter) ¿cuando miras la televisión, tienes picazón en el ojo?

Daughter (to mom): ¿Qué?

Mother:  ¿Tienes picazón? ¿Alergias en el ojo?

Daughter (shakes head no)

Me: ¿Te arden los ojos?

Daughter: No.

Me: (to daughter) ¿Los ojos están lagrimeando? (to mother): ¿Ve Ud. que sus ojos están lagrimeando?

Mother & Daughter: No.

Me: (To mother): ¿Ella no está tomando medicamentos y no usa gotas para los ojos?

Mother: No.

Me: OK, vamos a ver…(some minutes later). Bueno, ella tiene ojos saludables. El nervio óptico, la retina, el lente—todo está bien. Pero, es posible que, cuando mira ella la televisión, el ojo se seca, y es por eso ella está tocando los ojos.

Mother: OK.

Me: Me gustaría darle a ella lubricantes—gotas artificiales los que puede poner en sus ojos cuando ella mira la televisión. Y, otra cosa, la visión está bien. Con los dos ojos, ella ve 20/20, pero el ojo derecho es un poco mas débil comparado con el otro. Es porque el ojo tiene poco miopía. Ahora, no significa nada y no necesita lentes. Pero en mi opinión, ella debe regresar aquí cada ano por un examen de los ojos a determinar si ella necesita lentes o no.

Mother: Está bien. Gracias.

And the exam went well, the conclusion here being that in situations where the patient and family may not be on the same page linguistically, the best thing to do at the onset is to ask what they prefer and tailor the visit to those particular language needs.

One recurring theme you will find in this blog is the fear of looking or sounding foolish when trying to communicate in a non-native language.  I am always thinking in the back of my mind when I talk with  patients in Spanish, Did I say that right? Did I conjugate wrong? Am I verbally butchering my assessment and plan??.  I worry so much about how I sound, that I don’t stop to think about how tough it must be for the mother in the above scenario.  Here,  her daughter is easily conversing with a doctor in a language non-native to her.  Though the mother may know basic English, she doesn’t use it because she may also be anxious about appearing foolish. As in, how can she know less than what her young daughter knows? Being sensitive to these issues is equally as important as diagnosing and treating the medical condition at hand—and your patients will truly appreciate you for it!

Courtesy: D.Hromin

Eye has not seen

An interesting news article recently documented a young woman, Dorothy Villareal, of Mexican descent currently living in Texas.  Her family had moved from Mexico to Texas when she was 6 years old.  Growing up, she and her family always spoke Spanish in the home. Yet in school, she was educated and excelled in English.  Hence, she thought she was fluent in both languages.  But when the time came to study abroad in Mexico during her junior year at Harvard University, she discovered that her vocabulary in Spanish didn’t extend far beyond everyday conversational lingo.  Further, she was limited reading and writing it as well.

Because more and more people in the U.S. grow up in a household where English is not the spoken language (or, at least, not the only spoken language) more schools are creating foreign language programs for these ‘heritage learners’.  A heritage learner is someone who speaks a language conversationally because they grew up with it in the home, but would drown in otherwise higher educational classes conducted in the language.  More than 37 million people speak Spanish in the U.S., and classes geared toward Spanish heritage learners have flourished in California, Florida and southwestern states, and continue to grow nationwide.  Wides-Muñoz, Laura.   [Schools are introducing foreign language classes for “heritage learners”—students who speak a language like Spanish at home but were educated in English] Retrieved from: http://news.msn.com/pop-culture/2nd-generation-immigrants-study-heritage-languages

After reading this piece, I got to thinking that I can’t help but be fascinated by the concept of being able to speak a language—and know it by heart—without being able to read or write it!  I was first introduced to this possibility through my husband.  He is first generation Croatian American –his parents emigrated to the US in the early 1970s.  Since he was 2 years of age, his parents took him practically every summer to see his extended family in Zadar, Croatia.  So, needless to say, he is fluent in Croatian. 

