Saturday, February 13, 2016

Perfect Doctor-Patient Symbiosis

“I had to act quickly; that's why I jumped in. I knew if I were drowning you'd try to save me. And you see, you did, and that's how I saved you.”

-Clarence, AS2


Doctor: Primero tengo buenas noticias para usted. No tiene signos de diabetes o glaucoma. Estoy de acuerdo con el otro especialista, de que usted tiene sequedad de los ojos.

Paciente: Pero los ojos lloran. No son secos.

D: Bueno, esto va a sonar.... <pausa>...soñar (le mira al paciente). Perdóname, esta palabra me tiene confundida. ¿Cuál es la palabra correcta, ‘sonar o soñar’ por ‘to sound like’?

P: (sonríe) Sonar.

D: Esto va a sonar extraño pero, cuando los ojos son secos, a menudo,  lagriman. (Continua con la explicación...)

                                                                        *

I have mentioned ad infinitum in previous entries my anxiety and fears of sounding foolish when speaking Spanish with my patients. I’ll be talking, and I’ll hear myself make a mistake. Maybe I’ll end an adjective in an “a” when it should have been a masculine, “o”.  Or I’ll conjugate in the wrong person.  Or I’ll know exactly what I want to say in English, but, having to think on my feet quickly, I try to translate directly from English to Spanish and it comes out wrong. I never think so much about grammar and sentence structure when speaking in English. I feel that all this thinking trips me up in Spanish. But, if I don’t think about it, how will I eventually get it right? How did I get it right when learning English as a child many years ago?

The last thing I want to show as a doctor is vulnerability to my patients, or worse yet, the possibility of being fallible. However, I have found that in those moments when I’m confused about how to express something in Spanish, if I just let down my pride a bit and ask the patient or the patient’s family member to help me out, then the experience is dually rewarding.  They help me by contributing to my language growth, Spanish vocabulary and grammar. I show them my human side and hand them the reigns of control in a situation where unfortunately, most patients find themselves powerless: during the medical examination.

Asking questions about something as familiar as language and culture relieves tension in the exam room. It contributes to learning. It shows that I have a vested interest in more than just their retinal health or their visual acuity. It’s very rewarding all-around:


<después del examen de la presión del ojo>

D: Bueno, la presión del ojo ha mejorado enormemente con la gota que le di a Ud. la última vez cuando usted estaba aquí.

P: Sí, estoy feliz oírlo, pero, desde el uso de las gotas, los ojos se han convertido rojos. No me gusta la apariencia de los ojos.

D: ¿Ha continuado con los lubricantes también?

P: Sí, pero todavía los ojos rojos se quedan.

D: Es una lástima. Las gotas funcionan bien para bajar la presión del ojo, pero desafortunadamente, “ojos rojos” es un...efecto....side efecto...., <pausa, le mira al esposo del paciente> perdón, pero ¿Cómo se dice ‘side effect’ en Español?

El esposo: Es un efecto secundario.

D: Sí, gracias. Ojos rojos es un efecto secundario de este medicamento, desafortunadamente. Es posible que tenga una sensibilidad a los preservativos en la gota. Entonces, podemos tratar otra marca, sin preservativos.

P: Sí, me gustaría utilizar otra gota.

D: Está bien. <le da al paciente una botella> Esta es una muestra de la marca nueva. Las instrucciones para el uso son las mismas:  una gota en cada ojo una vez por la noche. Hago una cita de regreso aquí en tres semanas para comprobar la presión.

P y su esposo: Gracias por su ayuda. Nos vemos pronto.


Roads less traveled, Southern Utah, Summer 2015





Monday, February 1, 2016

Language Prophylaxis

In earlier blog entries, I’ve written about how using Spanish with my patients in the office has lead to positive, successful interactions with great opportunity to learn and become more versatile in the language. I’ve also discussed the days when having to speak in something other than my native English has been at times challenging, grueling and frustrating. Everyday I am trying to examine patients, explain complicated medical concepts, answer questions, carry on ‘small-talk’, create and explain a treatment plan, --all in Spanish and all within a span of about 5-10 minutes, the max time that is allotted me per patient. I don’t want any of my patients waiting too long for their appointments, but if a patient has an active ocular problem that needs attending to, this in and of itself takes more time than 10 minutes. Factor in having to then mentally translate everything I am saying and doing does add another element of pressure to the mix.

