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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

Me: “Thank you, and how is that?”

 

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

 

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

 

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

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

 

Wooded trail, Adirondacks, NY

Rose-Colored Glasses

Learning a language is a life-long process and for me, it means daily ups and downs.  In writing  blog entries documenting my experiences working in a Spanish language patient environment, I always try to remain positive for my readers, regarding my struggles speaking and understanding medical Spanish and I reflect on my occasional vocabulary faux pas.  Importantly, I attempt to center my focus on how I try and overcome these challenges. My hope is that someone out there may read my musings say, “Yes! I’ve been there too!” and perhaps gain something from my perspective,  if only the comfort of a shared experience with another medical professional.

There are times, however, when I’m having a particularly “bad” or “off” day in the language, when using Spanish with my patients leaves me feeling frustrated. Consider this: I know that if I was at native-speaking level, most of my frustrations would be moot.  This is because if I was at native-level, then speaking Spanish, or listening to it spoken, would not require any additional effort or thought on my part. And, as such, I could get on with the medical exam focusing only on the details of that, and not how those details are communicated.

But, the reality is that I am not at native level, and there are days when I really have to work hard to put together exactly what I want to say and how I want to say it in Spanish.  Even at the professional level of fluency I’ve achieved at this point in my career, there are still days when I have trouble understanding a patient when he talks – either because of his accent – how he pronounces certain words, or because he’s talking too fast, or because he’s using slang or Spanish colloquial phrases I’m not familiar with.

It’s on these days in particular, that I sometimes become agitated when I realize my office schedule is predominantly filled with Spanish-only speaking patients.  Now understand this, my anxiety comes from my own frustrations with myself and my abilities in the language, not with the patients themselves.  When I must conduct everything in Spanish, I know that I won’t be able to walk into an exam room and feel completely confident, like I want to feel when greeting a patient – because I go into translation mode, not speaking mode.  I  feel a certain sense of anxiety because, though I can express myself well in Spanish and begin my exam projecting confidence in this way, I worry that at any moment the patient may ask me a question I won’t completely understand, for whatever reason.  It’s at that point that I will have to let down my guard, my confidence, my pride, whatever you want to call it,  and tell the patient I didn’t completely understand what was said, and could he please repeat it for me: “Lo siento. No le entiendo – por favor repítalo, y un poco más despacio.” It could be when some of you are reading this, you’re saying to yourselves, “So? You ask them to repeat and then get on with it.” True. But I think every doctor wants to project confidence to a patient – and this is done with medical knowledge and communication ability.  Some missteps in communication may leave the patient feeling like he’s not being completely heard.  

If you can’t already tell, I put an enormous amount of pressure on myself to improve my Spanish to a high degree. I feel that is a part of me being the best doctor I can be to my Spanish speaking patients. There are on-going discussions in the medical community regarding whether all United States physicians should learn to speak Spanish to meet the growing demand of patients with limited English proficiency. Some argue that the patient needs to have enough information about his condition to make informed decisions, and he won’t be able to if he doesn’t understand the language the doctor is speaking. Further, medical mistakes can happen through a misunderstanding of the patient’s true symptoms, duration, medical history, if the physician has a limited ability to comprehend or speak Spanish. 

Others argue that it shouldn’t be up to the physician to learn Spanish, rather it should be the patient’s responsibility to take charge of his own health care and learn to communicate his needs to the doctor in order to get that accomplished.  Though Spanish is a very close second to English in the United States, English is still the primary spoken language, and it can’t be expected (or even be possible) that doctors become fluent in every language that is spoken in the country. And it’s not always convenient or financially reasonable to require translation services at all medical practices.   

I remember one time in residency when I was talking to a patient in her late twenties, I was using my medical/conversational Spanish which, though it wasn’t as good at the time as it is now, was good enough to be understood and convey meaning.  Or so I thought.  At one point the patient said to me in non-proficient English, “can we get someone else here who speaks better Spanish?”.  I remember feeling so angry and embarrassed.  I thought to myself, ‘look, I’m making an effort at communication here, and doing fairly well at it.  Where’s your effort?’ Shouldn’t the patient make an effort to be understood and to understand too? Am I expecting too much?

If I prescribe a medication and I instruct a patient on how to take it, and I explain in depth that without it, the patient can and will lose her vision, but she does not take it and hence loses vision, whose fault is that? Is it mine? What more could/can I do? Isn’t there a point where a patient has to take responsibility for her own health care? Shouldn’t that involve the communication to receiving good health care as well?

