Single Combat

(Al caminar para llamar al paciente de la sala de espera)

Good morning, Mr. Reyes- (extiende la mano al paciente) I’m Dr. Hromin, we can begin the exam now...

(me mira como un ciervo ante los faros de un coche)

Discúlpeme, pero, ¿cúal es mejor para usted, inglés o español?

Either one, it doesn’t matter to me.

OK! Then let’s get started! Please follow me to the exam room, this way...You can put your things on the side and have a seat in the exam chair when you’re ready.

(el paciente se sienta en la silla)

It’s been a year since your last visit – have you noticed any problems with or changes in your vision?

Bueno, I don’t really have problems with the vision for driving, pero when I read, it’s a problem.

Está bien.  Hay una condición se llama ‘presbicia’ – se ocurre después de la edad de, más o menos, cuarenta años. El cristalino natural dentro del ojo pierde la flexibilidad. Por eso, se necesita lentes para leer.

Sí, he comprado lentes de la farmacia, pero no sé si son buenos para mí. Si tengo el poder incorrecto para los ojos, ¿ello va a causarme daño a los ojos? I don’t know.

Para contestar su pregunta, no, lentes del poder incorrecto no le causarán daño a los ojos. El poder correcto es algo que se siente cómodo para usted. I’ll put the refraction from today into a trial frame. Here, try them on-

(le doy al paciente los lentes para leer y una página de una revista)

¿Puede leer todas las letras en esta revista?

Sí, es cómodo. I’m not having any problems.

Good, now I can write you a prescription for the glasses or you can pick them up over-the-counter.

(me mira con expresión confusa)

No necesita una receta si compra los lentes en la farmacia. Usted solo necesita saber el poder, y para usted, es +1.50. OK, empezamos el examen ahora- es importante examinar la retina, ¿se dice aquí que tiene diabetes?

Sí, pero it’s controlled. I go to the doctor every 3 months. He checks the sugar.

You have an endocrinologist? <pause>  ¿Tiene un endocrinólogo- un médico quien es especialista de diabetes?

No pero, I would like for you to give me names of doctors in the area – nutricionistas, para decirme lo que  puedo comer para mantener un nivel normal de azúcar en la sangre.

(Hago el examen de la retina.)

Bueno, tengo buenas noticias para usted. Tiene ojos sanos, no tiene signos de diabetes en la retina. So you have a clean slate to work with moving forward.

Ay, qué bueno, gracias a Dios. That’s good to hear it.

OK, so I’m going to send a report to your primary doctor, el médico de familia, y escribo el número de los lentes que necesita para leer.

Remember to give me names of –

Oh, sí, los endocrinólogos y nutrici-...nutrition-...er, nutritionists...¿cómo se dice en español otra vez?

Nutricionistas.

Y los nutricionistas también. (le da al paciente la hoja de códigos)

¿La entrego al frente?

Sí, nos vemos de nuevo en un año- pase  un buen día.

Igual. Gracias.

When taking an English to Spanish translation class recently, I recall my professor making a statement one day. He said, “I’m wary of the person who says he’s bilingual. Many ‘bilinguals’ are the worst offenders when it comes to communication in both languages.” I didn’t quite understand him at the time, but when reviewing my own experiences speaking with patients in the office, particularly the sample conversation I just shared, I’m beginning to see his point. 

Sometimes, in an effort to speak one language or another, the conversation devolves into a highly complex mix of the two. My Spanish is advanced- it represents a professional fluency - but it is not at near-native level...yet. If a native Spanish-speaking patient comes into the office with absolutely no experience in English, then the entire dialogue takes place in Spanish. The patient clearly makes all of his symptoms and complaints known, and I work linguistically to find the best way to instruct and explain to him his condition in Spanish.

If a native Spanish-speaking patient comes in for an eye exam, but he studied English previously, or has had experience working with English speakers so he’s reached a point in the language where he can understand and communicate fairly well in English, then I revert to my native English for the exam, and he flexes his linguistic muscle to communicate in his non-native language.

There are times, however, when almost near-native meets almost near-native, and that’s when the single combat begins. I walk out and greet the patient in English. They return my greeting with a confused stare. I assume they don’t understand me and I begin speaking in Spanish. They answer me in English. Now, I am not sure which language they are most comfortable using, even though they’ve answered that they can speak either.

I bring them to the exam room. I continue in English. They answer in English, but with bits and pieces of Spanish mixed in. I don’t want to show preference for either language, so I start to do the same. English with Spanish. Spanish with English. Before you know it, the dialogue becomes an intricate dance between the two. Almost like a couple struggling during a waltz because they both want to lead. Neither wants to be led.

This patient-doctor Spanish-English conflict is a tiny representation of a greater societal issue. In the United States, even native-born Spanish-speakers are in danger of having their Spanish language corrupted in time by English, which surrounds them. And vice-versa, native English-speakers may work to learn an academic Spanish, but never reach full immersion because they live in the United States. So, going back to my professor’s musing, when this “bilingual” person sits down to translate from one language to another – (remember, translation is written communication, not oral, therefore nothing can be hidden and everything is exposed) – one finds great gaps in vocabulary, sentence structure and grammar knowledge than previously imagined.

The question is, what do we do about it? I think the best we can do is dedicate ourselves to frequent reading and study. A dedication to the purity of a language. A pledge to not succumb to the easy verbal corruption that is commonplace in a mixed-language society. During the medical exam when almost near-native meets almost near-native, if the patient doesn’t pick a side, then you pick one for him. One or the other, not a mix of both. Chances are you’ll achieve clearer communication-- if you’re both speaking from the same linguistic side.

The Duel between Hector and Ajax

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