Category Archives: MEDICAL – DEAR DOCTOR

TRIGGER

The video turns on, and I am popped into a room with three residents and a gowned patient on a table. A man in a baseball cap hides under its brim in a chair along the distant wall.

“So we will give you the trigger and then you go to the lab by 9:30 tomorrow.”

Interpreter: “Trigger?”

Resident: “Yes.”

Interpreter: “You may not realize but I am given zero context, do I not even know what clinic you are in, and that word can mean a multitude of things.”

Resident: “Lupron trigger.”

Okay, yeah, thanks for that. This interpreter has only interpreted Lupron as a chemotherapy agent – used in the case of prostate cancer, and this is a young woman. A quick online scan of Lupron uses include suppressing puberty, fibroid uterine tumors, and ovarian and breast cancer as part of their chemotherapy protocols.

“What clinic are you in?”

“Oh! Sorry! Fertility!”

“Great. Thanks. So for the interpreter, as this is new, are you using Lupron instead of Human Chorionic Gonadotropin to induce maturation of the ova? I need to choose a word for “trigger” here. I don’t believe the patient would likely understand “agonist”. Would it be appropriate to use “activation”?

“Oh, yeah, thanks.”

I quickly back-interpret that conversation in the patient’s language, and then doctors go on the explain the in-vitro fertilization procedure in technical terms, some of which I ask permission to simplify. I get approval for my word choices and work with the team to maintain accuracy – and comprehension. My checkbacks provide useful feedback for the doctors in understanding what part of their language is less digestible.

When the doctors get to the part about how “your partner will go into a room and provide a sample once you go back into the OR for the egg retrieval,” the baseball cap in the corner pops up and I see a startled face – then the face disappears from sight again. Poor Daddy!

By the end of this session, we have managed to clarify many small misunderstandings, including:

The “sample” that hubby gave before was for analysis, not for fertilization, and so yes, he will need to get his own fresh sperm, all by himself, while his wife is in her egg retrieval procedure.

The Lupron trigger/activation requires a blood sample to check progesterone levels to determine whether implantation would be viable (there are more miscarriages with the new Lupron method, but less potential damage to the ovaries).

With Lupron, the patient will need high quantities of estrogen and progesterone (pregnancy-supporting hormones) because Lupron alone does not prepare the uterine lining to receive the embryo. There may be patches, and shots, and pills, and lots of bloodwork on a tight schedule. All to increase the success rate of a viable (able to live) pregnancy.

The patient to be impregnated showed visible relief to know why and wherefore on all the patches, tests, bloodwork, and schedule. It had been partially understood, with gaps and mysteries within a dark web of words and information.

I understand some interpreters, especially new to the field, may not feel comfortable with this level of requests for clarification, and then having to back-interpret what the dialogue in English was, but as a long-time professional, I determined that it was necessary for basic understanding. The other good thing is that once I asked for clarification, it gave the patient permission to ask her own questions, and she was able to get a lot of things cleared up. I see this happening quite a bit. Once the interpreter asks for a clarification, simplification, or even confirmation, it can open the floodgates. The patient lights up with relief and their face shows me, “Oh, we can ask questions? Cool! Me, too, then!”

As to the poor husband, he was clearly not enjoying talking about masturbation in a room full of young fast-talking, highly technical, and mysteriously uniformed masked women. Perhaps a truly activist (agonist? triggering?) interpreter who goes easily over the line into “cultural brokerage” would have asked the doctors to assure the husband that his activities in the bathroom – without the aid of his wife this time – do not constitute anything sinful, even for Christians of the first water, as the biblical prohibition related to Onan was to avoid “spilling his seed upon the ground” and in this case, it was to be captured in a plastic cup, and duly conveyed to the patient in order to follow God’s command to “be fruitful and multiply”. I did not go that far, of course, but limited myself to obtaining the linguistic context to help the patient get clear information about what she was going through.

We rarely see the outcomes of our patients, but I like to think there will be a little person sitting alongside Dad in a couple of years, bashfully hiding under their own little baseball cap at some family gathering, slowly warming up and then trailing off after the other toddlers, safe in the knowledge that Mom and Dad are nearby. In any case, I am happy that my patient was able to understand the whole procedure and the whys and wherefores of what was being done to her body in this very important attempt to start a family.

One more note for the linguists and philosophers among us: The phenomenon of doctors (and others) presuming that others know what they know (when we don’t) is actually a thing. It even has a name, which I love: The Curse of Knowledge. It is officially known as a cognitive bias, one which leads us to unwittingly (and falsely) presume that others know what we know, because we have become experts in our field. Our knowledge has become so deeply imbedded that it feels like “everybody must know this” but of course, we each have very different life opportunities and areas of expertise. This is why I so highly encourage my colleagues to step in as needed to make sure we have enough context and information to be accurate in our renditions. And to simplify for understanding, as appropriate, in a fully transparent manner. It is vital for our patients, and useful for the doctors to get these wakeup calls, so they can become better communicators.

