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.

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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

En la mezcla otra vez - Vuelvo al mundo de lenguaje

I just completed my first week in a new ophthalmology practice. In addition to meeting new people, seeing new faces and remembering new names, I quickly discovered that I had three languages on which I needed to brush up:

 

1) Plain language – the ability to explain medical jargon in clear, concise, lay terms

 

2) Computer language – in order to qualify for certain incentives, more doctors’ practices are embracing the use of electronic medical records (EMR). Unfortunately, EMRs are not universal throughout the U.S. Working in a new office means learning new software. 

 

3) Spanish language – after 8 months away from a real, live Spanish-speaking patient, the task of falling back into unstrained fluency is upon me and is daunting.

 

My first two Spanish-speaking patients were booked for standard full eye exams, so, easy to perform and easy to explain in Spanish. Neither patient had any particular pathology and neither was very talkative, so I didn’t have to worry about too much small talk ‘la charla’ while typing up their medical reports.

 

But as the days progressed, patients came in with problems. Concerns. Questions, in Spanish. And they came in with their individual accents and colloquialisms. And what I thought would be easy was hard all over again.

 

One woman had a long history of accommodative esotropia, but she didn’t use bifocals. She felt “better” when she wore distance glasses, but felt a “pulling” sensation in her eyes sometimes.

 

She had mild amblyopia.  She wanted to know if surgery could be done to improve her vision.

 

One man couldn’t remember his medications or his primary care doctor’s name. He had 20/60, 20/70 vision, refused to wear glasses, and wondered why he felt dizzy most of the time.

 

Another man asked why his eyes were always tearing. He thought it was because of his cataracts. He looked at me with an expression that indicated to me that he may not be taking me seriously. 

 

As I sputtered on and tripped over my explanations,  the patients listened to me, but not fully understanding what I was saying. I realized three main points:

 

1) When faced with giving an explanation in a second language, know what you’re saying in English first.  If you don’t know that, you won’t be able to say what you want in Spanish, either.

 

            Case in point: the White Dot Syndromes. How do you explain MEWDS to a young, healthy 22-year-old? Imagine what you’d say in English first. Think about it. Think about what makes sense. Then give your most concise interpretation in Spanish.

 

2) Familiarize yourself with the right vocabulary, and say it often enough so you’ll remember it.

 

            There are many disease states in ophthalmology that we just don’t come across often enough, for example, Susac disease, or Posterior Polymorphous Dystrophy. If we learn the vocabulary to use with one patient and never use it again, we will forget it. When you come across a less common eye problem and make the effort to explain it in Spanish, it’s worth writing down and keeping for future reference. It helps to use as a refresher when another patient with Sympathetic Ophthalmia walks through your door.

 

3) Always employ the approachable “plain language”.  ‘Side vision’ is more easily understood than ‘vision in the periphery’.

 

            Every time I see a glaucoma suspect patient, I want so badly to say, “your nerves look suspicious for glaucoma..”in Spanish, but I always forget the word for “suspicious” (sospechoso, incidentally, but after this I’ll forget if I don't use it), I lose confidence in my pronunciation of the word for ‘look’ (which translated would be the word “appear” or “aparece”). In the end, I find myself breaking the sentence down to the simplest explanation: “One optic nerve looks bigger than the other. This could be normal. This could be glaucoma.”   So choppy. So not me linguistically, at least in English. But just as the poet John Stone so eloquently put in his poem “He Makes a House Call”, medicine is what works. And so dialogue in a patient’s first language and a doctor’s second must do the same thing: what works. 

 

These are many concepts I’ve wanted to explain in Spanish, but struggled to do so clearly and concisely:

 

“It’s difficult to explain this, but the fact that your vision isn’t “crystal clear” is not all related to strabismus or the fact that you are hyperopic.  Since you have a fair amount of far-sightedness and astigmatism, and you had to start wearing glasses since 5 years of age and you admit that you did not wear them consistently, only “once in a while”, I suspect you have a level of amblyopia.  Amblyopia means that during the formative years, the visual part of the brain did not receive a clear image from each eye. This part of the brain stops forming when we are around 10 years of age.  After that, there is no surgery or eyeglass that can “force” the brain to see 20/20, when the best it can see is 20/30 or 20/40.  But  you are fortunate, because your amblyopia is mild. To be able to see 20/30 is great. Some patients with amblyopia can’t even see 20/400, which is equivalent to the big “E” on the chart.”

 

Is this plain language? Actually, no, it isn't. So why am I tripping myself up making it more difficult for myself and the patient? Maybe I should have thought about saying:

 

“Surgery cannot make your eyes see better. You did not wear your eyeglasses regularly as a child, and now the eye is lazy- it cannot see 20/20. But, your vision is still very good with your glasses. We can make the glasses a little bit stronger.”

