Single Combat

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

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

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

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

Either one, it doesn’t matter to me.

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

(el paciente se sienta en la silla)

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

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

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

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

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

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

¿Puede leer todas las letras en esta revista?

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

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

(me mira con expresión confusa)

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

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

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

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

(Hago el examen de la retina.)

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

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

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

Remember to give me names of –

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

Nutricionistas.

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

¿La entrego al frente?

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

Igual. Gracias.

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

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

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

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

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

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

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

The Duel between Hector and Ajax

I speak, therefore I am

To me, one of the great language-learning mysteries is how and when you reach a point in your non-native language when the words you speak pour forth from feeling, and not from thinking. You don’t have to translate in your head and check sentence structure before reacting to something. I have mentioned before in so many words that, in my native English, I don’t have to think about the words I want to use. I simply feel, and then I speak. But in Spanish, though I have improved immensely over the years, there is still a great deal of thinking associated with every feeling I want to convey.

So the question is, what gets you there? What allows you to achieve this level of fluency? I would imagine, immersion. Constant interaction. Constant listening and making sense of it all. And speaking. Hearing and answering. So you can imagine, here I am everyday in an exam room with the patient, and I’m trying desperately to immerse myself in his language, making it my own. I’m trying not only to hear and answer, but to feel, in Spanish. And at times I push myself to the point where I’m close, and then—I have to look at the computer screen in front of me. The patient’s chart. And it’s written in English. And I’ve got to document in English. And I find that my efforts to attain full submersion only leave me partially submerged. I’m bobbing at the surface between the two languages, never fully achieving either. And my notes end up reflecting that: a mix of the two. A confusion.

I can’t tell you how many of my chart notes over the years are inadvertently written as follows:

She stopped using plaquenil tres años atrás.

Ella sabe poco inglés, but prefers to speak in Spanish.

Historia personal: Él nunca fumaba, bebe casi two or three drinks a week.

Sometimes I just write the physician in-notes (those not transferrable to the medico-legal record) entirely in Spanish. The remainder of the chart stays in English, until I prescribe a medication and remember to write the instructions for the patient in Spanish.

It’s a lot of back and forth, a little of this and that. A constant interchange I imagine would be easy for a bilingual native speaker of the two. But for someone like me, native to one and only a frequent guest of the other, moving between the two languages can be difficult if not at times frustrating.

In the study of ophthalmology, when two eyes are properly aligned and the image of the object in sight falls on the same corresponding areas of retina in each eye, this is known as “retinal correspondence”.  If the eyes are misaligned, then the areas where the image focuses in each eye will not correspond and will result in a condition known as “visual confusion”. In the developing child, when the visual cortex is in its plastic period, visual confusion is not allowed because the image of the misaligned eye to the brain is suppressed. In adults, this suppression is not as active, and misalignment of the eyes leads to double vision.

Well, I was just thinking that, in many ways, when a non-native speaker is trying to juggle between his native and non-native language, I have found that, to a certain extent, there appears to be another type of confusion, a “verbal confusion”.  And the brain, being the excellent brain that it is, tends to suppress the non-native words.  I can say from experience that, years ago when my command of spoken Spanish was not as advanced as it is now, my “verbal confusion center” was active at suppressing those foreign words. It held them back, allowing the English to push through. Today, this suppression doesn’t appear as active. I can balance better, but there is still a stronger pull to the dominant English.

Does one reach a stage in language proficiency, where one can move fluidly between multiple languages, without much thought and with little to no confusion? Converse in one language with the patient, but write notes in another, without so much as a stammer? I don’t know. But the best I can hope for is that one day I will know the answer because I'll be living the answer.  For now, what I have is an eclectic, interesting mix of English and Spanish. If from that mix comes better patient-doctor communication, then the struggle for language harmony is certainly worth a little confusion.

Utah desert. Courtesy: D. Hromin

Un chin-chin of Spanish

¿De dónde es usted....es cubana?

No. Soy de aquí- los Estados Unidos.