STAY IN YOUR LANE

In spite of their fragile and easily shattered egos, at times we simply must shake a select subset of our newly hatched doctors out of their complacency and overwhelming sense of entitlement, in order to gently guide them closer toward following their oath to do no harm. To that end, I am writing up another babydoc today, this time a first year resident in Neurology. Unable to limit herself to the “meet and greet” in the patient’s language, and then move on to appropriate use of interpreter services, anxious as a new doctor, lacking confidence in her budding yet fragmentary specialty skills, and eager to display knowledge – on any topic – she confused and endangered the patient. I do believe it is mere ignorance coupled with subconscious bias and nothing overt or ill-intentioned, but her very lack of awareness is what harms her patients. I am reporting Dr. X in the hopes that she and others can get needed training. It will read something like this:

Today, I was interpreting via video remote for the neurology team with a cancer patient who has developed seizures and numbness post-surgically along with severe dizziness. Dr. X, who I presume is a new first-year resident, needs some additional training in working with interpreters that I am not able to provide during video remote rounds. I am concerned for the quality of the communication, the unnecessary confusion, and for patient safety, as well as this patient’s fundamental access to interpreters after he clearly requested and requires this service. Dr. X does not seem to be aware of our hospital system’s language policy.

When I was called, Dr. X was already mid-conversation, speaking in her Spanish to the patient. I interrupted to introduce myself and my role. Instead of continuing the visit per our policy by speaking through the interpreter, the doctor kept interspersing words in both languages, talking at the same time as the interpreter and sometimes even talking over the patient to eagerly show that she believed she had understood, interrupting me before I had the chance to render his utterance. Several times, she even cut the patient off to eagerly offer her English rendition of what she thought he had said so far, leading me to wonder whether she may have been trying to interpret for the team before I was brought in as video interpreter.

I announced clearly at the beginning of the session that “doctor, you are talking over the patient and the message is being garbled. I am hearing several voices at once.” I later asked her directly to please speak one a time, and pause for the interpreter. The doctor tried, but continued to be anxious to display her knowledge and could not stop herself from popping out words or phrases throughout the session, even while others were speaking. This created confusion and interfered with communication.

Patients who regularly use interpreters are very used to the flow of Spanish and English, and when the staff switches to Spanish (or any other language) the patient will commonly automatically feel compelled – even as they are unaware that they are doing it – to switch to English. I have seen this phenomenon hundreds of times. This patient did this as well, and made his best attempt at answering a couple of the questions in English, in response to the doctor’s attempts at Spanish questions, and then mixing the two languages as Dr. X was doing. This added to the confusion.

I had to remind Dr. X on several occasions during the session to “use the interpreter” and “go ahead and speak English” so the patient can understand (as is his right!) But through to the end of the session, Dr. X was still focused on practicing her second language, to the point that she was not fully engaged in patient safety or the medical care she was supposed to be providing. For example, she told him to “get up and walk across the room so we can see how you walk”, and he had to tell her “no, I am a high fall risk. I have to use a belt and have assistance to get up and move, and they even have an alarm on my bed!” She did not seem to have understood that when the two of them spoke alone off-camera, or to have read the fall-risk notes that are routinely displayed both on the door and the wall chart, with her unnecessary focus on practicing her Spanish.

With video, I do not have an easy way to confer with staff about this for our “on-site in-the-moment teachings” beyond a few quick suggestions and comments. I did everything I possibly could within the context of video remote. At one point while discussing his medicine regimen with three sets of 2-week dosage changes as a precursor to titrating down on a medication suspected of causing his dizziness, I told the doctor that “as you were talking over the patient while he was explaining his meds, I will need the patient to repeat what he just said” she responded before I had the chance to ask him for repetition, stating, “No, that’s okay, I understood him!” and moved on.

The specifics were vital details related to anti-seizure and blood pressure meds and how to titrate or adjust them to avoid dizzy spells and interactions – very important to patient safety and fall risk. There were several times when due to poor video reception I asked for repetition of the medication names or dosages and was told “that’s okay, I already know”. I have no way of knowing whether the supervising physician off-camera was clear on what this patient reported about his medication regimen at home. It sounded like the patient is discharging today and traveling out of state tomorrow. This adds to my concern.

Dr. X also brought up what she had mistakenly understood the patient to say before the video interpretation session began. For example, she told him, “I know you said you never walk outside the house” (thus presumably his dizziness is not such a big issue for fall risk after discharge). The patient replied, “I never said I don’t go outside! I said I do go outside, I even go shopping and hold onto the cart to move around the store to buy groceries, although I cannot load them in the trunk these days.” This was not what Dr. X had understood when communicating with him directly, and this is nowhere near as complex as the medical information to be gathered and communicated.

