Throughout my medical training, my most enduringly useful skill has had nothing to do with accurate diagnosis, wise treatment, or calming bedside manner. Instead, it has been a rather pedestrian skill shared by nearly a billion people across the planet: the ability to speak Spanish.
I’m not a native speaker of the language, but studied it formally for many years and used it professionally for many more. I’m quite a functional speaker by now, and this skill has been beyond useful in caring for many many Hispanic patients over time.
One in particular stands out in my memory as a stark example of the power of language as a tool, and as a weapon.
I was working on the acute inpatient psychiatric unit at the time. Typically one on-call resident would take admissions overnight, and the rest of us would pick up our new cases when we came in the next morning. I came in one morning to see a new name on my roster.
Prior to meeting the patient I scrolled through her notes from the emergency room the night before. Evidently she’d been brought to the ER by her husband after attempting to jump from a third-story window. She’d been quickly deemed a danger to herself, placed on a legal hold and transported with all possible efficiency to our locked psychiatric unit.
I composed a picture in my mind of a wild-haired woman bent on suicide, suffering so intensely that she had been poised to hurl herself off a building. She might be depressed, or psychotic, or possibly both.
When I went to the bedside I was somewhat surprised to find a calm, soft-spoken, neatly dressed woman with a shy and pleasant manner. She spoke no English. I quickly switched to Spanish, and asked her to relate to me the story of how she had come to the hospital.
Her tale raised the hairs on the back of my neck. She reported, in quite neutral tones, that her husband used psychiatric admissions as a way to control her. He had strict rules regarding where she could go, with whom she could socialize, and how she was to care for their three children. When she transgressed, he would threaten to have her locked up. And the threat was not empty, for he had done it twice before.
The process was always the same. He would bring her to the ER and inform the staff, in English, that his wife had tried to kill herself. She would try to tell her side of the story. The harried ER staff would use her apparently uxorious and conveniently bilingual husband as their interpreter. Inevitably, the patient would end up on the locked psychiatric unit.
The patient adamantly denied that she had ever tried, or thought about trying, to harm herself. She denied each of a long list of symptoms of various psychiatric disorders. She gave me the telephone numbers for her sister and aunt, who she said could confirm her story. She desperately wanted to be discharged, as she was worried about her children. She said her husband, whatever his other shortcomings, had never been violent with her.
I called her sister, who also spoke no English but who was able, in Spanish, to confirm the patient’s story in every particular. After a brief conference with my attending and a scramble to pull together some appropriate domestic-violence resources, we dropped the patient’s hold and discharged her from the unit. We were at a loss as to what else we could do for her. Nonetheless the patient thanked us profusely before she left; apparently discharge from her previous psychiatric hospitalizations had not been so easy.
I wondered how many similar stories we could have been missing over the years.
Non-English-speaking patients throw a huge wrench in the gears of the already overburdened medical machine. A fifteen-minute med check, inadequate under the best of circumstances, becomes even more unmanageable when the need for a translator extends from minutes to hours the time it would take to complete necessary basic communication. Additionally, hospital interpreters can be hard to come by, or may be available only by telephone. Often the temptation to use readily available family members as interpreters, or even to forgo interpretation altogether, legal requirements notwithstanding, is too great to pass up.
Such temptation is stronger on non-psychiatric services, where simple questions about pain and breathing can be answered in pantomime, and further detail can too easily be dispensed with. It is impossible to conduct a psychiatric interview without a shared language; but in many gray-zone cases there is a temptation to rely on a patient’s weak English rather than seek a professional interpreter.
Nonetheless, cases such as this one illustrate the importance of being able to reach a true consensus with the patient, and in particular why it is often a poor idea to use a family member as an interpreter (although admittedly there are times when this is unavoidable). I felt good that I had been able to help this woman for the moment, but knew I was powerless to prevent her husband from continuing to exploit this gaping weakness in the medical system.
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(PS: A note about my second extended absence. I stopped adding to this blog in 2010, for a number of reasons that included the all-around, just-plain-too-busy variety.
However I recently googled my own screen name (looking for a comment thread somewhere) and found this. It felt really good to think that there's at least one individual out there who appreciated what I was doing enough to remember it years later, and made me remember that I liked writing this stuff, and apparently there are at least a couple of people out there who enjoyed reading it. So I am going to commit to a good-faith effort to keep posting, at least once in a while. I still have quite a lot of unused material from residency, and when I run out of that, well, maybe I'll start posting about my boring research. Or maybe something else will show up. Anyway, thanks for reading this far if you have. I'm off to explore what's new around here but will, I hope, be back again in the near future.)