¿Nació en los EE. UU.?

Sí, ¿por qué?

Su español es como lo que se hablan en las Islas Canarias, o como las islas del Caribe. ¿Ha viajado a España, o vivía allí por un rato?

No, desafortunadamente. Mi conocimiento de español – la mayoría de ello – es teórico. Aprendía español en la escuela.

Hmm, interesante. Bueno, ¡suena cubana!

I’ve heard this from patients frequently enough that my curiosity is officially piqued! When I speak to them in Spanish at the office, they assume I’m either Cuban or from Southern Spain-- the Canary Islands -- to be exact. They tell me that my Spanish is very similar to the dialect spoken in those locations. This is very interesting and highly unusual to me, since I’m an Italian-Polish-American born to an English-only speaking family in the suburbs of New York City. I decided to do a little investigating...

Incidentally, all Spanish spoken in the Caribbean shares the same basic dialect, and there is a historical reason behind this. In the 19^th and 20^th centuries, there was a large migration of people from the Canary Islands and Andalucía (southern Spain) to Cuba and the other Caribbean islands. The speech patterns in these areas were heavily influenced by these new settlers. Common language characteristics include:

1) the “debuccalization” of the end consonant “s” – in laymen’s terms, the weakening of or even complete dropping of the “s” sound at that end of a word. For ex:

Los niños no están aquí.   --> Lo’ niño’ no están aquí.

2) the complete dropping of “s” at any position in the word. For ex.:

Disfrutar --> Difrutar  

  

Después --> Depue’ (de-pwe)

3) the dissimilation of the final “r”, particularly in infinitive words. For ex.:

Nadar --> Nada’

Although I have been known to make the pronunciation changes as described above – which could give the listener, potentially, a sense of my Spanish language origin – there are other characteristics of Cuban/Caribbean Spanish that I don’t follow. For ex.:

4) the use of “ico” or “ica” at the end of a word for the diminutive (instead of “ito/ita”), for ex, to indicate a small or quick moment, a Cuban speaker would say:

“un momentico, por favor” ,

whereas I was taught to say “un momentito, por favor”

Dominican Spanish, in addition to the southern Spain, Canary Island Spanish influence, also represents a combination of borrowed vocabulary from the Taíno language (the language of the original native inhabitants of that region) and the 17^th  and 18^th century Portuguese colonists.  In addition to the language characteristics I’ve listed above, it is also not uncommon to hear the following in Dominican Spanish:

5) Silencing of the “d” in words ending in “ado”. For ex.:

Él es casado ---> Él es casao.

Mire al lado --> Mire al lao.

6) the letters “l” and “r” are substituted for one another. For ex.:

Miguel  is pronounced Miguer

Arturo   is pronounced Alturo

7) the unique indigenous vocabulary of the region:

guagua – bus               (Castilian: autobús)

chin-chin – a little       (Castilian: un poco)

All of this research got me to thinking about my early introductions to Spanish language: who taught me, and where were they from? I was introduced to very basic Spanish (alphabet, vocabulary lists, etc) in the 7^th grade by a teacher who was French Canadian. In high school, my studies were conducted by a Peruvian teacher. It wasn’t until I reached college, and began taking advanced classes in Spanish literature and composition, that I had a Cuban professor. It was in college that I firmly dedicated myself to ‘getting the language right’, so to speak. I wanted to sound authentic, more like a native speaker, so I paid more attention to and practiced how words should be pronounced. Having a Cuban professor as my guide, it is not so unusual now to imagine how my Spanish began sounding more and more Caribbean in origin.

There is the standard, textbook language taught in school. And then there is the language spoken by the people. What they say and how they say it reflects who they are as a culture and from where they come historically. Speak the standard language with them and you open the channels of communication. But speak in their dialect, and you open the doors of trust, friendship and understanding.