However, fast-forward 30 years to when we met, and I started to try to teach myself some basic Croatian to communicate with his family.  In an effort to cement the new phrases in my mind, I would send him short emails or text messages written in the language, and was surprised to discover that—he could barely read them and couldn’t write back very well.  This really intrigued me.  In other words, how could you know a language, and yet not know? How can you base all of your understanding only on sound?

There are various theories that were formulated in the 1970s-1980s as to how a person learns and acquires information.  The most popular of these theories is Neil Fleming’s VAK model, for : Visual, Auditory and Kinesthetic learning styles.  (Incidentally, the reason behind trying to figure out how people learn and acquire new information was to be able to apply it to the educational setting in the hopes that matching a person’s learning style to how they’re taught would increase knowledge learned. Unfortunately, this was never scientifically proven to be of benefit).

Cherry, Kendra.[VARK Learning Styles. Visual, Aural, Reading, and Kinesthetic Learning.]Retrieved from: http://psychology.about.com/od/educationalpsychology/a/vark-learning-styles.htm

Anyway, without taking any special ‘what’s your learning style?’ quizzes, I immediately knew how I acquire information the best: VISUALLY.  I have always been able to remember things by reading –I remember by seeing what I’ve read in my mind.  Even though we know our primary language only by sound initially—by hearing our parents and family members talk in the home—I can distinctly recall that my vocabulary in my native English didn’t increase exponentially until I went to school and learned to read.   I needed to assign a visual representation to the sound I was making in order to remember.  And this is the way I’ve always been.

So what does that leave us with? When we’re in Croatia, my husband can get anything done in the Croatian language (which is Hrvatski, by the way): bring a car into the shop for repair, buy a phone card, rent a kayak, find out the ferry schedule. Me? I don’t understand a peep of their jargon and can speak even less, but…. I CAN DIAGRAM A SENTENCE  AND DECLINE NOUNS AND ADJECTIVES PROPERLY, GOSH DARNIT!  But….What good, you might ask, is that??

This brings up some valid points for consideration:

                1-Which situation is more functional for everyday life?

                Yes, it’s important to know how to read and write the secondary (and tertiary, quaternary etc.) language,  but speaking and understanding the language seem to be what serve you the best as far as communication.

                2-What constitutes knowing, I mean, really knowing, a language? 

                This is a topic I’ll cover more in-depth in another blog entry, but there are people out there, polyglots, who claim to KNOW several languages. And they very well may! But what is the definition of “know”?   Is it conversational? Is it scientific? Do they know just enough to locate the nearest bathroom or are they able to counsel and comfort a friend who has just suffered a death in the family? Do they know the school-taught vernacular, or are they intimately acquainted with the tongue’s dialects? Can they just speak and listen, or can they read a newspaper and write a documentary?  

I remember numerous occasions when I first started using Spanish in the office. As I’ve mentioned several times before in this blog, my listening skills and conversational vocabulary were choppy at best. But I could always write out instructions on what drops to use and how frequently, and where to buy them, all in Spanish. Many times the patients couldn’t believe I could write all that, because my written skill and my spoken one just did not coincide at all.  It has taken years to reach a level where I can understand and answer a patient’s questions fluidly in the exam room.  So what is my advice in regards to use and/or mastery of a non-native language? To be honest, I’m not sure—I have trouble using the word ‘mastered’ to describe my Spanish, even though I have grown by leaps and bounds in it over the last two decades.  Simply, know how you learn best, and apply this to your every day. Eventually, the words do make more sense—and their corresponding sounds don’t sound so foreign anymore.

Courtesy: D.Hromin

A Rose by any other name…well, except for ischemia

Medicine is its own language.  Walking into an exam room and using every Latin or Greek root word learned along the way from undergrad through residency is not advisable.   Coronary infarction!  Diabetic retinopathy!  Retinal ischemia!  Non-arteritic anterior ischemic optic neuropathy! 