 

“Cirugía no va a corregir la visión.  No se vestía los lentes regularmente cuando era niña, y por eso el ojo es un poco ‘perezoso’- Usted no ve 20/20. Pero, la visión es todavía muy buena con los lentes que tiene.  Podemos hacer los lentes un poco más fuerte.”

 

 

Or how about when I tried explaining why a patient’s eyes were tearing? I wanted to say:

 

“Your eyes are tearing because they are dry. I know this sounds strange (I know this is an oxymoron), but eyes tear as a reflex response to not having enough basal tears to cover and protect the cornea. I have to examine your tear film first to see for sure, but if this is the case, then likely you will need to use artificial tears regularly.”

 

But maybe I should have simply said:

 

“Your eyes are dry. They tear because they are irritated, but this is not normal tearing. You have to start using artificial tears regularly.  If you put a drop in each eye 2-3 x a day regularly, especially when you are reading, watching TV, using the computer, sewing, then the tearing will stop.”

 

“Los ojos son secos.  Están lagrimeando porque tienen molestia, pero no es lagrimeo normal.  Tiene que usar lágrimas artificiales regularmente.  Si ponga una gota en cada ojo 2-3 veces al día regularmente, especialmente cuando lee, mira la television, usa la computadora, cose, el lagrimeo va a parar.”

 

Better. I still want to use the word ‘oxymoron’ (el oxímoron, incidentally.  That can’t be too difficult to remember!)

 

Of course, the International Classification of Disease, Ninth Revision, prefers doctors speak in this type of language:

 

“You have 375.15, 365.0 and a touch of 368.03.” 

 

Statistical. Universal. Alas, impersonal.

The bottom line is that practicing medicine today is about more than simply practicing medicine.  It's about being fluent in, at minimum, three languages: the language of your patient, plain language and the software language to document the visit.  Maintaining fluency requires constant use. Language growth requires the patient encounter.

Adirondacks, NY

 

Tanto tiempo sin verte

In one of my earlier blog entries, No lo olvides , I talk about how important it is for a native English-speaker who lives and works in a primarily English-speaking environment to seek out various sources to help maintain her second language knowledge.  To keep knowledge of my second language, Spanish, alive, I talked about reading online Spanish newspapers, Spanish blogs and books, perusing medical Spanish websites,  listening to Spanish radio and watching telenovelas en Español.  I even listed a personal favorite of mine, the link www.mylanguageexchange.com where a person can find a penpal to practice any language anywhere at any time.  Such is the global nature of our world now. Information is here at our disposal with the touch of a fingertip, but all this information is useless if we don’t actively make it a part of our daily routine.  

 

All the sources in the world are no substitute for using a language in real-life scenarios every day. Those are the situations that, I have found, solidify language meaning into my long-term memory. Lately, I have been living and learning this truth the hard way: this past winter I made a transition out of the medical practice where I worked for the last seven years. When my position there ended, my real-life teachers, my Spanish-speaking patients, were suddenly not in my life on a daily basis anymore. 

 

I no longer found myself every day asking someone, “¿Qué le pasa Ud.? “ or “¿ Por qué Ud. está en la clínica hoy?  I stopped hearing regularly their explanations in Spanish, about how their child accidently scratched his eye, or how their vision was fine a week ago but now is terribly blurry and “empañada”. The more I heard what they had to say and listened to their life stories, the more real all the Spanish vocabulary and sentence structure and grammar became.  I was able to move away from the sentence-by-sentence translation I was doing every day in my head and instead was able to just listen and respond. My teacher, the patient, and my school, the clinic, made Spanish come alive for me.

 

Winter is a dead season, especially so in the ophthalmology job market.  I knew it would be some time before I would find my way into a new practice.  Eight months have passed since I have sat down face to face at the slit lamp.  I feel like the tin man left too long in the rain. My hinges are rusty, as is my Spanish, frozen in place since December.  Now, a new opportunity has opened for me which I will embark on in a few short weeks. I will be treating a fairly large-size Latino patient population many of whom are only Spanish-speaking.  I wonder if my Spanish, stagnant for so long and not given the opportunity to move forward, has actually regressed? I wonder how quickly I can feel comfortable again.  I wonder when Spanish will become more second-nature and less a far second to my primary language, English. Only time will tell.  

 

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

 

Patient: Vine aquí por un examen de los ojos porque mi amiga, la Sra.—, ella es un paciente aquí, me dijo que ella tenía una experiencia buena con Usted. Ella me dice, “aj, vas a gustarle a ella”, y ahora veo lo que ella dice.

 

Doctor: Gracias. ¿Y por qué es eso?

 

P: Bueno, ella me dijo que Ud. habla español.  Eso es muy importante para mí. Me gusta la habilidad a hablar con mi medico en mi idioma, a saber que ella me comprende completamente. Es muy importante a mí.  Yo sé un poco íngles, pero no bastante para expresarme completo—todos mis problemas de salud—en íngles. 