“Language is the roadmap of a culture. It tells you where its people come from and where they are going.” –Rita Mae Brown

References

 “Cuban Spanish.” Wikipedia: The Free Encyclopedia. Wikimedia Foundation, Inc. 22 August 2016. Web. 26 August 2016.

“Dominican Spanish.”Wikipedia: The Free Encyclopedia. Wikimedia Foundation, Inc. 6 July 2016. Web. 26 August 2016.

Brod Fortress, Slavonski-Brod, Croatia

La Narración

A person can’t be a good translator unless she can express the same mood and sentiment of the source language in the target language. José Ortega y Gasset was a Spanish philosopher, writer and translator who lived from the late 19^th through early 20^th centuries. In his work, “Miseria y Esplendor de la Traducción”, he writes about the experience of the art of translation. He comments that,

“...La traducción no es un doble del texto original...por la  sencilla razón de que la traducción no es la obra, sino un camino hacia la obra.”

“Translation isn’t a carbon-copy of the original...for the simple reason that the translation itself is not the work, but a path toward the work.”

He goes on to say,

“Lo decisivo es que, al traducir, procuremos salir de nuestra lengua a las ajenas y no al revés, que es lo que suele hacerse.”

“The imperative thing is that, when translating, we need to leave our language behind to go to the other one and not the reverse, that is what needs to be done.”

So, in order to do a proper translation, one must know more than vocabulary and sentence structure in the target language – one must be able to express the same sentiments, the same feelings, as in the original, but within the expressive capabilities of the target language. How does one get to this level of understanding and knowledge in the target language? Well, if you were raised speaking that language, then those abilities of natural expression are innate.  If, however, you’re  like me: someone who started learning the target language later in life, then it requires years of reading, studying, conversing, interacting—and ultimately reaching a point where you can dream and ponder and be creative in that language. I don’t feel there is a time limit that can be set on this level of learning. We all march to the beat of our own drummer. With dedication, we can all achieve this degree of language proficiency.

I had mentioned in an earlier blog entry that I recently completed an English to Spanish translation class. Part of that class was dedicated to creative essay writing in Spanish. There is no better way to practice and hone expression in Spanish than writing a story documenting a personal experience in Spanish. I wrote this story based on my experiences and observations during a visit to Positano, Italy. Aside from a few grammar mistakes indicated by my professor (whoops! wrong preposition!  preterite vs imperfect!) which have since been corrected, I want to share with you the end result in its entirety. I am proud of it. At the risk of sounding pretentious (but with the hope of the most humble pretension) I consider myself a skillful creative writer in my native English. To be able to express myself in Spanish—not through translation, but through expression of the original sentiment in Spanish—felt quite freeing. I can tell the same story in two languages and from two perspectives. Not the same words, but the same meaning.

Imagine un lugar completamente tallado en la roca. Una ciudad, esculpida de una montaña cerca del borde del mar. Un lugar finito, lo que se experimenta desde la base a niveles superiores. En la base, se camina por la arena de la orilla. Hay un hombre, un pintor, quien trabaja para capturar la escena: el mar, la arena, los visitantes, una fuente antigua que existe ahora solo de decoración. Las tiendas donde se venden baratijas y recuerdos. Por el lado, la boca de una calle con el cuerpo de una serpiente. Apresuradamente, se desliza y se desaparece arriba de la montaña. 

Me encontré aquí un verano. Yo quería ver este lugar secreto, el lugar del que todos hablaban. Fue el último verano de libertad, de juventud. Antes de que todas las cosas se volverían rutinarias. Tuve que escoger. Yo podía ir por la calle, seguir la serpiente misteriosa y luchar por espacio entre turistas y autobuses de turistas. Yo podía escalar las escaleras de piedra, directamente a la montaña. Allí, más sereno, pero más difícil. Pero creo ahora lo que siempre creía:  la vida le recompensa a quien toma el camino menos transitado.  Y por eso, fui yo, arriba de las escaleras.