The implications of these diagnoses physicians well know spell trouble for the patient. But for the patient, the words themselves are troublesome and scary!  Even in English we have our own layman’s speak for medical terminology. And this is true in every other language, not only English. Case in point: the technical term for a dark, harmless growth on the skin is a “nevus”. But how many people do you hear saying, “I have a nevus” in English?? Not many. Maybe a medical student. Maybe they’ll go as far as to say “compound nevus”. (Insert geek.  I am allowed to say that—I was a medical student once myself and studied dermatologic pathology)  

But that’s an exception to the rule. Most people call it a mole.  And one day, when I was examining a sweet grandmotherly-like lady, she referred to a nevus as “lunar” in Spanish. ‘El lunar’ is the Spanish equivalent for ‘mole’.  What is a ‘mole’ anyway? Well, depending on the day (and context) it can be a small, ground-burrowing animal or a spy who plays an important role in the security of a country or 6.023 x 10²³ or, well, a nevus. 

When I talk to my English speaking patients who have poorly controlled diabetes, I will tell them:

“As a result of your poorly controlled sugar, you have something called, ‘non-proliferative diabetic retinopathy’ which means you have leaky blood vessels in your retina. This happens because high blood sugar makes your blood vessels weak. Blood leaks out.”

If you do this in English, you have to expect to explain it in a similar way in Spanish for the non-medical layman:

“Porque el azúcar no es controlado, tiene Ud. algo se llama “retinopía diabética” –significa que las arterias y venas en la retina son débiles y, por eso, están fugando sangre y fluido. Este fluido afecta a la  visión.”

I’ve heard other substitutions for medical vocabulary used as well:

Tela (cloth; cover) for a pterygium or a cataract

Nube (cloud) for cataract

Carne (meat) for pterygium/pingueculum

Polvo (dust) to describe a sandy sensation in the eye

The above represent a few examples in Spanish. Remember, there are technical Spanish terms for these words, ie catarata for cataract. But not everyone knows that word, or what it means. Nube, a cloud, something that blocks the vision and makes it blurry, is more universal and understandable to the layman.

Just as you do in English, tailor the conversation to the patient. You’ll speak to an 86 year old retired banker differently than you would to a local mid-forties pediatrician. You’ll assess who has some medical knowledge background and who needs the terminology broken down a bit. I have always liked educating my patients on medical vocabulary. I do introduce them to it all the time. But I also want the patient to understand what I’ve said, and I adjust the dialogue accordingly.

Me: ¿Por qué está Ud. en la clínica hoy?

Patient: Estoy aquí por un examen general.  Pero tengo problema. Tengo una tela aquí en el ojo izquierdo (points to nasal corner of left eye).  Me molesta.

Me: Sí , esa tela, se llama “pterigión” es algo muy común en el ojo.  Es muy común particularmente en personas quienes viven en países cerca de la línea ecuatorial. La piel crece cerca de la córnea.

Patient: ¿Puedo ser ciego?

Me: No! Si la piel crece a cubrir la córnea, hay un procedimiento lo que podemos hacer a sacarlo. Pero el suyo es pequeño. Use Ud. lágrimas artificiales dos o tres veces durante el día para lubricar el ojo.  Eso es todo que necesita.

Patient: Gracias. Ud. es muy amable. 

Courtesy: D.Hromin

Spanglish

In the office, I have my good days and bad days in Spanish.  Sometimes, the words come so effortlessly. Other times,  I stumble through my sentences and everything seems (at least to me)  forced.   I really don’t know what contributes to these ups and downs. I’ve just come to the conclusion that some days, I’m afflicted with a sort of ‘Broca’s aphasia’ of the Spanish part of my mind, and I just muddle through the best I can.

Today in particular was one of those days.  A young woman came in complaining of red eyes:

Me: ¿Por qué está Ud. aquí hoy?

Patient: (pointing to her left eye):  Estoy aquí por esto, un ojo rojo. Dos semanas atrás tuve la misma cosa en el otro (points to the right) y ahora este ojo.

She has one of the few diagnoses in ophthalmology that you can diagnose from across the room: a subconjunctival hemorrhage.  I proceeded to ask her questions:

Me: ¿Ha estado enferma?  ¿Está tosiendo? ¿Tiene presión alta?

Patient: No, no.

Me: ¿Está esforzando en el baño?

