Finding the Right Ritmo

Me acerco a la paciente, una mujer de 85 años, y su hija que está aquí para acompañarla.

Doctora: Hola,¿Sra. López*? Soy Dra. Hromin (sonrie,mira a su hija)– vengan Uds. conmigo por favor, vamos a empezar el examen ahora.

Sra. L: Mucho gusto (apoyada en el brazo de su hija)

D: Aquí estamos. Sra. L, usted puede sentarse ahí (le muestra la silla de examen). Y usted puede sentarse en el lado, gracias (le muestra a la hija otra silla).

(se enfrenta a la Sra. López)

Se dice aquí que tiene problemas con los lentes – no funcionan para usted—que quiere usted lentes nuevos para leer.

Sra. L: (con expresión confusa-le mira a su hija con cejas fruncidas) ¿Qué dice ella?

D: (habla con la hija) ¿Ella no comprende mi español? ¿Por qué?

La hija: No, ella la comprende, es solo, ella es vieja....(a su madre) Mama, ella le pregunta si tiene 

problemas con los lentes. Me dijo que ellos no funcionan para leer, ¿no?

                                                                          *

(Translation:

I’m approaching the patient, a woman 85 years of age, and her daughter who is here to accompany her.

Doctor: Hello, Mrs. Lopez? I am Dr. Hromin (smiling, looking at the daughter)-come with me, please, we are going to start the exam now.

Mrs. L: Pleased to meet you (leaning on the arm of her daughter).

D: Here we are. Mrs. Lopez, you can sit there (shows her the examination chair). And you can sit on the side, thank you (shows the daughter the other chair).

D: (faces Mrs. Lopez) It says here that you have problems with your glasses – they are not working for you – that you want new glasses for reading.

Mrs. Lopez: (with a confused expression – she looks at her daughter with furrowed brows) What is she saying?

D: (talking with the daughter) She doesn’t understand my Spanish? Why?

The daughter: No, she understands you, it’s just, she is old...(addressing her mother) Mama, she is asking you if you have problems with the glasses. You told me they are not working for you for reading, right?

                                                                        *         

When I was first learning how to communicate in Spanish, through real, live, conversations with patients during my medical school days, it was very rough-going for some time.  I tend to advance quickly in reading and writing language skills, but speaking and listening are a unique and different skill set.  Unlike written text, which can only appear one way on paper, spoken dialogue varies from person to person, based on accent, rapidity of speech, dialect. Does this person slur his speech when he talks? Does he drop the final consonant? Does he talk so quickly that a sentence becomes one, long, continuous word? Native speakers of a language know the various ways something can be pronounced and still make sense of it. They know the inflections, the accents, the slang, the dialect. They know when to listen, and how to listen. And they know how to speak.

In the beginning, when my Spanish vocabulary was poor, my understanding of grammar was limited and I had minimal previous interaction with native speakers-- talking in full sentences was painfully slow and choppy. It took tremendous time and effort to spit out one complete thought in the language, and it required a listener who was willing to wait to hear what I had to say-- not get frustrated and complete my sentence for me. Understandably, because my practice in the language was minimal, my pronunciation of words more often than not, was incorrect. I would put the emphasis on the wrong syllable, and native Spanish speakers listening to me would look at me curiously, with one brow raised.

That’s how it was in the beginning. But now, fast forward almost 15 years later, and I’ve worked with many Spanish-speaking patients. Their countries of origin vary, but have included a rich mix of Dominican, Puerto Rican, Chilean, Guatemalan, Mexican, Salvadoran and Peruvian patients. As a result, I’ve been exposed to various ways of speaking the language, including lenguaje llano (plain language) typical of the regions the speakers are from (known as localization in translation circles). I know what to listen for now, and I judge myself a pretty good mimic of the correct pronunciation. I don’t sound like a typical “English speaker learning Spanish” anymore. I’m proud of that.  Most patients now mistake me for someone of, say, Puerto Rican, descent, based on my Spanish. I am thrilled. I feel accomplished.  

