Category Archives: MEDICAL – DEAR DOCTOR

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.