Patient: No.

Me: ¿Qué tipo de trabajo hace? Por ejemplo, ¿está levantando cosas de peso en la casa o en su trabajo?

Patient: No. Pero en mi trabajo hay mucho polvo, ¿tal vez lo puede causar ojos rojos?

Me: No en este caso. Bueno, ¿toma aspirina o Ibuprofeno?

Patient: Sí—ibuprofeno. Tengo migrañas, y uso ibuprofeno de vez en cuando.

Me:  ¿Cuánto? ¿doscientos miligramas, tresciento…más?

Patient: No. Sólo una píldora, no más.

Me: ¿Tiene un neurólogo o médico de familia?

Patient: Tengo médico de familia, Dr.--. Él me refiere a un especialista—un neurólogo, pero no he le visto todavía.  

All in all, here we have a conversation that 1) reveals to me enough information to make a diagnosis and 2) a dialogue that the patient understands and leaves her feeling confident enough that I can address her concerns.    Fine.   But I commonly review interactions like this in my mind long after the patient has gone home and my work day is over, thinking about how I could have sounded less elementary and choppy and, instead, more sophisticated and urbane.  

Take the phrase “¿Está esforzando en el baño ?”   lit. : Are you forcing in the bathroom?

This is my attempt at asking the patient if she is constipated, when in fact, I’ve forgotten the word for constipated (estreñido) and have to improvise at the meaning.

And, “¿Está levantando cosas de peso en la casa o en su trabajo?”  lit. : Are you lifting things of weight at home or at work?

Here I want to ask if she’s picking heavy things up at home or at her job. Again, my translation is a little sloppy sounding, but some would argue - so what? The patient understands. But I think to myself:    I’m a professional so….. shouldn’t I sound professional?

This was the remainder of the encounter:

Me: (after examining the eye) Ud. tiene ojos sanos. El nervio óptico, la retina, el lente y la presión del ojo—todo está bien.  Ud. tiene algo que es muy común—sangre debajo de la piel blanca del ojo. Significa a veces, que subió la presión de sangre—lo puede pasar particularmente cuando una persona tiene dolor—por ejemplo, en su caso—migrañas.  La arteria en el ojo explota y, aunque parece mala, la visión y la salud del ojo no son afectados.  Y recuerda, Ud. está tomando Ibuprofeno ahora para el dolor de cabeza.  Ibuprofeno, como aspirina “thins” la sangre. Entonces, lo puede sangrar más—un poco más que es normal para Usted.

I basically tell her the eyes are healthy, and that she has a common eye problem: subconjunctival hemorrhage. I relate that the origin of such a hemorrhage can be a rise in blood pressure, and this often  happens when a patient is in pain (as is this patient because she suffers from migraines).  I mention how the burst artery may look bad, but vision and eye health are unaffected.  Finally, I remind her that because she uses Ibuprofen for migraines, she may bleed more than average, as Ibuprofen effects the clotting ability.  

During my explanation to her, I resorted to using the English word “ thins “ because frankly, at the time, I didn’t know the Spanish equivalent (anticoagulación).  The patient understood me just fine.  In the end, if you can’t think of the vocabulary word, my advice is: say it in English.   

Incidentally, one of the unique things, I feel, about practicing medicine in Spanish in the United States, especially here in the New York area, is that American Spanish has evolved as a new Spanish, a sort of  ‘Spanglish’. Even if you’re a true Castilian Spanish speaker,  all bets are off here in the United States.  Native fluency doesn’t guarantee that you’ll be able to communicate in the clearest way with patients. A Spanish speaking doctor or health care worker needs to be more versatile in a Spanish influenced by American English.  

And isn’t that one of the beautiful things about language communication? It’s always changing, growing and adapting—and it requires us to do the same!