So that is why when I come across a patient like this older woman in the above dialogue, who needs to look to her daughter to interpret my Spanish to her Spanish, I am dumbstruck. I listen carefully to the daughter to see if she’s using any special vocabulary or colloquial phrasing. She’s not! In fact, oftentimes the daughter says verbatim in Spanish what I already said- and somehow the mother understands better. ??? In these scenarios I have no answers to give on what to do when this happens. I only try to speak more slowly, loudly (if I suspect a senior patient has a hearing problem) and place more emphasis on proper accent pronunciation.

Out of curiosity, I attempted to look online to see if anyone else in the healthcare field or elsewhere, wrote about a similar experience. Not many useful hits came to light, except for one messaging site where a native Spanish-speaker wrote that when someone non-native speaks Spanish, if she doesn’t have the right “ritmo”, or rhythm, to her speech, then he has difficulty understanding her.

It seems the reality of language learning is this:  you may have built quite an arsenal of vocabulary. You may be following all of the grammar rules. You may have excellent reading, writing and listening skills.  But when you open your mouth and speak,  if you don’t have the right ritmo, then all of that knowledge is for naught. Your listener won’t understand you. You’re missing a key component in oral communication. Getting the rhythm right only comes over time, from interactions with many different native speakers. This is yet another argument I have against these “be fluent in 3 months” language programs. It took you a lifetime to get your native language’s ritmo right, why would you expect anything less from any other language?

Una conversación con un paciente

(el examen médico de los ojos ha empezado)

Doctora.: Se dice aquí que usted dejó de tomar los medicamentos para la diabetes, hace un año ahora. ¿Por qué?

Paciente: Es porque perdí el seguro, y no podía gastar el dinero en las pastillas para la diabetes – y los suministros para auto diagnóstico en el manejo de la diabetes.  Tengo miembros de la familia que dependen de mí – un niño en la escuela y una madre enferma.

Dra.: Qué pena oír eso.

P: Sí, gracias. Pero, entiendo que la salud sea muy importante, especialmente si quiero continuar a cuidarlos a los miembros de la familia. Entonces, hace algunos meses, solicité para el seguro nuevo, y hice las citas con los médicos, incluye usted ahora, para cuidar la salud.

Dra.: Está bien. Entonces, empezamos el examen, vamos a ver....

(algunos minutos más tarde)

Dra.: Bueno, tengo que decirle que, tiene ojos muy sanos.

P: Gracias a Dios.

Dra.: Sí, no veo signos de la diabetes, o “retinopatía diabética”, los ojos no son sospechosos del glaucoma. Todo está bien, solo necesita usted lentes para leer. Es la resulta de una condición común después de la edad de más o menos cuarenta años: presbicia.

P: Gracias a Dios- estoy muy feliz oírlo.

Dra.: Sí, entonces siga hacer un buen trabajo con la azúcar – esa es la clave para mantener una retina sana.

P: Sí, lo haré. Gracias-

                                                                        *

(the eye exam has started)

Doctor: It says here that you stopped taking your diabetic medication about a year ago. Why?

Patient: It’s because I lost my insurance, and I couldn’t waste the money on pills for diabetes—and the supplies for testing myself to manage the diabetes.  I have members of my family that depend on me—a boy in school and a sick mother.

D: I’m sorry to hear that.

P: Yes, thank you.  But I understand that health is important, especially if I want to continue to take care of my family members.  A few months ago I applied for a new insurance, I made appointments with my doctors, including you now, in order to take care of my health.

D: Fine.  Then, we will begin the exam.  Let’s see...

(some minutes later)

D: Well, I have to tell you that your eyes are very healthy.

P: Thank God.

D: Yes, I do not see signs of diabetes, or “diabetic retinopathy”, the eyes are not suspect for glaucoma. Everything is fine, you only need glasses for reading.  This is the result of a condition that is common after more or less forty years of age: presbyopia.