Los escalones de piedra cortan a través de jardines cultivados en niveles diferentes hacia la cima. Los jardines de verduras, aceitunas, frutos secos y uvas, cultivados por los habitantes allí.  De vez en cuando, entre  respiraciones fuertes, vi a una persona, cubierta con un sombrero de paja, que se ocupaba del jardín. Paré para beber de una botella de agua, mientras él esquilaba las ramas de las plantas, levantó la cosecha y fue a la casa. “Verduras para cenar”, pensé yo. Sequé el sudor de mi frente y continué adelante, cada pisada más pesada que la anterior.

Después de una hora y media, llegué a la cumbre. A la cúspide había un pueblo pintoresco, enteramente hecho de piedra. Yo pasaba por una iglesia, una tienda, un café. Cada hogar, diminuto pero fuerte, rendía homenaje a la Virgen María.   Me paré frente a un hogar. Un letrero decía: “Ristorante”. Tuve hambre y curiosidad. Entré. Seguí a una mujer a una mesa, cerca de una ventana con vista a todo: la montaña, los jardines, la ciudad, el mar. La mujer era la camarera y la hija del cocinero. Ella nació en ese pueblo. Vivía allí. Trabajaba allí. Se había ido para asistir a la universidad, pero regresó. Esa fue la vida que conocía. “Me gustaría espaguetis de aceite y ajo”. Ella desapareció a la cocina con mi pedido.

Mientras me sentaba, a esperar por la cena, pensaba de no solo la camarera en el restaurante, pero todos los ciudadanos de este lugar;  turistas, como yo, llegarían y se irían, pero los habitantes se quedarían. Estables y firmes, como la montaña así. Literalmente, vidas talladas en la roca y piedra. Ellos aprendían a vivir con el mar y el viento. Se ajustaban a su entorno, no al revés.  Pensaba en mi vida, en mi ciudad de origen.  Dondequiera que vaya, estoy llamada a volver a casa. “¿Quiere queso con eso?”, la camarera esperaba la respuesta.  Sacudí mi cabeza y sonreí.

*

Narration translated:

Imagine a place completely carved in stone.  A city, sculpted in a mountain near the edge of the sea.  A place with boundaries, which one experiences from the base level to great heights.  At the bottom, one walks in the sand along the shore.  There is a man, a painter, who works to capture the scene: the sea, the sand, the visitors, an ancient fountain that exists now only for decoration.  The stores were they sell trinkets and souvenirs.  On the side, the mouth of a street with the body of a serpent.  Quickly, it slithers and disappears up the mountainside.

I found myself here one summer.  I wanted to see this secret place, the place that everyone talks about.  It was the final summer of freedom, of youth.  Before all things would become routine.  I had to choose.  I could go by the street, following the mysterious serpent and fight for space between the tourists and the buses of tourists.  I could climb the stone steps, directly up the mountain.  There, more serene, but more difficult.  But I believe now what I always believed: that life rewards he who takes the road less traveled.  And as a result, I went, up the steps.

The stairs of stone cut through  gardens grown at various levels up to the summit. The gardens of vegetables, olives, nuts and grapes, cultivated by the inhabitants there.  Once in a while, between heavy breaths, I saw a person, covered in a straw hat, that busied himself in the garden.  I stopped to drink from a bottle of water, while he dodged the branches of plants, he picked up the harvest and went into the house.  “Vegetables for dinner,” I thought to myself.  I dried the sweat from my forehead and continued forward, each step more heavy than the last.

After an hour and a half, I arrived at the top.  At the summit was a picturesque town, entirely made of stone.  I passed by a church, a store, a café.  Each home, small but strong, paid homage to the Virgin Mary.  I stopped in front of a home.  A sign said, “Restaurant”.  I was hungry and curious.  I entered.  I followed a woman to a table near a window with a view of everything: the mountain, the gardens, the city, the sea.  The woman was the waitress and daughter of the cook.  She was born in that town.  She lived there.  She worked there.  She had left to go to college, but she returned.  That was the life she knew.  “I would like oil and garlic spaghetti.” She disappeared into the kitchen with my order.