 

D: Está bien. Yo sé que mi español no es perfecto…no soy hablante nativa…

 

P: No importa. Me entiende y puedo comunicar con Usted. Eso es lo que es importante. Me contenta que Usted está aquí.

 

With all of my fears about expressing myself appropriately in Spanish, how I sound, the words I use, the way in which I speak, I realize it is worth risking mistakes in grammar or “sounding foolish” if the end result of my attempts  sets my patient at ease. That’s what the doctor-patient relationship is all about-- making that special connection, earning trust and communicating.   Afterall, treating the disease can only start first with treating the person. 

Courtesy: D. Hromin

 

A Thousand Words is Worth a Thousand Words

Blefaritis

1-Tenga que limpiar los párpados cada mañana y noche con una toalla tibia.

2-Tome 1,000mg de Omega-3 (dos píldoras con la comida).

3-Ponga dos gotas de lágrimas artificiales en cada ojo dos veces al día.

One of the topics that I repeat ad infinitum in this blog is that, no matter the language or the culture, people are people.  We are all subject to the same concerns, fears, questions, hopes. We all have the same goals as patients—we want to stay healthy, be well and are willing to do what we must to keep things that way.  Ophthalmology patients want the best for their most important sense: they want to see the sharpest, maintain their vision, and continue with their daily routines sans eye irritation or discomfort. They of course have concerns, having an understanding of what conditions like ‘macular degeneration’and ‘retinal detachment’are-- they want to make sure such vision-threatening diseases are preventable or at the very least, caught early and treated.

It’s alot to think about, and as a patient in a doctor’s office (a place where many people have a low-lying level of nervousness to begin with), sometimes it is difficult for the patient to A) remember all the questions he want to ask his doctor and B) listen to and remember all the doctor is telling him regarding his diagnosis and instructions for treatment. And this is assuming that the doctor is explaining things in plain language.  If technical medical jargon is being used, then this adds an extra element of confusion to the mix for patients.

I have found time and again since my third-year medical school clerkship days, that even when I explain in my native English a patient’s diagnosis and treatment to a native English-speaking patient, many times in the end my patient will still have difficulty remembering everything I’ve said, let alone the steps to take to treat the condition. I make every effort to use plain language and not medical terminology. I take as much time as necessary to explain everything and answer all questions to my ability. Yet, when I ask the patient to repeat back to me what her understanding of her eye condition is and how I want her to proceed with the treatment regimen, many times she can’t do it! She nods her head in understanding, but in the end she still does not fully remember everything I’ve said. As I mentioned earlier in this post, most of this has to do with a certain level of anxiety the patient may be experiencing, in addition to having to take in a large amount of new information which, honestly, takes time to digest.

Think about it—if this happens, and it does frequently happen, in my native English language, imagine how much more convoluted and confusing the story gets when I am attempting to explain the same diagnosis in my secondary language of Spanish! Sure I have a professional fluency, but it is not native level, and the native Spanish-speaking patient is therefore subject to my personal interpretation, my accent, and my linguistic angle of his language. –Eso es decir, hablo el idioma bien, pero no soy un hablante nativo de Español, y estoy segura que hay veces cuando mis frases suenan extrañas. –>Maybe even this sentence!  When speaking or listening in a non-native language, there will always exist misinterpretations or confusing elements. Add to this scenario the usual time crunch in a busy clinical setting, and we have the perfect storm which can result in a patient leaving the office frustrated and not fully understanding his/her diagnosis and what to do about it.

To make life a little easier and clearer, what I like to do is have written material available in Spanish which I can give to the patient at the end of his visit.  This serves as a take-home reminder of what we discussed in the office. The American Academy of Ophthalmology is one of several sources that offers  brochures on their website which thoroughly cover a variety of eye diseases in Spanish (see below for link).  However, I find that sometimes, such information is a little bit too lengthy.  Even written information, when given in too large a quantity, becomes a giant ocean where the main points are lost.

During my residency, when the time crunch really really mattered, I became master of writing out instructions on small pieces of paper or index cards of the most common eye maladies I treated: dry eye, blepharitis, corneal abrasion, bacterial keratitis, open-angle glaucoma, metallic corneal foreign body removal, the list goes on and on. I would photocopy them and hand them out at every opportunity.  I did this in both Spanish and English, and I opened this particular blog entry with an example of my “Blefaritis” treatment information card.  A little extra work to prepare these went a long way in driving home understanding of the disease and/or treatment. It meant the difference between seeing a patient at follow-up who was fully recovered versus the patient who was still suffering because he/she couldn’t remember how many times a day to use the drops.

Of course, some patients returned the next visit having lost my cards, but I would hand them another copy and we’d start all over again!  In the end, it’s about doing all you can to make sure there is an understanding between doctor and patient, regardless of the language in which you communicate.

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American Academy of Ophthalmology Patient Education Brochure link:

http://www.aao.org/practice_mgmt/patient_ed/brochures.cfm

The Adirondacks, NY