P: Thank God- I am very happy to hear it.

D: Yes, then, continue to do a good job monitoring the sugar – that is the key to maintaining a healthy retina.

P: Yes, I’ll do it. Thank you- 

Oasis in the Desert, 49 Palms, Joshua Tree Nat'l Park
Courtesy: D. Hromin

First Impressions

Brian: Hola, me llamo es Brian,...oh, God, let’s see, uh..Nosotros queremos ir con ustedes.

Traveler: That was pretty good. But actually when you said, ‘me llamo es Brian’, you don’t need the ‘es’. Just, ‘me llamo Brian’.

Brian: Oh, you speak English.

Traveler: No, just that first speech and this one explaining it.

Brian: You, you’re kidding, right?

Traveler: ¿Qué?

“Road to Rhode Island.”Family Guy. Fox. 30 May 2000. Television.

                                                                        *

In my opinion, what makes good comedy really good comedy is how closely it reflects what happens in everyday life. The more realistic it is, the more one can say, ‘yeah, that happened to me, once!’, and the more personal and funny the joke becomes.

In this short conversation taken from Family Guy, the dog, Brian, is talking with a Mexican migrant worker. Brian doesn’t speak Spanish well, but he’s trying to communicate and he does pretty well. The man he’s speaking with responds to him in perfect English (and though it’s not evident from the written dialogue, it is an easy-flowing, natural-sounding English when the dialogue is spoken). Because this man speaks so well, Brian assumes that he is fluent in English. However, the man says no, indicates it’s limited only to the English spoken in this particular conversation, and when Brian tries to talk in English with him further, the man does not understand.

A little bit exaggerated for emphasis and humor, but honestly, in my personal experience, this is very close to what I encounter every day in the office with some of my Spanish-speaking patients.  There have been numerous times when I’ve gone out to the waiting area to call a patient back to start the exam, and the patient answers so naturally in English, I assume that he is bilingual and has no problem conversing in either English or Spanish. However, a trip back to the exam room quickly reveals that the patient’s English is limited. Here’s an example of such an encounter: *names of patients have been changed to protect identity

Me: Mr. Gonzalez*? Hi, I’m Dr. Hromin- it’s nice to meet you. Please come with me, we can start the eye exam now.

Mr. G: Hi, how are you? It’s nice to meet you too. OK. Can I leave my things here? (motions to jacket and hat)

Me: It’s better to take them with you, we won’t be coming back to this area after the exam.

Mr. G: OK

(entering exam room)

Me: You can have a seat in the grey exam chair.

Mr. G: Thank you very much.

Me: Ok, so I was reading some of the information written by the technician, it says here since the last visit you’ve noticed a change in your distance vision. In your own words, tell me-

Mr. G: Uh, I don’t speak English well. They tell me you speak Spanish?

Me: Oh, sí, está bien, perdóname, pero usted habla inglés muy bien, pensé que fuera bilingüe.

Mr. G: Gracias, pero para mí, el español es mejor.

Me: Está bien. Entonces, se dice aquí que....

                                                                        *

In this blog, I often reiterate how my goal is to make the patient comfortable. I’ve said many times before, that I don’t want to walk into the waiting room starting in Spanish, and have the patient feel offended in thinking that I assume they don’t speak English. At the same time, I don’t want to start in English, and have the patient who only speaks Spanish feel confused and nervous that they have a doctor who won’t understand them. I check the chart to see if there are clues from the last exam (assuming this isn’t a first-time visit to the office) as to what language they prefer, and I’ll begin in that language. But in the end, if there is no previous visit to review, and the patient hasn’t indicated a language preference on the in-take forms, then I’ll default to English and change if necessary.