I want to be clear that as interpreter, I have no opinion about the medical advice given, as a matter of course. I am absolutely not trying to second-guess the medical advice given, or make any suggestions outside the scope of my profession, as I raise my concerns for the welfare of the patient as behooves any member of the care team. My concern is strictly with the quality of communication that needs to happen, so that our excellent doctors can convey their excellent medical advice in a clear and understandable fashion, and understand everything the patient is saying. My only concern here is to help make sure that our medical staff know and agree to follow our language policy.

With the best of intentions, new residents especially may wish to “help out” and display some of their knowledge to the team, but it is not appropriate to take over the role of the interpreter. Refusing to call the interpreter, or calling and refusing to use the interpreter, is exclusionary, racist, goes against our language policy and best practices, and beyond being dismissive and disrespectful, can even endanger our patients.

I hope that Dr. X, and eventually all new staff, can be trained that when they refuse or in any way hinder or discourage the interpreter service that the patient requires, they create a completely avoidable barrier to care, a safety risk, and offer a second-class, lower standard of communication to an already vulnerable patient population. As our hospital invites us to erase more and more of these disparities in healthcare delivery, and some of the less obvious barriers to equal access to care, I hope that our new reporting system can help encourage training especially for new staff, and in this case, Dr. X.

SAME COIN

Fellow interpreters, have you ever wished to pay back a resident doctor who is so full of their new medical vocabulary that they simply cannot speak understandable English? Ever been tempted to use a string of verbiage that would give them a taste of their own medicine? I have certainly sinned in thought. Recently, I had a doctor could not lower the register even after the patient said she could not understand, so I switched to making suggestions:

We note vesicular lesions (may the interpreter say blisters?)

Based on your serology (may the interpreter say blood tests?)

You report myalgia (may the interpreter say muscle aches?)

We expect to use a polypharmocological regimen (may the interpreter say give you several medicines?)

You appear to have photophobia (may the interpreter say sensitivity to light?)

And no, I did not make any of this up. These terms and more are from a single session, and not atypical. Of course there are patients, myself included, who can understand medical terminology. But this patient could not. And this patient needed to know about their own healthcare situation and make momentous decisions based on that understanding, including choosing between proposed treatments. This patient needed to understand and weigh the potential risks and benefits. What we healthcare workers like to call “informed consent”.

There are many arguments from the purists (and there will be many more) as to whether interpreters must “keep the register” even if the patient cannot understand (under the theory that the patient should speak up or stay in the dark – or in this case, do both). Other practical types argue that we can request the provider to speak in simpler terms, point out a miscommunication, or in an open and transparent manner, offer simpler terms that are more likely to be understood. Some activist interpreters may even argue that it is appropriate to ask whether the patient has understood, or suggest the doctor do a teach-back, and have the patient repeat what they understood. The devil is in the details, and we can all come up with scenarios for further argument. But let’s go back to the doctor who cannot or will not “speak English”.

When a doctor does not seem willing and able to lower their register to easily comprehensible speech, and consistently talks “over the head” of patients who struggle with literacy and comprehension, I admit that I sometimes feel an evil urge to make an obscure statement of my own to the doctor, to give them the actual experience of how they sound to the patient. To pay them back in the same coin, as the old saying goes. No, I have never done it. But my fantasy goes something like this (after asking them to join me in the hall for a quick consultation):

“Doctor, having performed a cursory sociolinguistic analysis, applying both near-side and far-side pragmatics to your subconsciously hegemonic discourse in an effort to resolve its multitudinous ambiguities, I reluctantly conclude that your compulsive overuse of your incipient medical idiolect renders your speech equivocal and far from intelligible, in marked discordance with and even opposition to patient comprehension. By way of illustration, your use of “photophobia” is a stumbling block as the auditor may not easily parse out the two morphemes combined to form a compound noun, nor their syntactic and semantic interrelation. Moreover, while hardly a neologism, a loanword with Greek etymology is ill-advised in this context when serving a population that historically lacks the linguistic capital with which to decode your privileged terminology, let alone the social capital with which to declaim it without fear of retribution.

“Doctor, the term “photophobia” is not only superfluous, as we have a perfectly understandable English term (might I suggest light sensitivity?) It is also misleading on its face due to the customary and habitually preferred semantics of each lexeme of the dual morpheme complex construction you favored. You must be cognizant, doctor, that “phobia” is well nigh universally sanctioned semantically as a morbid fear of something, and atypically renders the concept of a simple sensitivity. Thus, fronting this obscure non-preferred meaning, the usage of which is as rare as hen’s teeth, is inapposite. And while the lexeme “photo” has its etymology in Greek as well, originating in the concepts of light or shining, its current generic semantic usage is relationally equivalent to image, not to light. To wit – a picture taken. Your use of “photophobia” while theoretically correct as a technical term, inherently requires disambiguation from common usage in the more widely shared lexicon.