While I was seated there, waiting for dinner, I thought not only of the waitress in the restaurant, but of all the inhabitants of that place; tourists, like me, would come and go, but the townspeople would remain.  Stable and firm, just like the mountain.  Literally, lives carved in rock and stone.  They learned to live with the sea and the wind.  They conformed to their environment, and not the reverse.  I thought about my life, my city of origin. Wherever I go, I am called to return home.  “Do you want cheese with that?”,the waitress waited for my response.  I nodded my head and smiled. 

Vernazza, Italy. Courtesy: D. Hromin 

Difficulty is in the Eye (and Ear and Mouth) of the Beholder

“Usted habla español bien. ¿Dónde lo aprendió?”

“Gracias. Aquí...en las escuelas aquí en los EE.UU.”

“Es bueno tener un médico que habla mi lengua, porque no hablo ni entiendo inglés.”

(el examen continúa)

“Pienso que inglés sea mucho más difícil que español.”

“¿De veras?—¿En qué manera?”

“Bueno, las palabras – no se dicen  como se escriben. En español, se dice una palabra exactamente como la se escribe. Y también, la ortografía es bien diferente. Pero, me gustaría saber el idioma, un día.”

“Sí, es bueno saber más que una lengua- especialmente en este mundo global.”

It surprised me when my patient said she thought English is a more difficult language to learn than Spanish. It made me think back to a quick search I did once a while back-- it was one of those days I had some down time and for interest’s sake decided to compare languages.  I looked up “most difficult languages to learn” (from an English speaker’s perspective) and what I saw didn’t shock me. In no particular order: the Asian languages: Chinese, Japanese, Korean etc, Hungarian, Icelandic (can you pronounce: Reykjavík?), Native American languages such as Apache, Cherokee, Choctaw and Navajo (incidentally, the Navajo language, due to its varying inflections, the existence of few native speakers and, at the time, the fact that it was an entirely oral and unwritten language, was used as a method of communication between US Marines during WWII, in an effort to hide military plans from the Japanese. The most skilled of Japanese decoders couldn’t break the Navajo communications during WWII).   Other languages making the difficult list include Polish, Russian and German followed by the romance languages.

But grammar rules and pronunciations aside, I personally feel a language is difficult to learn if it is significantly different in its rules, sound and structure to the one you grew up learning. Then again, anything different from what we know and are familiar with would seem daunting, minus any practice or experience.

In an effort to research more about language difficulty, specifically related to English and Spanish, I located an interesting article on the web: “The Differences Between English and Spanish,” which begins by stating that written English in and of itself is not problematic for the native Spanish speaker. However, the pronunciation, or phonology, causes several problems for a Spanish speaker learning English.   The length of the vowel, when pronounced in English, is very important to discerning the meaning of the word. Examples include:

sheep/ship

cat/cut/cart

fool/full

One personal example of this that I encountered in the office one time when asking a patient what pharmacy he uses:

“Quiero mandar la receta a la farmacia. ¿Cuál farmacia utiliza usted?”

“La una aquí en Garnerville...Drew-car. Pienso que sí. ‘Drew-car’.”

“Perdón, pero no conozco ‘drew-car’.  ¿Tenemos CVS...o Rite Aid...tal vez Walgreens?”

“No, no...hmmmm. Está ubicada cerca de la estación de gasolina. Ahí, en la carretera <202>. Drew-car.”

“<al pensar> ¡¡¡O!!! Usted quiere decir ‘True-Care’....True-Care Pharmacy!”

“<al reír> Sí, sí. Drew-car.”

This is particularly interesting to me, because there are several aspects of the English language that I take for granted as a native English speaker. But, if one can’t pronounce the subtle difference between the ‘tr’ of true and ‘dr’of drew, then he will not be understood by the listener.