Some may think I’m over-analyzing, but this is really something to think about. Imagine if you made an appointment with a primary care doctor who you’ll be seeing for the first time. You check in, you fill out the papers. You are called to the exam room. You’re sitting on the exam table, and your doctor walks in. The doctor smiles and starts speaking to you, in Japanese!(insert here any language you do not know) You interrupt her and say in English you don’t understand, and she smiles and switches to English, which is pretty good but it is not native fluency, and you feel a little uneasy. Will she really be able to understand everything I’m telling her? Would I get a better exam if I spoke Japanese? How can I make a personal connection with my doctor when we don’t speak the same language? Does my doctor think less of me that I can’t speak Japanese? etc etc. I think about all of these things during such an exam. Here is how I have come to handle it over the years:

Mientras hablo con el paciente en inglés, él parece confuso.

Me: Señor, ¿cuál es mejor para usted, (o ¿qué prefiere usted?) inglés o español?

Paciente: Sé poco inglés, para mí es mejor en español.

Me: Está bien. El idioma no me importa a mí. Ok, se dice aquí que usted quiere lentes solo para leer?

Paciente: Sí, pero a veces cuando manejo por la noche, es difícil ver los letreros de la calle en la distancia. Pienso que yo necesite lentes permanentes...

 y el examen continua...

Translation of the above dialogue:

While speaking with the patient in English, he appears confused.

Me: Sir, What is better for you (or, which do you prefer?) English or Spanish?

Patient: I know a little English, but for me Spanish is better.

Me: That’s fine. The language isn’t important to me. Ok, it says here that you want glasses only to read?

Patient: Yes, but sometimes when I drive at night, it is difficult to see the street signs in the distance.  I think that I need glasses all the time.

and the exam continues.

                                                                        *

I think it’s important to address the subject of language right away, so you can get the full details of the history and do a complete exam. I feel that letting the patient know it doesn’t matter which language you both speak in sets the patient at ease.  He knows he’s being heard, he can express everything he feels, and he doesn’t feel judged for not knowing how to communicate in English. You win the confidence and trust of your patient. And at the end of the day, that’s what any good doctor wants.

Greetings.   Courtesy:Amanda Johns Vaden

Scripted

después del examen con el paciente

Paciente: ¿Por qué no puedo ver bien?

Doctora: El problema es que usted tiene cataratas, muy densas. Esta es la razón por qué no podemos mejorar la visión con un cambio en los lentes.

P: ¿Qué es lo que puedo hacer ahora?

D: Si fueran mis ojos, querría la cirugía para sacar las cataratas. Usted tiene una retina saludable- no hay una razón por qué no verá una perfecta 20/20 después de la cirugía.

P: Sí, estoy de acuerdo. Dime más información de la cirugía-

D: Bueno, si decide tener la cirugía, tiene que regresar aquí para una cita con el cirujano. Él necesita hacer otras medidas del ojo para determinar cual implante se requiere después de que él quita el cristalino natural.

P: ¿Qué --------------------------cirugía----------------tiempo---?

D: (¿Qué exactamente él me dijo? Me preguntó algo del tiempo de la cirugía—¿Cuánto tiempo para hacer las medidas y escoger una fecha para el procedimiento? ¿Cuánto tiempo dura el procedimiento actual? ¿Cuánto tiempo se necesita para recuperar y regresar a las actividades cotidianas? No estoy segura de que fuera la pregunta. ¡Ahora tengo que contestar todas las posibilidades!)

Bueno, si decide seguir con la cirugía, el próximo paso es que tiene que hacer una cita con el cirujano. Él va a hacer medidas del ojo para determinar el poder y el tipo de implante ocular que necesita después de le ha sacado la catarata. Generalmente, el horario de cirugía es abierto. Puede tener el procedimiento en las próximas semanas.

En el día de la cirugía, usted llega al hospital por la mañana. No se requiere anestesia general, solo anestesia tópica. El procedimiento dura 10-15 minutos. Inmediatamente después, cuando usted se levanta de la mesa quirúrgica, usted se da cuenta de que ve mucho más claro que antes.  En la sala de recuperación, las enfermeras le dan las instrucciones para el cuidado del ojo con antibióticos y medicamentos antiinflamatorios, y también la fecha de la cita para su primera visita postoperatoria. Resumiendo, usted va a pasar en total 4-5 horas en el hospital el día de la cirugía: de la hora de llegada al fin de la recuperación después del procedimiento.