“Thus, doctor, my metalinguistic analysis concludes that when you espouse these medical phraseologies with Greek etymologies instead of fully integrating the more comprehensible, conventional and common-place English terminology, you augment the risk of proliferating misconstructions that are at variance with the foundational, constitutional and contractual concept of informed consent. Photophobia, for example, based on our common socially constructed lay lexicon, could lead one to the erroneous but not unnatural conclusion that they are suspected of having a morbid fear of being photographed! I trust my exemplification is comprehensible and serves to clarify the controversy of competing language usage amongst the stakeholders, through the lens of language nomenclature as a perpetually contested social construct that should never be weaponized against vulnerable members of the population, especially those you have sworn to serve without harm.

“Doctor, as a proposed antidote to your culturally bound and socially noxious overuse of arcane, recondite and cryptically exclusionary classist and hegemonic terminology, it is my professional sociolinguistic perspective that it is incumbent upon you to comply with the standard language policy for patient care by embracing and implementing language that is lucid as well as accessible as a consequence of being generally intelligible, even at the risk of your potentially suffering a vague (hopefully ephemerous) discomfort based on noting an unwonted dearth of syllables in comparison to your habitually imbricated and convoluted clarifications. This interpreter is happy to assist in your illumination if you cannot determine for yourself what sounds – ironically enough – like “a lot of Greek” to the patient, as hereby exemplified by the concatenation of applied sociolinguistic analysis manifested for your edification by the linguist at hand.”

Then I would love to look the person right in the eye and ask in all seriousness:

“Is this what you want to sound like to your patients?”

And yes, this is a serious question, because informed consent is only possible through clear communication.

SIMPLIFICATION

Today, one of the residents called me a few minutes early, so I was able to hear the team’s summary of the case in the hall before they went into the patient room to tell the mother how her premature baby is doing. It really struck home how hard it must be for the doctors, especially young ones who just picked up all the “doctor” terms, to immediately turn and simplify what they just said into terms that the patient and family can understand. But interpreters can play a role as soon as we find a miscommunication or a lack of understanding, and gently suggest simplification of the conversation. It can be a delicate matter, and interpreters often dispute when, how and even whether to step in. My own practice is to wait and see if there is a communication breakdown and then make the request.

The doctors spoke among themselves in what most lay people would consider coded language, not just acronyms but partial and varying terms for the same thing, or even brand names. The younger residents carefully said stool, while older doctors just said “poop”. Four different doctors used four different terms – heart UA, cardio UA, echo, and echocardiogram – to refer to the same study. They said desats for low blood oxygen, tachy for racing heart, and gavage for tube feeding. They talked about “going with Poly-Vi-Sol” to mean administering a liquid form of a multivitamin solution (which may or not be the brand name mentioned).

I cannot recall off the top of my head all of the acronyms and doc-talk terms used in just a few minutes of conversation. Among them, PO was short for pulse oximetry, the method for gauging oxygen saturation in the blood. They called feedings “nutritional support”. They used the term CHD – an acronym for congenital heart defect – as a shortcut to to mean the test that can help detect it, not the heart condition itself. They said baby’s GA was 37.6 to mean Mom was 37 weeks and 6 days pregnant when the baby was born (gestational age). Many more numbers and measurements were tossed about in highly cryptic and somewhat convoluted sentences.

When the resident tried to tell the mother how baby was doing, her first sentence was: “Your baby was borderline on the CHD so we may need an echo to determine whether anything cardiac may be implicated in the desats your baby has during nutritional support, which we don’t anticipate.” This interpreter carefully stated that in the same register, to which the mother responded (to my relief) that she didn’t understand. I conveyed the mother’s words and added from the interpreter, “Could you please restate what you said in simpler terms to ease understanding?” The resident paused for a moment but was able to simplify while still being accurate (and more power to her):

“We consider your baby stable. But his breathing test came out just a little low. So just to make sure it isn’t anything with his heart, we are going to look at it with ultrasound. We don’t expect to find anything, since he only has trouble with low oxygen while he is feeding. Any questions?”

Mom’s answer was that she had understood this time and had no questions. And this interpreter did her best not to grin with great satisfaction, knowing my face looms large on the video remote screen. Hats off to the medical providers who can do this, with or without prompting. It is actually quite a cognitive load to try and convey highly technical information while conscientiously considering word choice and sentence structure. And I would guess that especially residents are already on chronic cognitive overload. But becoming excellent and accessible communicators is a skill that will last a lifetime and is well worth endeavoring. So I am glad to do my part.

CHEEPING AND CHIRPING

I had a patient the other day who finally gave voice to what so many patients experience in so many settings when a care provider thinks they speak a second language well enough to bypass the certified interpreter and practice (their second language skills) on the patient. What a brave soul this patient was! If only she could be heard.

This patient was about to undergo a major surgery to remove body parts she didn’t want to lose, but she had cancer. A young resident (one of the know-it-all infamous teenagers of the caregiver world) came in and started speaking to the patient in her language, even when I presented myself as the certified interpreter and let him know I was here to interpret. When I interrupted, he literally waved me off with a hand and said, “Oh, that’s okay, I got this,” then launched into a flurry of rapid-fire but clearly second language speech.