The article continues by addressing the consonant sounds--which in general are not problematic for Spanish-speakers--except when used in particular instances, and other tricky nuances to the language:

a. Not pronouncing the end consonant hard enough:

            ie. “saying brish for bridge or cart for card ...”

b. Trouble deciphering phonetically similar sounding words like see/she or jeep/cheap/sheep..”

c. Problems with auxiliary verbs. Remember, in English the auxiliary, or helping, verb works with the main verb of the sentence to add clarity to the phrase. Auxiliary verbs, though used in Spanish, are not used as commonly in oral conversation. For example, in English:

            ie. Did he remember to put the garbage out?  Main verb: remember, auxiliary: did

            A Spanish speaker commonly makes this error when trying to say the same thing:

            ie. He remember to put the garbage out? The auxiliary is left out, and the sentence sounds wrong. There are only three auxiliary verbs in English: to be, to have, and to do, but using them appropriately is important to providing clarity to communication in English.

d. Inability to infer the spelling of a word in English from its pronunciation:

            In Spanish the sound of a word is strongly correlated to its spelling. As any native English speaker knows, this is not the case at all in the English language. For example:

            won, one  They’re pronounced the same, but the spelling and meaning are different

            their, there, they’re  Same concept

            And what of heteronyms? Words in English that are spelled the same, but when pronounced differently have different meanings, for example:

            bow  if said BAU: the front of a ship or to lower one’s head; if said BOH: a device for shooting arrows or a decoration for one’s hair

            contest  if said kahn-TEST: to argue;  if said KAHN-test: a competition

And the list goes on and on....

Researching more into my native English makes me appreciate more the difficulty that my Spanish-speaking patients encounter when in the process of learning the English language.  It gives me new insight into my own native tongue, and why certain concepts of my own Spanish learning come more easily than others.  I’m either aided or, conversely, tripped up by preconceived grammar and pronunciation rules molded and shaped by years of English education. Though there are some tools from our native tongues that we can take with us when embarking on new language learning, we invariably have to leave other concepts behind. Letting go of a lifetime of foundation can be scary, but it is precisely in the letting go that we evolve to something more unique and beautiful.

References

“Auxiliary (or helping) Verbs.” Ginger Grammar Rules. http://www.gingersoftware.com/content/grammar-rules/verbs/auxiliary-or-helping-verbs/ (Accessed August 6, 2016).

Ellis, J. “Welcome to the Heteronym Homepage!” 6/1/96

http://www-personal.umich.edu/~cellis/heteronym.html (Accessed August 6, 2016).

Shoebottom, Paul. “The Differences Between Spanish and English.” Frankfurt International School. http://esl.fis.edu/grammar/langdiff/spanish.htm (Accessed July 31, 2016)

Wilsont, William R. “World War II: Navajo Code Talkers.” HistoryNet. 6/12/06 http://www.historynet.com/world-war-ii-navajo-code-talkers.htm (Accessed August 6, 2016).

Barn Owl. Courtesy: Rogers Wildlife Rehabilitation Center

When Translation is Law

“The single biggest problem in communication is the illusion that it has taken place.”George Bernard Shaw.

As a follow up to Intro to Translation, I would like to review exactly what types of documents physicians are required by law to translate for their practices.

If a physician has a practice which provides care to a substantial number of non-English speaking, or LEP (limited English proficiency) patients, then providing these patients with translated documents has a number of benefits. The United States federal government defines LEP as a patient’s own self-assessment of his or her ability to speak and understand English as less than very well.

Patient satisfaction surveys have consistently shown that LEP patients have 36% lower satisfaction rates than English speaking patients and 47% --almost HALF of them – are more likely not to return for future care as a result. Although there are 6 types of medical documents that must be translated in order to remain compliant with federal law, it may be worthwhile to consider including other practice materials, such as patient education materials or patient survey forms, in an effort to improve the LEP patient experience.