Durante la primera semana después de la cirugía, se le equipa con una protección ocular cuando duerme. Pero, generalmente otro que eso, se permite que usted vuelve a su rutina diaria, sin restricciones, casi inmediatamente después de la primera visita postoperatoria.

P:Ajj-esa fue mi pregunta. No puedo perder más días del trabajo que son necesarios para la recuperación.

(Supongo que estaría más fácil, la próxima vez ,le preguntar al paciente para repetir su pregunta, en lugar de “adivinar” lo que quiera del principio. Es solo que, no quiero mostrar al paciente  que mi entendimiento del idioma de español no es completo. No quiero que el paciente pierda la confianza en mí. Como te he dicho muchas veces antes, no quiero aparecer como tonta cuando hablo el idioma. Trabajo muy duro para hablar en una manera natural, sin fuerza.  Tengo que conformarme al idea de que voy a preguntar para ayuda o para una explicación cuando se necesite. En este caso, habría salvado tiempo precioso en mi explicación si hubiera comprendido la pregunta en primer lugar. Ahora, la hago una lección para mí y para todos ustedes para referencia futura.)

                                                                          *

after the exam with the patient

Patient: Why can’t I see well?

Doctor: The problem is that you have very dense cataracts.  This is the reason why we cannot improve the vision with a change in the eyeglasses.

P: What can I do now?

D: If it were my eyes, I would want surgery to remove the cataracts.  You have a healthy retina – there is no reason why you will not be able to see a perfect 20/20 after the surgery.

P: Yes, I agree.  Give me more information about the surgery.

D: Well, if you decide to have the surgery, you have to return here for an appointment with the surgeon.  He needs to do other measurements of the eye in order to determine which implant is needed after he removes the natural crystalline lens.

P: What-------------------------surgery------------------time---?

D: (What exactly did he ask me? He asked me something about the time of the surgery—How much time to do the measurements and choose a date for the procedure? How much time does the actual procedure last? How much time is required for recuperation and a return to normal daily activities? I am not sure what the question was.  Now I have to answer all the possibilities!)

Well, if you decide to go ahead with the surgery, the next step is that you have to make an appointment with the surgeon.  He  is going to do measurements of the eye to determine the power and type of ocular implant you will need after he has removed the cataract.  Generally, the surgical schedule is open.  You can have the procedure in the upcoming weeks.

On the day of the surgery, you arrive at the hospital in the morning. General anesthesia is not required, only topical anesthesia.  The procedure lasts 10-15 minutes.  Immediately after, when you get up off the surgical table, you realize that you see much more clearly than before.  In the recovery room, the nurses give you instructions for the care of the eye with antibiotics and anti-inflammatory medication, and also the date of the appointment for you first post-operative visit.  In summary, you are going to spend in total 4-5 hours in the hospital on the day of the surgery: from the arrival time to the end of the recovery period after the surgery. 

During the first week after the surgery, you are given an ocular shield to wear when you sleep.  But generally other than this, you are permitted to return to your daily routine, without restrictions, almost immediately after the first post-operative visit.

P: Ahh—THAT was my question.  I can’t lose any more work days than are necessary for the recovery period.

(I suppose it would be easier, the next time, to ask the patient to repeat his question, instead of “guessing” what he wanted in the first place.  It is only that, I don’t want to show the patient that my understanding of the Spanish language is not complete.  I don’t want the patient to lose confidence in me.  Like I have said to you many times before, I do not want to appear foolish when I speak the language.  I work hard to speak in a natural way, without forcing (my words). I have to get used to the idea that I am going to ask for help or for an explanation when it is needed.  In this case, I would have saved precious time in my explanation if I had understood the question to begin with.  Now, I make it a lesson for me and for all of you for future reference.)

