Child as Translator

The following encounter is a very common one. I call Juana Sanchez* into my room to begin her eye exam. Juana smiles and nods, shyly says ‘hi’, and is followed closely behind by Maria, her daughter, who I estimate can’t be more than 8 or 9 years of age. After the initial greeting, Juana hasn’t shown me any indication that she does not understand me when I speak, so I continue to converse in English during the beginning of the exam. I ask her to sit down, directing her toward the exam chair, and usher her daughter to the chairs on the side.

Me: “ I understand you’re here today for a complete eye exam. My technician was mentioning you lost your reading glasses and would like another prescription.”

Juana (tensing up and turning quickly to Maria): “Díle a ella que no hablo íngles.”

Before the child turns to me, I say to her,

“No, está bien. Hablo español. Podemos hacer el examen en español.”

Juana smiles and Maria goes back to her chair, appearing relieved. And I’m happy to know that, at least during the time that they spend in my office, I can relieve Maria of her translator duties.

Parents using children as translators has become more of a commonplace issue in the United States- and  it’s not something only found in the doctor’s office. These children will help their parents with banking, legal documents, and licensing exams. They negotiate rent with the landlord. They fill out mortgage applications. They interpret job applications.   From 1980 to 2000, the country’s “limited-English” proficiency population doubled from 6 to 12 percent. (1) A 2013 census report found the number of people speaking a language other than English in the household rose 153% over the last two decades. As a result, it is projected by 2022, employment of translators and interpreters is projected to grow 46 percent. (2)

In Cara Nissan’s article regarding the use of children as interpreters, “Innocence lost in Translation”, she asks the question, are these children, “..learning valuable life skills, or shouldering too much family responsibility?”. Many children of immigrant parents, when asked if they mind translating for mom and dad, say they don’t mind. (1) However, one has to ask if exposing a child to highly personal information, such as that found during a medical exam, is potentially harming the child.

I have mentioned previously in my blog that I grew up a third generation Italian/Polish American. By the third generation, all foreign language was lost and only English was spoken in my household growing up. My husband, on the other hand, is a first generation Croatian American. His parents moved here in the 1970s and while they were learning the English language, my husband- of elementary school age at the time- had to interpret and translate for them in Croatian. This included, among other things, translating the household bills and negotiating with their renters. I remember when he first told me about this, I was shocked that as a child he shouldered this kind of responsibility and pressure. But to my husband, it was all matter-of-fact, nothing unusual. Still, just because something can be done doesn’t mean it should be. I feel children should be allowed to be simply that-- children.

Sabriya Rice makes an interesting point in her article for Modernhealthcare.com, “Hospitals often ignore policies on using qualified medical interpreters”, that even hospitals with an interpreter services program in place still have problems making those services available to those who need it. Many times, the busy setting and sheer volume of patients in an emergency room make taking the time to access an interpreter unpalatable to the hurried physician/nursing staff. In this scenario, they often will use their own limited language abilities or a family member to do the translating. (2)

I remember well my own experiences during my residency days at NYU. I worked at Bellevue Hospital and commonly encountered Farsi, Russian, Hindi, Cantonese, Mandarin, Spanish and Creole on a daily basis. I felt a giddy sense of relief when my patients were Spanish-speaking, because my own language skills allowed me to avoid using the hospital’s Languagelines services. I could get my eye exams with them done faster, more efficiently, and frankly, more personably.  For any other language, Languagelines was an excellent service, but it took time. I’d call in, get an operator and then I was told to wait while an interpreter was found. Depending on how remote the language was, this waiting could last anywhere from 3 to 10 minutes or more.  I remember one patient of mine who spoke a remote Chinese dialect called Fuzhou. I had to go through a Mandarin and Cantonese interpreter to discover that she spoke neither, and then had to wait longer until a Fuzhou interpreter was found. All in all this took 15-20 minutes, and this did not yet include exam time which would be another 10-15 min of back and forth talking between doctor – translator – patient. Twenty minutes may not seem like a lot of time, but when you are seeing 40-50 patients within a span of 4 hours, these minutes do add up. This is why I can empathize and understand with the health care professional who desires to create an ideal interpreter situation with her patient, but in the end chooses the faster route of having a family member, be it a child, step in for that role.

I am not a polyglot and will never be one. I know Spanish well and fortunately, I work in a community of patients where my language encounters are either in English or Spanish. I’m not advising that every doctor should attain fluency in every language of every one of his patients. That would be impossible and unreasonable. But I do feel that a doctor should look at the community she serves and the language(s) spoken, and work on becoming professionally fluent in them. Language translation/interpretation services are wonderful, but they are costly and they do take time. They also make an exam encounter less personal by introducing a third party communicator. When this is the only option you have, by all means it should be employed. Patients need to understand their health status to make informed decisions about it. But if you take the time to know the language and can speak it yourself, you save time, you save money and by far, foster a bond with that patient beyond what can be obtained over a phone or through a video. It’s not easy. It takes work. For me, it is taking a lifetime of learning. But for me in the end, the rewards far outweigh the trials and efforts to get there.

Returning to the conversation I had with Juana and Maria at the beginning of this entry:

Me: OK. Usted tiene ojos sanos, pero para contestar su pregunta, ‘¿Por qué no puedo leer sin lentes?’, es porque tiene una cosa muy común después de la edad de más o menos 40 años, “presbicia”. Significa que, el cristalino dentro del ojo no tiene la abilidad a cambiar en configuración a permitir una persona leer como facilmente que en el pasado. Es normal, una parte de vida, y ahora, para ver todas cosas cercanas claramente, va a necesitar lentes. Escribo la receta ahora para Usted.

Juana: Gracias. ¿Dondé los compro?

Me: Traiga la receta a un óptico- tenemos un óptico en nuestra otra oficina.

Juana: Está bien. Gracias- muy amable.

Me: Un placer conocerle, pase un buen día.

Maria: Wow. You speak Spanish well.

Me: Thank you – it can always use improvement, but thank you. Have a good day-

Maria & Juana: ‘Bye.

*patients' names changed to respect privacy

References

(1) Nissman, Cara. “Innocence lost in translation”. http://www.salon.com/2004/08/04/interpreters/ Aug. 4, 2004.

(2) Rice, Sabriya. “Hospitals often ignore policies on using qualified medical interpreters”. http://www.modernhealthcare.com/article/20140830/MAGAZINE/308309945  Aug. 30, 2014.

Zadar Square, Croatia

"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