Under the Civil Rights Act of 1964, Title IV, patients cannot be discriminated against because of national origin by any institution that receives federal funding. When documentation is not provided in a language the patient can understand, this too is considered discriminatory under this act. The specific requirements for translation were further elucidated upon in 1997 by the Critical Access Hospital Program which focused on hospitals in areas of the U.S. that have a higher percentage of LEP patients. The six types of documents that must be translated are:

1 – notices of free language assistance

2  - eligibility for services of language assistance

3 – patient intake forms

4 – informed consents

5 – patient complaint forms

6 – discharge instructions

The Office of Civil Rights (which is part of the Department of Health and Human Services) requires that these documents be translated when “the LEP language group constitutes 5% or 1000 persons – whichever is less – of the population served.”

State government interpretations of this law may be more strict, as in the case of New York State, where the requirement given by the Office of Civil Rights has been expanded to “1% of the hospital service area.”

It is further important to note that the Affordable Care Act (ACA) has shifted incentives for doctors and hospitals to offer better quality, not quantity, of care. In essence, there are financial repercussions to providing care that does not result in patient satisfaction. Medicare provides higher rates of reimbursement with more readmissions. Doctors receive bonuses or penalties if they receive high or, conversely, low scores on patient satisfaction surveys.

Therefore, it is in the doctor’s best interest, aside from satisfying the legal translation requirements for providing care to LEP patients, to try to overall improve the LEP patient’s entire office experience by offering as much patient material as possible in the language the LEP patient can understand. These include as mentioned earlier in this blog entry: patient education pamphlets, surveys, and marketing materials.

The consent forms I have been referring to in this article apply to procedural consents provided to patients. In my office, they would include cataract surgery, laser iridotomy, chalazion/eyelid lesion excision, selective laser trabeculoplasty and YAG capsulotomy consent forms- to name a few. However, it is important to note that research-related consent forms are also included in this category.

The Institutional Review Board (IRB) requires that consents for research must be written in the language in which the patient interview is conducted. Further, according to information provided on the Language Scientific website regarding IRB-specific consent forms, there are 4 specific scenarios to consider when deciding if consent forms have to be translated from English:

1 – If the patient/participant has the ability to read and understand sixth-grade level English, then no translation is necessary. Forms may be provided in English.

2 – If the patient/participant cannot read but understands spoken English, then it is possible to have someone read the consent form to them with a witness present. Understanding by the patient must be documented and the patient, witness and reader of the consent must all supply signatures at completion.

3 – If the patient/participant cannot read or understand spoken English, but is fully literate in another language, then the consent and all related materials may be translated into the language the patient understands.

4 – If the patient/participant cannot read or understand spoken English, nor is literate in another language but can understand another language when spoken, then the consent must be translated into the other language and another person must read the translated consent to the patient with a witness present, documenting that the patient understands all that is being said. In the end, the patient, the reader of the consent and the witness will provide their signatures to this effect.

Further, the IRB “.. must review and approve all translated versions of an informed consent form before the form is used in a study.” If the study itself is complicated or carries with it significant clinical risk, then an added safety measure for quality assurance of a proper translation must be provided to the IRB via a back translation. A back translation is one where the translated document is translated back into the original English by a separate translator, to ensure that everything written in the language correctly reflects that which was written in the original English.

References

duMont-Perez, Suzy .“The 6 Medical Documents You Must Translate to Remain Compliant.” LanguageLine Solutions. http://blog.languageline.com/6-medical-documents-must-translate-to-remain-compliant (Accessed July 22, 2016).

Markert, Cory. “Medical Translation: Is Translation of Vital Documents Enough?” LanguageLine Solutions. http://blog.languageline.com/medical-translation-is-translation-of-vital-documents-enough (Accessed July 22, 2016).

“Office Guide to Communicating with Limited English Proficiency Patients.” American Medical Association. https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=what+is+the+definition+of+an+LEP+patient (Accessed July 23, 2016).

“6 Things to Know About Translating Informed Consent Forms.” Language Scientific. http://www.languagescientific.com/6-things-to-know-about-translating-informed-consent-forms-2/ (Accessed July 24, 2016).

Dubrovnik, Croatia. Courtesy: D. Hromin