Preferred language

Yesterday, before I called a patient into my office to begin the eye exam, I looked over the intake forms he filled out. Under the section where it said “preferred language”, he had checked “Spanish”. So, when I went to collect him from the waiting area, I greeted  him in Spanish. I brought him to the exam room and had him sit down. I started my usual Spanish dialogue of, “Está aquí por un examen completo de los ojos. La enfermera escribió aquí que necesita usted lentes nuevos, particularmente para leer, y también que tiene un diagnóstico de la diabetes, y necesita un examen de la retina,” and so on and so on. He answered me in English, “Yeah, my glasses are two years old and I need new ones. My doctor wanted an exam of the eyes because of the diabetes.”

His English was good and he continued speaking it, so I changed to English and onward the exam went. But I wondered, why did he start speaking English at all? Especially when he had checked off that his preferred language was Spanish? It’s not like he spoke in English to everyone else in the office. After I finished the exam and he brought the coding sheet out to the front desk to schedule his next appointment, I could hear him talking and joking in Spanish to the front office staff, who happen to be Latinas from the Dominican Republic.

This situation has been happening more often lately, and it just has me thinking, why? Is it because I’m a doctor, and these patients want to show someone who they perceive to be an authority figure that they are capable of conversing in either language?

Is it because they see me, a non-Latino person, speaking very good but not perfect Spanish, and would rather communicate with me in what they assume is my native English?

Is it due to the recent political climate--the random deportations of illegal immigrants--creating a fear in these patients that they feel the need to show that they do speak English well, and are a permanent part of American society?

Is it simply that they want to flex their English-speaking muscles, while I flex mine in Spanish?

I turned to a simple, but sometimes vacuous source for more information: Google. I searched, “Spanish-speaking patients who feel the need to speak English at the doctor’s office”, or something along those lines. Not many relevant hits came up.  The closest situation was one where a man, who was learning Spanish, described his frustration that every time he would try and practice his Spanish with Latino restaurant workers, they always answered him in English. Someone angrily answered his query, saying that it’s rude and racist to assume that just because someone is Latino, that he automatically should speak and be spoken to in Spanish. Well, I can just as quickly say, don’t assume just because someone is non-Latino that he doesn’t speak Spanish. You may find out quite readily that he does, if you give him a chance to speak.

I grew up in the 1980s. Back then, you could honestly and innocently do something or say something, without the observer or listener automatically assuming that you had racist or malintent.  What is so wrong with encountering a person, hearing that she has a heavy Spanish accent, and trying to converse in Spanish with that person? Is that racist?

 Nelson Mandela once said, “If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”

Therefore, can’t it simply be that you are trying to make a more personal connection with that individual, by speaking in his native language? In my particular situation, I work as an ophthalmologist in an office in the northeastern United States. It happens to be situated in a community of mostly Spanish-speaking people, many of whom who only emigrated to the US within the last few years. That being said, I do not go out into the waiting area and start speaking Spanish when I see a Latino patient. At the same time, there have been many Latino patients I approach greeting them in English, and they give me the look of any person who does not understand spoken English: one of confusion, dismay, even fear. I don’t want dismay and fear to be the first impressions that a patient has when coming to my office. I don’t want the patients to think that they will have a language barrier with their doctor, and therefore will not get the help they came to receive.

So, I look to the intake forms. If someone marks off Spanish as preferred language, I greet her in Spanish. I allow the patient to choose to either continue in Spanish or not. If she continues in English, then I will follow her lead. If I happen to greet a patient in English who indicates preferred language as English, but I see right away that he is having trouble understanding and/or communicating with me, I’ll ask,

“¿Qué es lo que prefiere usted—inglés o español?

and if he says,

“Prefiero español, gracias.”, then so be it, and onward the conversation takes place.

I’m very flexible as far as the way I run my practice. The goal of any doctor –patient dialogue is clear communication. The language choice is simply a means to an end, and shouldn’t mark the end of meaningful conversation.