The patient made eyes at me and I interrupted him again to tell him the patient could clearly not understand him and even his pronunciation of “cancer” was nonsensical to her. (As if in English someone pronounced it “Conth-Hair.”) The patient truly didn’t know what the resident was talking about. But he hurried on heedless until the brave and frustrated patient herself burst out in a torrent of – native – language. The doctor may have understood some of it, but it was my extreme pleasure (and my job) to convey the following:

“You are just cheep – cheep – cheep – chirp – chirp – chirp – parakeeting along like a little bird but honestly I cannot understand a word you are saying – you pronounce everything really weird and you are talking way too fast! I am just nodding and saying yeah, yeah, yeah, but I don’t have any idea what you just said! You just sounded like a parakeet!”

This resident was so utterly oblivious to the needs of others, even when verbally slapped across the face by this courageous patient, that he simply ignored her, and went on. He literally said, “I will try to speak in more slow-mannered,” and continued to insistently spew his second language upon this suffering patient.

I talked to his attending surgeon about it who arrived after the resident had happily gone off to prep for this surgery, and she agreed that he was inappropriate and plans to talk with him about it. I hope this may help his future patients. But what about this patient? How safe and comfortable do you suppose she felt, getting wheeled into surgery with this resident participating? Where is her informed consent? Why do we have a lower standard of care for her?

Dear doctor. I understand you are justly proud of your language skills. But this is not a friendly chat in a bar when you find out the next guy is from a country where you once studied. This isn’t show and tell. Someone is about to lose some body parts and she is here for professional competent care.

Please, doctors, please, everyone. You have an assigned job, with a written description outlining and limiting your scope of practice. Interpreters are meticulous about not practicing medicine or giving medical advice. Please do your job and let interpreter do ours. Not for the sake of our egos, but for patient safety, dignity, and respect.

REPEAT

Doctors tend to be in a hurry.  They come into each patient room with a mental list of subjects to cover, and very limited time.  When rushed and anxious, they can succumb to the temptation of pouring forth a verbal gush without regard to patient comprehension.  Doctors in this situation have a hard time adjusting when they are talking through an interpreter, because they are busy with their mental checklist and not fully present. When doctors talk too quickly and for too long, especially on multiple topics, it makes it very difficult for interpreters to convey the information accurately and completely.

As interpreters, we have various techniques.  We can raise a hand.  We can start interpreting, even if the doctor has not paused for us.  We can switch to simultaneous mode.  I have another technique I like to put into play that I believe helps the doctor to gain awareness of how much they are running on and how disjointed their speech has become.  I only use it as a last resort when I see we are approaching a communication breakdown.  I repeat back in English the last set of speech so the doctor can hear what they just said.  Their eyes get big as they experience how it feels to be on the receiving end.

It is important to note that I am not just displaying my prowess.  I am engaging the doctor.  I am asking the doctor to actively listen, compare what they now hear me say to what they remember they just said, notice if anything is missing or incorrect, and be ready to feed that back to me before I convey it to the patient.  I believe this is akin to what the doctor is asking the patient to do: listen, understand, remember, and mentally prepare any questions or comments to what is being stated.  We are asking a lot of the listener when we speak in a healthcare setting.  What we say matters.  How we say it matters.  How it it received matters most of all.

Yesterday, for example, I had a doctor dealing with multiple risk factors in a new patient.  The appointment had gone over the scheduled time, so the doctor unthinkingly sped up and started rinsing out her mental palate by spitting out words without any apparent awareness of patient or interpreter.  Her face was showing the relief of “getting it out” but it was a rapid-fire presentation.  So I raised a hand, and said,

“Doctor, to make sure the interpreter isn’t missing anything:  We’ll do a glucose intolerance test at your next exam, in which you’ll drink a really sugary liquid, then after an hour, they’ll do a blood draw, and if you handled it great, but if you didn’t, then there are two different ways we can follow up, either a longer test with another sugary drink or you’ll take a little machine home and poke your finger and check your blood sugars and then you might have gestational diabetes which means diabetes during the pregnancy but you might not – we don’t think you do it’s just something we offer everybody – we’ll have to see and we’ll do a blood test to see if you are anemic meaning low blood iron and also to see if the right side of your heart is getting stretched from having to work too hard since you had that mitral valve condition even though we don’t know if you still have it because we don’t have your records but we also need to repeat the transvaginal ultrasound, right, because we want to see if the cervix is changing.  It looks like it changed from the ER visit but different machines, different techs, hard to say.  Is that all, doctor?  Is that everything you just said?  Shall I now say all of that in the patient’s language, doctor?”

The doctor looked at me in complete surprise and said, “Oh my gosh!  I am so sorry!”

I went ahead and rendered all of that in the patient’s language while the doctor stared at me blinking as if she had just woken up.

After that, the doctor spoke a couple sentences at a time, and I interpreted accordingly, and the patient was able to grasp the information.  The patient went home feeling safer about her pregnancy and clear on warning signs and followup.