So, what is the answer? 

I notice that there is an inverse proportion between my insecurities with my Spanish speaking encounters and my level of knowledge and experience in the language.  As I have gotten more and more proficient in medical Spanish, my insecurities and frustrations have equally decreased. My goal in the language is that one day, it will come as naturally to me as examining a retinal fundus with a 78 Diopter lens. I do believe that day will come, but it is not here yet. Until then, I have to accept that there will be frustrations when attempting perfection in a language non-native to me, and that patients can’t and shouldn’t be passive regarding their own health care. They, too, should take an active role in learning how to express their needs so they will be understood and understand. If doctor and patient work together to bridge the communication gap, they’ll soon find that all along, they’ve been speaking the same language. 

Preko, Croatia

The Dissatisfied

The other day a patient of mine came back to the office for a “glass check”.  A “glass check” visit, for the uninitiated, is one where the patient who was recently prescribed glasses comes back to the office unhappy with her new pair. 

Sometimes this is due to a simple error of the optical lab: a wrong cylinder axis, a minus sphere used instead of a plus sphere or readers-only given when a progressive lens was expected. 

Sometimes it is because the patient has an underlying pathology: cataracts, keratoconus, corneal scar, diabetic retinal issues, or a fluctuating tear film, any of which may be contributing to less than perfect vision. In these cases, the patient is reminded that they have an underlying problem that is affecting the vision.

Sometimes it’s a mis-aligned visual axis. It could be induced prism, or distortion, or image jump or displacement. But if it’s not any of these things, then it is hard to know exactly why the patient just can’t “get used to” her new glasses. Then it can be difficult to reassure the patient and come to a mutual resolution to solve the problem.

Trying to address a dissatisfied or unhappy patient is a challenge in and of itself, regardless of the language in which the conversation takes place. However, when you have to be diplomatic, maintain a positive outlook and convey confidence that the problem will be resolved all in a language non-native to you, the experience can certainly feel overwhelming. 

For the ophthalmology exam in Spanish, I’ve memorized plenty of  “how are you's”, “what brings you here today's” and “look left and look right”, but surprisingly after 7 years of private practice and conducting general eye exams with my patients, I’ve rarely had to address an unhappy patient in Spanish. Given this situation,  I had to think first about what I would say in English and then mentally translate it. But somehow, it all just sounded, to me, unnatural and uncomfortable. Maybe it’s not so much saying it in another language that bothered me.  Maybe it’s simply the frustration and disappointment that comes with not making a patient 100% happy with his/her office experience.  Regardless of the etiology of the patient’s dissatisfaction, I think every doctor feels a certain sense of loss when the outcome isn’t what was expected. 

With this patient’s glasses, I tried to find the root of her problem and then give her reassurance:

D: ¿Qué es el problema con los lentes?

P: Bueno, cuando me los pongo, no puedo ver nada. Es incómodo. No puedo usarlos.

D: ¿Cuándo los compró?

P: Dos semanas atrás. Me los pongo una vez, inmediatamente me los quité y ya no he los usado.

D: Vamos a ver—(comprobando la visión)—bueno, puede ver 20/20 con cada ojo, en la distancia y para leer con los lentes. Y, el óptico hizo los lentes correctamente. A empezar, el poder de los lentes es mínimo. Es sólo a ayudarle funcionar por la noche, cuando maneja el coche, por ejemplo, o cuando quieres ver las letras escrito en la pantalla de la TV muy clara – eso es todo.

P: Sí, pero cuando me pongo los lentes, es borrosa la visión.  Cuando uso los lentes de mi amiga, son demasiado fuertes al princípio para mí, pero cuando estoy acostumbrada de ellos, puedo ver más claramente con ellos. 

D: (mirando la receta de los lentes de su amiga). Oh, no, estos lentes son demasiados fuertes para Usted. No es bueno para la salud de los ojos a poner anteojos con la receta incorrecta.

P: Lo sé, pero, veo mejor con ellos.

D: Bueno, Usted sólo se pusó los lentes una vez. No es bastante tiempo a acostumbrarlos. Pongaselos otra vez y uselos diario, por a menos dos semanas. Si no le los gustan todavía, llame la oficina otra vez.

P: Está bien. Es mi primera vez con lentes, entonces, no sé como debo sentir. Yo trataré...

D: Está bien. Pase un buen día.