Death Valley National Park 2016

  

Una conversación con un paciente

Doctora: (al mostrar a la paciente y a su hijo al cuarto) Por favor, siéntese ahí, (mira el hijo) y hay una silla para usted en el lado.

Paciente+hijo: gracias.

D: Ok, leí la información que trayó – sus antecedentes medicos – esta información me ayuda saber la historia de sus ojos y el cuidado –lo que proveía su medico en Puerto Rico.

P: De nada.

D: Veo aquí que usted recibió un diagnóstico de glaucoma hace algunos años ahora, y que está utilizando la gota latanoprost – una gota cada ojo por la noche.

P: Sí. One drop in each eye at night.

D: Bueno, la presión hoy es alta- 25,26-necesito revisar la presión con esta máquina, la lámpara de hendidura- es el estándar dorado para revisar la presión del globo del ojo.

Hijo a la madre: Ella quiere revisar la presión con—

P al hijo: Sí, la entiendo. I understand.

D (hace el examen, revisa la presión y el nervio óptico, acaba el examen y da vuelta para afrontarlos)

El tamaño de nervio óptico es pequeño, no es sospechoso para glaucoma, pero sí, la presión es alta mediados de los veinte. No pienso que funcione para usted este medicamento.

Quiero—

P: I also feel pressure in the eyes – como una presión adentro de los ojos – when I move down or look down.

Hijo: Ella te dice que la presión es tan alta-

P: Sí.. I understand.

D: It is possible with the pressure this high that you might feel uncomfortable or have head /eye pain with a change in body position. Es posible que tenga el dolor adentro de los ojos porque la presión es elevada.

Entonces quiero cambiar los medicamentos. I want to start different eye drops.

P: (asiente con la cabeza) Yes I agree. What should we do?

D: Tengo aquí muestras de dos otras marcas de gota para el glaucoma. En vez de latanoprost, la que tiene ahora- va a utilizar esta marca (le muestra a ella la otra) una gota por la noche, cada ojo. Y esta marca en el boxeo colorado rojo, una gota cada ojo dos veces al día. (le da los medicamentos a la paciente)

P: So I put this one at night, and this one morning and night, both eyes?

D: Yes. Then we’ll make an appointent for you to return, I’ll check the pressure on the new drops, and we’ll do another visual field test and photo of the optic nerve, to compare with those taken at your other doctor’s office.

Hijo: Ella quiere hacer una cita para revisar la presión después de utiliza estas gotas nuevas y para hacer examénes del nervio.

D: Sí para hacer un campo visual y sacar una foto del nervio óptico.

P: Yes, I understand what you’re saying.

D: (al dar a la paciente los boxeos de gotas y hoja de códigos) OK, puede entregar este papel en el frente para hacer la cita para la próxima vez. Hand in this sheet up front to make the appointment.

P + hijo: Gracias, doctora, dios le bendiga-

D: Igual, pasen ustedes un buen día.

Of note, this conversation took place with a Puerto Rican patient – she had just moved up to the U.S. and was in the process of switching over her medical care to local doctors. You can see the dialogue was a mix of English and Spanish. This type and level of mixed conversation never happens when I see patients from other Spanish-speaking regions of the world. I tend to see it more with the Puerto Rican patient population. I did some research online in this regard and found some interesting information regarding the reasons for this, mainly due to Puerto Rico’s political history. The island was initially claimed by Spain in 1493 and the language of the conquistadors prevailed. However, after the Spanish-American war, Puerto Rico joined the U.S. in 1898 and was granted citizenship in 1917. English began having a dominant influence.