The only way to improve in a language is to keep using it. Use it, make mistakes, learn from them. Make mistakes again, continue learning. Because I have been working with a large community of Spanish-speaking patients, my Spanish skills have greatly improved. As a result of this, I don’t feel the same sense of worry or tension that I had when initially practicing ophthalmology in Spanish. It’s better now, but what I have found helps immensely is to break down patient cases into diagnosis topics that I’ll preemptively find myself preparing vocabulary for so that I don’t waste time opening my mental thesaurus when speaking with patients.

To give you an example of what I’m talking about, I wrote down a quick synopsis of various patient cases I’ll see in the office. I then isolate the diagnoses and start by thinking about them in Spanish. For reference, I use material provided by the American Academy of Ophthalmology on their website: ojossanos.org. With each subject topic I compile a list of medical vocabulary in Spanish that I can build upon. The more frequently I encounter these eye problems in Spanish, the better equipped I become in anticipating the kinds of questions patients will ask and how I will answer using plain language, or lenguaje llano. This process helps ensure that for these patient exams, and future ones like them, the communication moves along fluidly. For example:

Patient 1: 45 yo coming in for first time eye exam. C/o problems seeing at near, occasional burning sensation in eyes. 

(la presbicia, ojos secos)



Patient 2: 52 yo comes in for annual exam, first time patient to the practice, DV & NV worsening, on exam optic nerves suspicious for glaucoma. Mild cataracts noted.

(la presbicia, las cataratas, nervios ópticos sospechosos por glaucoma)



Patient 3: 23 yo CL over-wearer. Comes in with red, irritated eyes. Exam shows significant pannus and dry eye. Patient adamant that he does not want glasses and wants to continue in CL.

(el abuso de las lentillas, ojos secos, educación como cuidarse las lentillas)



Patient 4: 42 yo woman with a diagnosis of moderate to severe dry eye, started on restasis last visit. Follow up appointment is now 6 weeks later. Upon asking how she’s tolerating the new medication, pt states she couldn’t tolerate it. It burned. So she stopped it three weeks ago and wants to know what else could be done for her dry eye.

(ojos secos, la educación del uso del medicamento, palabras de aliento)



Patient 5: 51yo diagnosed with advanced open angle glaucoma at the last visit, was given a sample of lumigan to use 1 gtt OU qhs and is now here 4 weeks later for an IOP check. However, pt admits to “running out” of the drops and therefore hasn’t been using them for two weeks.

(el glaucoma del ángulo abierto, el incumplimiento del paciente, la educación de la importancía del glaucoma)



Patient 6: 36 yo with poor uncorrected vision OU, told years ago he had cataracts, exam shows extreme anisometropia and anisometropic amblyopia, one eye correctable to 20/20 with significant cylinder, optic nerves suspect for glaucoma. Pt interested in CL for his good eye.

(la ambliopía, discusión del protección monocular)



Patient 7: 85 yo woman, first-time patient to the office, had cataract surgery with PCIOL OU 8 years ago at another practice, comes in today with VAcc 20/30 OD, 20/150 OS. When asked if her vision OS had always been poor or just started immediately after or sometime after her surgery, the patient states she can’t remember. Dense PCO OS found on exam. Macular drusen noted OD.

(la cirugía para sacar la catarata y las complicaciones, la opacificación del implante de lente, la degeneración macular relacionada con la edad)



Patient 8: 54yo deaf  patient with limited speech. Vision stable over the course of his life except for the last 2 years, after patient diagnosed with and treated for meningitis (suspect viral). 20/30 with correction one eye, CF other eye. Wants glasses to fix everything.

(la neuropatía óptica infecciosa, discusión del protección monocular)



Even for the cases that I do not see as frequently, I still try to maintain a general working vocabulary in Spanish through my on-line tools like www.ojossanos.org when teaching the patient about his/her condition. But again, with more experience in a language, with repeated exposure to certain topics, my understanding of Spanish and my ability to express myself in Spanish become better and better. Each patient adds to my understanding and learning. And don’t be afraid to include your patient in on your learning process! I have found patients to be more than happy to teach me what they know when I ask them vocabulary, language and cultural questions. Doing this really makes them feel like I care enough to make sure  that they fully understand all aspects of their eye health.

Riomaggiore, Italy. Courtesy: D. Hromin