This is not a bad doctor, in fact she is a good one.  But as the saying goes, bad systems overcome good people all the time.  And when we have a set-up that doesn’t allow enough time for patients, especially new patients, we are setting ourselves up for communication failures, confusion, and possible harm.

BACKTRACKING

I had two appointments back to back with two very good doctors yesterday.  But only one great communicator.  What was the single difference?  Backtracking.  One did.  One didn’t.  And what a difference.  Try to be patient and read through both versions.

Your baby is sitting on its bottom, inside.  This means the body may come out just fine, but the head could get stuck.  There is also a small risk that your uterus could rupture during labor, because you have scars from your other cesarean. And since you want your tubes tied, that could be done during a cesarean.  Knowing all this, which do you prefer?  Would you like to come in to Labor and Delivery and have us try to change the baby’s position next week?  And then try for a vaginal delivery?  Or would you like to just skip that and schedule a cesarean?  Up to you.  For today, I would like to take a quick swab for Strep to see if you may need antibiotics during the birth process.

Or:

So your baby is sitting, well, bottom down, bum down, I mean not head down – and that is an indicator, well not always but usually we would do a cesarean, I mean it is up to you, but you know the head, the head could get stuck. Then again I mean the baby can still change so it may end up head down.   And you had already, I mean, you had a cesarean, right?  Yeah so oh shoot, what was I saying?  Just a sec, I have to remember to swab you for strep, but anyway, your uterus could rupture and start bleeding, well, you could bleed out and the baby could – well we’d have to do a cesarean, I mean, it is high risk, but um you want your tubes tied so we could do that during the surgery, but I don’t want, I am not saying you have to have surgery, just that, oh, here is paperwork for the swab, I mean, we do it routinely, so anyway we can do an external cephalic inversion where we kind of move the baby um but you can bleed during that or well it depends on the location of the placenta and they might not be able to do it, but you don’t have to have it so you can sign and then not do it or change your mind but we should do it next week but the baby can still change back, I mean it can still move, so we don’t really know.  They do that at Labor and Delivery, not here in clinic.  I’m gonna let you change clothes so I can do the swab but oh! you can just schedule a cesarean and that is lower risk but then there are always risks to any surgery, right?  But if you try for vaginal you might have a cesarean anyway and the baby can still move – and the version doesn’t always work, and plus we can’t be sure they can do it, right?  But right now, well, just get changed and I’ll be right back and we can talk more, oh, did you already sign for the cesarean, just a sec – let me check in the file, so do you have any questions?

As a professional communicator with a mind like a steel trap, well, haha, I am using humor here, but no, let me – I mean, uh, yeah, so.  If it is hard for me, a really gifted, or say truly gifted, yeah, truly gifted is better, let me start over: If it is hard for a professional interpreter to process and utter what you are saying, dear doctor, please consider thinking before you speak, and staying on track so your patient can follow along an easy and logical succession of ideas.  No false starts.  No false stops.  No retractions.  This is my advice to you, with or without an interpreter.  Think before you speak, and serve up your valuable medical advice in a digestible form.

INTERRUPTING

A few problematic doctors just cannot help themselves from displaying extraneous and irrelevant knowledge in patient encounters.  My theory is that they were praised almost from birth exclusively for intellectual accomplishments.  I imagine the future doctor in the high chair being asked things like “what does the cow say?” and being fed extra bits of cheese in reward.  This unwarranted display of knowledge in the workplace is not exclusive to the medical profession, but it is a great source of irritation for professional communicators.  And please understand.  Our concern is not for ourselves, but for our patients.

Last week, a doctor was so eager to keep showing that she could understand some of what the patient said, that the dialogue went like this.  I am rendering it all in English, but of course the patient was speaking another language:

P: I started bleeding on Tuesday afternoon.  It was bright red.  I was scared.  My sister has miscarried. I told my husband, and he called the clinic, but they said to just come in today to this appointment.  Do you think something is happening to the pregnancy?

I: I started blee-

D: I know!  Tuesday, Tuesday!  But no cramping?

So……does the interpreter skip all the rest of the patient’s message, presuming if this genius knows the word Tuesday she also knows everything else the patient said?  Does the interpreter just skip the patient’s statements and question and move to doctor’s question?

Or should the interpreter raise a hand, and calmly begin the patient message over from the start?  Not knowing what all was understood, having been interrupted, and wishing to convey the patient’s urgent question, I chose the latter course.

I: I started bleeding –

D: I know!  Tuesday! (Waving her hand in the air like swatting flies.) Cramping?

Now maybe the doctor understood everything and maybe she didn’t.  But there are a couple things she does not understand, and this information might prove useful to improve the old bedside manner.  Take it from a professional communicator.

Dear doctor, when you interrupt the interpreter, you are for all practical purposes interrupting the patient.  Yes, it’s true.  The patient has REQUESTED an interpreter, which is her legal right, and she is sitting there, often scared, on edge, worried, and waiting to hear her words, or something of about that length, conveyed into the dominant culture’s magical language.  She is right there, doctor, having her own independent subjective experience of the appointment, and the whole appointment is about the patient’s body, the patient’s illness or health, and the patient’s experience.  If you insist on the business model, which most hospitals now do, she is the client.  She is the customer.