P: Igual.

                                                                        *

D: What’s the problem with the glasses?

P: Well, when I put them on I can’t see anything. It’s uncomfortable. I can’t use them.

D: When did you buy them?

P: Two weeks ago. I put them on once and immediately took them off, since then I have not used them.

D: Let’s see (checking the vision), well, you can see 20/20 with each eye, at distance and near with the glasses. And, the optician made them correctly. To begin with, the power in the glasses is minimal. They’re only meant to help you function better at night, when you’re driving your car, for example, or when you want to see letters on your television screen more clearly—that’s all.

P: Yes, but when I put them on my vision is blurry.  When I use my friend’s glasses, however, they are too strong at first but then when I get used to them, I can see more clearly with them.

D: (Looking at the prescription of her friend’s glasses). Oh, no, these glasses are too strong for you.  It isn’t good for the health of your eyes to wear glasses with the wrong prescription.

P: I know, but, I see better with them.

D: Well, you only wore your glasses one time. That isn’t enough time to get used to them.  Wear them again and use them daily, for at least two weeks. If you don’t like them after that, call my office again.

P: Fine. It is my first time wearing glasses, so, I don’t know how I should feel. I will try...

D: Fine. Have a good day.

P: You as well.

Street Graffiti, Zadar, Croatia

Now You're Speaking My Language

Paciente: Su español es bueno. ¿Nació aquí? ¿Dónde nació?

Me: Aquí  - Nací en Nueva York. Gracias. Pero, no es perfecto. Tengo que practicar más...

P: Sí, bueno, su español es bueno. Para mí, inglés es muy difícil.

M: Ajj, ahora sabe lo que digo yo, es difícil aprender un idioma - porque no quiero sonar estúpida, o como una tonta, cuando lo hablo.

P: Es muy difícil.

M: Le entiendo. Pero he aprendido que,  a aprender un idioma bien, tiene que usarlo a menudo.   Tiene que hablarlo.  Escucharlo.  Escribirlo.  Leerlo. Tiene que escuchar al radio en inglés, la televisión en inglés.  Tiene que leer libros en inglés.  Lo tiene que llegar a ser una parte de su horario al diario. 

P: Bueno, cuando trabajaba como pintor, sabía bastante inglés a hacer el trabajo, ¿me entiende? Yo sabía como decir: ‘Lift this up’, ‘Paint the wall’, ‘I need the brush’, pero eso es todo.  Ahora, hace muchos años desde trabajaba y olvidé mucho del idioma. Puedo entender más a escuchar inglés. Pero tengo miedo hablarlo.  No quiero sonar como tonto.  

M: Le entiendo.  Es un problema que todas personas quienes aprenden una lengua tienen que enfrentar y de que tienen que superar.

                                                                        *

Whenever I go through something difficult or challenging in my life, it has always been helpful to know that-

1) I am not alone in the struggle—someone else is going through it,too  &

2) that other people have risen above the same struggles and succeeded

Of the many years I have worked with the Spanish-speaking patient population, no one has ever talked about his personal struggle learning English.  Yes, the patients have expressed gratitude to me for trying to communicate with them in Spanish, but they’ve never shared their own personal challenges learning and communicating in another language themselves.

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

I completely understand this, because I have felt this way many times myself. There have been many days in the course of my Spanish learning that I have felt tongue-tied and frustrated. There have been times when I felt embarrassed, not wanting to look or sound foolish when speaking to a patient. And then there have been moments when I even felt a twinge of anger knowing I would have to use Spanish with my next patient, because I knew that it would mean a longer exam time (due to my slow explanations in Spanish) and potentially a more awkward exam (not always understanding everything a patient says to me, and not communicating fully everything I want to say and could so easily say, if I was speaking in English).   

I visited my husband’s family in Croatia for the first time in 2011. In Croatia, not surprisingly, the people speak Croatian.  I bought some Berlitz books for myself before the trip and gave myself a crash-course in basic Croatian phrases.  When I finally got there, I did well communicating, yes, until I ran out of basic phrases. And when his family spoke to me, well, anything beyond the bare minimum was tough to comprehend. And this doesn’t even include regional accents or dialects, which took the difficulty of the language to a whole new level.

It is daunting to be different.  To be thinking in one language, and yet speaking another.  To sound different. To know that even if I use every word correctly, my accent and mannerisms expose something that I’m trying to conceal:

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

Dare to be Different, Mohonk Mt., NY