Sophia Manduca, MS3, NYU Grossman School of Medicine
“¡Hola, soy la estudiante de medicina!” (Hi, I’m the medical student!”) That was how our conversation started. You had asked to speak to the doctor about your husband’s cancer care. You were in high spirits. Someone was finally “doing something” about the massive hepatocellular carcinoma he had growing in his liver, now so distended that it protruded through his shirt and compressed his inferior vena cava, causing bilateral edema so severe he could not bend his legs. Your husband had come to this hospital after experiencing what you deemed as “negligent care” at a different one. I do not know how your experience went at the other hospital, nor how well their messages could be communicated to you from across a language barrier. Still, from what you said, and after reading the chart, it seemed to stem from the doctors there not considering surgical resection of his tumor or a liver transplant to be feasible at this point, given his comorbidities, instead, opting for chemotherapy. Now, you were elated two days after your husband returned from a procedure done at our hospital.
I was still translating after-care instructions from the resident, but you were excited. “¡Mira, la hinchazón ya es mucho menor!” (“Look, the swelling is already so much less!”). “¿Cuánto tiempo hasta que el tumor desaparezca?” (“How long until the tumor goes away?”). This part caused me to pause. The procedure was an intrahepatic embolization intended to stop the bleeding that was happening inside the friable tumor. While it might cause some shrinkage from decreasing the overall blood supply to the tumor, the intent had not been to treat the cancer. Our surgical oncology team had the same opinion as your previous one. However, that was not the understanding that you and your husband had. Somewhere along the line, there had been a miscommunication, and you had both spent the last two days thrilled that your husband’s tumor would finally be treated.
“Lo siento, pero los médicos de este hospital tampoco creen que el tumor de su esposo sea operable.” (I’m sorry, but the doctors at this hospital also do not think your husband’s tumor is operable). That was how our conversation ended – tearful, confusing, and disappointing. This could have been avoided if there had been better, perhaps what some would call “proper” communication. I do not know which of your conversations were with translators or if that would have made a difference. I believe that if you and your husband had spoken English, there likely would have been better communication about this procedure. As “la estudiante de medicina,” I had the opportunity to finally clarify what exactly was happening to your husband’s body and, in the process, figuratively break your heart after the roller-coaster ride of emotions you had dealt with over the past few days.
Being “la estudiante de medicina” can be a strange position. On the one hand, it allows you to establish great rapport with patients, and often, the relief patients feel once you introduce yourself is almost palpable. However, many Latinos, myself included, do not learn proper medical Spanish while growing up. This could be seen as I fumbled to explain what precisely an “embolization” is, eventually landing on a roundabout explanation of how we had used little balls, or “pelotitas,” to fill up this patient’s hepatic arteries. At this point, I do not believe my medical Spanish is good enough to replace a proper interpreter.
For healthcare providers, translators are the treatment of choice for a communication barrier's potentially lethal side effects. However, like most treatments, they are not foolproof. Time and time again, as “la estudiante de medicina” in the room when a translator is used, I have seen small nuances slip through the cracks. Just a few days prior, I had seen an older Spanish-speaking woman almost have her discharge delayed after mentioning she would prefer to leave when her home health aide could pick her up in the later afternoon, but it was translated as her need to have one set up, a process which could have taken days. On other occasions, I have seen patients emerge confused and needing clarification or even having incorrect understandings regarding their pharmaceutical regimens, the reasons why they are on each pill, and their illnesses in general. Most of the time, this was due to slight discrepancies between the physician's intentions and the translator’s interpretations of words in different medical contexts. This is not the translator's fault, as they do not know the patient, their illnesses, or necessarily have the medical context to fix this problem. Nor is it the fault of the physician, as they do not speak the target language. However, having the medical context to understand better the patient’s illness and the ability to understand both the patient and translator, “la estudiante de medicina” is put in the position to politely jump in and provide clarification when necessary.
These experiences are shared by many “estudiantes de medicina”, illustrating that much must be done to establish equity in the care of those with limited English proficiency (LEP). Access to bilingual staff and translators lies at the heart of the issue. Perhaps translators could undergo medical education to contextualize better what they are translating, but one could not expect them to get medical degrees of their own. Perhaps more bilingual staff could be hired, as Latinos comprise 18% of the US population but only 7% of physicians, illustrating the stark need for more URM (underrepresented in medicine) doctors (1). Or, perhaps all physicians should be counseled on these issues, understanding that they are happening even today in our wards, with the recommendation to take the extra time to ensure their LEP patients adequately comprehend their health information. Perhaps then patients wouldn’t spend days mistakenly believing their cancer will be resected or remain confused after their encounters with physicians. Until then, I will do my duty as “la estudiante de medicina” and help where I can.
References:
Velasco-Mondragon, Eduardo, et al. Hispanic health in the USA: a scoping review of the literature. Public Health Reviews, vol. 37, no. 1, 2016, https://doi.org/10.1186/s40985-016-0043-2.
About the Author: I am a Cuban 3rd-year medical student at NYU Grossman School of Medicine.
About the Work: An emotionally guided description of and reflection upon being a Latina medical student interacting with Spanish-speaking patients.
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