Second language learning takes us along a lifelong path from knowing nothing of the target language to being perfectly bilingual, an ultimate destination very few of us ever reach.  Patients who need interpreters are anywhere along this continuum.  Like all language learners, they understand much more than they can speak.  So while they cannot say exactly what they want to say, they will often recognize it being said in the language they are learning, and it is a great satisfaction and comfort to hear that interpretation.

These are their words – their thoughts – their questions, rendered into the dominant language.  Their body, their health, their dignity.  Need I go on?  Or do you need to interrupt me?  Please at least realize that by doing so, you interrupt your vulnerable patient, who is not here to inquire as to your second language skills, but seeks exclusively your medical expertise.  Can you really not see how you are disrespecting her?  How upsetting it is?  Please, for the love of medicine, don’t ask the patient to stroke your ego.  She has more important things on her mind, and it is not her job.

In crude terms, nobody gives a flying squirrel how much second language learning you were able to pick up in your privileged and lovely mysteriously educated life.  Truly, we don’t care.  But we are vitally interested in your medical knowledge, dear doctor.  In fact, that is why we made a medical appointment.

And as an institution, we are very interested in following the law on equal access, and language access, so we have hired a state certified professional communicator to render your very valuable, sometimes life-saving, words – and to convey to you, doctor, in front of your patient, the actual words and cares of your patient.  Just because your patient is not usually educated does not mean her words have no value, and you disrespect her just as much whether you interrupt her directly, or you interrupt her interpreter.  So please, stop interrupting the patient by cutting off her words.  She said them for a reason, and she wants them conveyed.

As to interrupting to display knowledge, dear doctor, here’s a news flash! Interrupting is a train that can run both ways.  Believe me, as a long-time professional medical interpreter, I could finish 90% of your sentences with laughable ease and better accuracy than you can mine.  Because I have heard it all so many times.  How would you like the following encounter in front of a patient?  And I am not talking about your dignity.  I am talking about the patient experience.  How do you suppose the patient would feel about this encounter?  She’s getting the same information, and what is more important, she may be impressed with the professional communicator’s incidental medical knowledge.  Let’s try this on.

D: So the main risks to surgery are –

I: I know!  I know!  Bleeding, infection, and damage to surrounding structures including blood vessels and organs!

D: Those risk are –

I: Minimal, because we take precautions to avoid these, and if they arise, we can treat them either during or after surgery!

D: Now because of your diab-

I: Stop! Let me say it!  Because of your diabetes,  ma’am, you are at higher risk for infection or slow wound healing, so we are going to give you prophylactic antibiotics and closely monitor your blood sugars throughout the process.

D: After surgery, you may-

I: I know!  Need wound care follow-up, but don’t worry because we have a wound care clinic that focuses on patients with conditions that can impede wound closure – and this includes patients like you with diabetes! Oh!  And we may keep you in the hospital one extra day post-partum, depending on how your wound looks.  Ha ha! I got this!

(All the while I would have the smirk of displaying knowledge on my face – mirroring the doctor’s from last week – and wave her words away like so many gnats.)

I have no doubt that this same doctor who routinely interrupts would be surprised, disconcerted, and even horrified were the interpreter to give her a dose of her own medicine.  And we could.  Quite easily.  Because virtually any long-time interpreter could interrupt any routine appointment to finish these sentences.  We are actually trained to predict what doctors are going to say as it helps us render better interpretation – always being prepared for the surprise twists or variations.

And to be perfectly honest, as a professional communicator, with a much closer link to the refugee and immigrant population than the typical doctor, I think I could render most medical information in a much more accessible – and more respectful – way.  But I do not have any burning desire to practice medicine without a license, or finish the doctor’s sentences to show that I could.  Especially in front of our patient.

If I wish to practice medicine, there is a clear route for me to become a Physician’s Assistant.  If any medical staff wish to use their excellent second language skills on the job, most institutions have an in-house certification program by which medical care providers can demonstrate that they are functionally bilingual, and thereafter forego the interpreter for that language.   So there are appropriate routes for us to expand our professional scope.  Interrupting is not an appropriate route.  And it is not professional.

And doctor, the reason the interpreter does not interrupt you – even knowing very well what you are about to say – is due to her great and abiding respect for the patient, for your professional position, for the institution where she provides services, and for our health care model itself, with all its flaws, in which each care team member has a specific and limited role.  Please keep this in mind next time you eagerly interrupt just to show you think you know what the interpreter is going to say on behalf of the patient.  Please believe that your respect for the patient’s message – as rendered by the interpreter – will go a long way toward healing.  And toward gaining the patient’s trust and respect.