Examples of Spanglish commonly encountered in the U.S. which have also infiltrated the island include:

el roofo = the roof (instead of azotea or techo)

parkear= to park (instead of estacionar)

la carpeta= the carpet (instead of alfombra; a confusing mistake, because carpeta in Spanish means folder)

el lonche= the lunch (instead of el almuerzo)

and a personal favorite of mine which I encountered as a doctor:

checkear= to check/toexamine (instead of revisar) – This one I caught myself using incorrectly for a long time based on what I heard patients say, until I looked up the true Spanish way of expressing “a check up” and found “una revisa” from “revisar”. Now I make it a point of saying it correctly.

Voynich Manuscript

BE the Interpreter

One day I was getting ready to call a patient from the waiting area  to begin his eye exam. He had marked “Spanish” as his preferred language on the intake forms, so I walked out to greet him.

He was sitting in the waiting area with a woman who looked about his age, and a younger man.  I called his name:

“Sr. Vasquez*, podemos empezar el examen ahora. Por favor, venga conmigo.”

*(names changed to protect patient privacy)

He got up and followed me, and the woman he was with stayed seated. But the young man stood up and trailed behind us toward the exam room.

I had just motioned for the patient to sit in the exam chair, when the patient’s ?friend ?family member reached the door.

“I’ve come to do the translation.”

I felt a twinge of irritation, but kept my composure,

“Oh, no es necesario – yo hablo español. Why? Is my Spanish that bad?”

The young man said “No!” and started laughing, and then I laughed, and then he turned and went back to the waiting area.

I shut the door and proceeded with the eye exam.

The truth is, if this man wanted to come into the room, or if the patient himself had insisted, I certainly would have allowed him to keep the patient company while I did the exam. It’s just, as I’ve said before many times in this blog, my attitude toward the use of Spanish during a medical exam runs a sinusoidal gamut of emotions, changing on any given day and even throughout the course of one day.

I go from feeling confident in my second language abilities, to being unsure. I feel frustration, at having to work harder, at having to think to communicate, and then there are the days when it’s easier and I’m more relaxed in my speech. At times I’m resentful, that out of the group of doctors where I work, I’m assigned all the Spanish –speaking patients while the other docs get to work comfortably in their native English. But almost simultaneously, I feel personal pride and a bit superior to these doctors, knowing I provide care in two languages. Knowing I am growing an ability and a talent that they lack, and it’s an ability that is not confined only to the exam room. Being able to communicate in Spanish – or, really, any language beyond our native one- widens our scope of interaction with the people around us. It broadens horizons. It enlarges our world. The other docs I work with live in a fish bowl. I’m sailing the high seas.

They say you have to push yourself outside your comfort zone to grow. Growth and change are uncomfortable. I have to remind myself of this constantly – when I get frustrated from forgetting a vocabulary word or from having to ask the patient to repeat himself more slowly so I can understand.  I have to remind myself that if I keep pushing ahead, what feels foreign will become second nature. Second nature means I can work more quickly and efficiently in Spanish.  And it really is to my advantage and to the advantage of my patient if I put in this extra effort.

There’s a poignant scene in an old Jim Carrey movie that I like, Bruce Almighty, that I’m reminded of at this time.  Morgan Freeman, aka God, endows his protégé Bruce (Jim Carrey) with all his powers.  Bruce takes the use of those powers to an extreme and to his advantage: walking on water, changing his beat-up old car into a sports car, dragging the moon closer to his house for a romantic evening, etc etc. But in the end, Freeman tells Bruce that all of his antics amount to nothing more than magic tricks. He tells Bruce, “You want a miracle? Be the Miracle!” After this Bruce, aka Jim Carrey, stops self-serving with these magical acts and instead simply reaches out and helps other people.

Similarly, I say, “You want an interpreter? Be the Interpreter!”  You want to communicate directly with your patient? You do the communication! So when my patient’s ?friend ?family member approached me and said,

“I’ve come to do the translation.” (he meant interpretation, but who’s mincing words?)

I just wanted to cut out the third party. Communication is clearer, faster and to-the-point when there is no middle man.

“No es necesario. Soy la traductora. Yo soy, la intérprete.”

2016 Adirondack Balloon Festival, Queensbury, NY