Courtesy: D. Hromin

Patients with patience

It wasn’t until I went to medical school that a breakthrough came for me.  Well, a semi-breakthrough.  It was 2002 and I was doing my third year clinical rotations.  I became smitten with a certain Puerto Rican family medicine resident, and we started dating.  For purposes of this blog, I will refer to him as ‘Carlos’, partially for privacy reasons, and partially because I don’t remember his name (!)  But when we dated, Carlos made it a point to talk to me only in Spanish, and the deal was I had to answer back in Spanish.  It was so difficult at first—I would partially understand what he was asking me, or telling me, but when I had to respond, uh! It was so difficult.  I would take minutes to sputter out grammatically incorrect fragmented sentences. The best I could say many times was, “Lo siento, no comprendo.” (I’m sorry, I don’t understand) Or “No te entiendo” (I don’t understand you)  Or “Por  favor, repitelo” (Please repeat it).  I got VERY good at using these phrases—phrases that excused my ineptness.  But he was patient, thankfully, he spoke VERY slowly and the very act of forcing me to speak back actually made me more comfortable answering in Spanish. It was still very difficult—and would be difficult for years to come. 

Carlos:  “Qué hiciste hoy?”

Me: (To myself:  Think!!   ‘What you did today?’  Hmmmm … What DID I do today??   I went to class, later I went for a walk in the neighborhood. “Uh,….Yo” (think: ‘I went’, now  conjugate it!   Yo fui) ”…yo fui a clase, ..uh…. luego, yo…” (think!  Is it ‘fui al paseo’? No, it’s dar un paseo, can’t be literally translated) fui a dar un paseo en el vecindario.” (Still a few grammatical errors here and there, but at least it was an intelligible, complete sentence!)

So, a question that, in English, would take me a millisecond, no, a nanosecond, NO! a femtosecond, to understand and answer, would take me approximately one to two minutes in Spanish.  Too much thinking, and the thinking slowed me down.

I would wonder to myself, why is this so hard?  I know a good amount of Spanish vocabulary.  What do I do when I speak English that’s so different?  How do I teach myself to feel in Spanish, and not think? When do I reach a point (or will I ever reach a point) when the sounds mean more to me than the actual words?  

I went to medical school in Pennsylvania Dutch country, so the opportunities to use Spanish in the clinic were few and far between.  But there were occasions when I was able to interpret a bit.  There was a small women’s health clinic just outside of Bethlehem, PA.  I found that the most frustrating aspect of attempting to speak to the patients there in Spanish was that, in my head, I would be quickly translating as I was speaking.  In other words, as I spoke, I could see my answers in English and would be translating them, almost verbatim, into Spanish. So talking, in essence, became a huge grammar lesson. I just couldn’t answer fluidly and comfortably. I had to THINK. I had to TRANSLATE. I had to recall conjugation rules and feminine vs. masculine and how to make a singular noun plural all as FAST as possible. But the thinking took forever. It didn’t feel normal or natural.  And in my mind, this is how I always perceived my language experience would be since I missed that precious window of opportunity to hear Spanish as an infant. Still, I forged on.  This is an example of the simple intakes I would do on patients visiting the clinic for prenatal checks:

Me: Toma medicina? Vitaminas?

Patient: Si, vitaminas para el embarazo. Eso es todo.

Me: Es su primer embarazo?

Patient: No, el segundo. Tengo niña.

Me: Tiene algunos problemas hoy? Resfriado? Tos? Se siente débil?

Patient: No, todo está bien.

Me: Tengo que obtener las dimensiones del bebé ahora.

Patient: Está bien…<pause>…hablas español bien.

Me: (with a smile, knowing the patient was just being nice regarding her linguistically challenged doctor)         Gracias. Tengo que practicarlo.

Honestly, that is what has made the learning journey easier all along. Patience. Understanding. Gratitude--from patients who have appreciated my efforts at better communication.

It felt good, even then, with the few words I was able to muster, to be able to walk into an exam room and communicate on some level—without a third party translator interrupting the doctor-patient bond.  Don’t misunderstand me!---translators and/or interpreters absolutely serve a vital role in health care.  It’s just, when it comes to something as private AND personal as a person’s health, if you can serve as the sole listening ear in such a conversation and give the patient the privacy that he/she deserves,  the doctor-patient relationship is strengthened all the more.

Courtesy D. Hromin