 

 

 

 

 

 

PRACTICE MAKES IMPERFECT

Doctors sometimes think it is appropriate to practice their varying language skills on patients during their appointments.  It is not.  Those who insist on doing so, even in the presence of a certified interpreter, don’t seem to understand what is wrong with it.  These are not the most sensitive souls in the medical field.  And mid-appointment in front of the patient, during precious few minutes of doctor time, is the most awkward time to try to correct this.  To those doctors who don’t get why they shouldn’t practice their second language skills on their patients, here are some answers for you:

  1.  It is not your job.  We each have a specific and limited role to play with the patient.  Would you be okay if I start practicing medicine?  Think about it.  An experienced interpreter could easily explain the major risks of any surgery to a patient (bleeding, infection, damage to surrounding tissues including organs, nerves and vascular structures) but we are not allowed to.  Sure, your second language may be good.  But it is not about how “good” we are.  We each have our job.  You are the doctor.  You don’t need to confuse the patient by playing the piano. making the bed, or practicing your language skills.  Just as others are not allowed to give medical advice, no matter how sound.
  2. You sound stupid, unless you are very close to bilingual.  Sorry, but it is true.  Here is a transcription of a recent resident encounter:  “Get on the – the there.  Up there.  Lay backwards.  I knead your belly. Is your poo like, like, uh, slippery, or like boulders?  Is it brown or black or the color, uh, bright, like, like, the floor color, this floor?  Look the floor!”  Yes, the resident had to be written up and this encounter is in their employment file.  And the patient asked to switch doctors to someone who “speaks English”.
  3. Instead of speaking in the full range of your luxurious native tongue, bolstered by your years of medical school and formal training in English, you are unwittingly limiting your medical advice and the information you provide to your patient due to the limitations of your second language vocabulary.  Is this treating them equally?  Or are you giving them stunted advice?
  4. You may not understand everything the patient says to you.  This will limit the information upon which you base your diagnosis or treatment.  You may even understand something very different than what the patient is trying to convey, and actually base your medical opinion on your mistaken guesswork.  This is dangerous.
  5. The patients may not understand you.  And your polite and humble refugee and immigrant patients will not tell you that they cannot understand you.  You are an authority figure, with social capital that makes you more than a millionaire in their eyes.  You cannot expect them to say they don’t understand you.  More likely, patients nod politely, then leave scared and frustrated.
  6. Let’s say you are near fluent, though, or even bilingual.  So you walk into a hospital room with your team, and speak a second language to the patient.  Very impressive!  Only one problem: Your care team, the nurse, and your other colleagues do not know what you are saying, so you are excluding your own care team from the vital information you are conveying.  For in-patients, you are leaving the patients for hours or a whole day in the care of nursing staff who were unable to understand what you just told the patient.  How is that helpful?  What happened to teamwork?
  7. To those doctors who are used to “practicing on patients” and who insist that the interpreter should simply correct you as you spit out your spotty second language, we do not know exactly what you are trying to convey with your limited language skills.  So it is quite dangerous for us to play a guessing game of “fixing” your second language.  Imagine how you would like your ten-minute appointment with a Chinese doctor – in China – to turn into an English lesson, assisted by the interpreter you thought would be there to interpret for you.  How scared would you be?
  8. If we are going to trade roles, why stop halfway?  Let’s just trade roles.  Give me your stethoscope, and no one will be the wiser.  We can even use each other’s names and badges for these special encounters, and I will gladly give good, solid medical advice, and you can interpret it into the vocabulary you know.  The boundaries of our knowledge, our scope of practice, our ethics, and concerns of patient safety, along with hospital liability, are not that big a deal, right?  It’s just like, uh, uh, what’s the word?  And hey, if I make a mistake, just correct me.  It’s cool.  And fun! For everybody except the patient and the hospital.
  9. Seriously, it is not safe, appropriate or ethical for us to trade jobs and take on areas of practice for which the hospital has specific licensing and certification requirements.  And it’s hella rude.  Which reminds me, doctors airing out their down and dirty second language skills routinely use a mixture of slang, impolite words, informal greetings, and sarcastic jokes that come across as ignorant and disrespectful.  So knock it off!
  10. Patients feel safest when they know who each team member is, what our respective roles are, and how we will help them.  They feel safe when they know we are each specially trained for the job we will do.  They feel safe when they experience that we are mutually respectful, and working as a team.  Stepping out of our roles to “display knowledge” (AKA show off) is a dangerous indulgence.  It has no place in health care.

So rein in your ego, take a step back, and follows the most basic tenet of healers: First and foremost, do no harm.

Of course, Doctor, if you would like to practice your second language skills in order to improve them, you are free to hire a teacher or a native speaker – on your own time and at your own expense, and off the hospital’s liability insurance.  Who knows, you might even get to the point where you could become certified as bilingual at your medical center, and ethically provide direct bilingual care.  Until then, enjoy the free lesson given at no burden to the patient by carefully listening to the interpreter as your session transpires.  It is a great non-intrusive way to pick up vocabulary, language and even cultural skills.  You might learn something.