In the rest of the house, the noise of the party is deafening: the clink of glasses, the sizzle of burgers on the grill, the excited cries of relatives reunited after long absences. But in the bright light of the kitchen, Mark is talking to me without sound. He presses his right hand over his left then moves up its length, separating his thumb from the rest of his fingers as he goes replicating the open and shut motions of a jaw. “This is the sign for cancer,” he says.
“Ooh, creepy,” I cringe. “I didn’t know ASL was so morbid.”
“Exactly,” Mark agrees, punctuating this with open hands. Mark is an American Sign Language interpreter and, even when not working, a little bit of gesticulation is to be expected when he speaks. “So that’s why her son got mad at me.”
Mark has been explaining to me how he had been translating for a client at her doctor’s appointment and had been given the unfortunate task of delivering the news that this woman had cancer. When he’d done this, using the sign for cancer that he had just demonstrated to me, the woman’s son had become very agitated and snapped at him.
“I don’t think I would have liked the picture of something eating my mother either, to be perfectly honest. So what did you do? Spell it out?” I ask. I’m certainly showing my ignorance of ASL here, but I’m genuinely curious.
“I used a couple of other signs for the same idea.” He says and his fingers unconsciously form them in the space between us. I’m not sure he realizes he’s done it, and they flash by so quickly I’m not able to gather what they mimic.
“The metaphor of it is so different from English. Much more graphic. I guess the nature of a visual language, but I’d just never thought about it.”
“It makes translating very…” he pauses, searching for the word. He finally settles on “strange,” but doesn’t seem quite content with it, and he quickly revises it to “challenging.”
“You have to think about a thousand different things. I’m always having to think about what’s being said and how that translates into sign, but also the way it was said and how to convey that. Sometimes I have to think about the setting — some of the ASL gestures are just more graphic and might not be appropriate in certain settings. I dance around a lot of things to fit the tone of the conversation.”
“Like saying ‘passed away’ instead of ‘died?’”
“Exactly. I just end up changing a lot of the words so I keep the intention and the meaning of the speaker because I can’t always hold 100 percent to the words. Not everything translates.”
I laugh. I tell Mark that is a feeling I am very familiar with. Although I’m sure that translating from one spoken language to another is nothing like the challenge presented by translating a spoken language to a signed one, I am familiar with the feeling of confusion at exactly how to translate the untranslatable. I tell Mark the danger of ever letting anyone at a hospital know that you speak another language. As a medical student, the second a doctor I’m working with notices me speaking with a patient in Spanish, I quickly find that I’m being grabbed and asked to translate in every situation that arises — many beyond my level.
I’m constantly turning people down when they ask me to translate. I don’t have the skill to communicate the results of the MRI with this patient because I’m not sure how to say “adrenal gland” or “not concerning for malignancy.” I don’t have the comfort level to ask a patient very detailed questions about his or her medical history, where one error — one transposed word — could change a treatment plan.
But often times I do step up and try to help physicians communicate with Spanish-speaking patients. I often work as a stop-gap measure until a translator arrives in emergency situations, or I step in when I realize an attending is going to do that thing where you just speak very slow English to a non-English speaking person in hopes that they’ll somehow be able to understand just by decreasing the velocity of the words thrown at them. I hate when people do that. I don’t speak Chinese. I will not speak Chinese no matter how slowly you speak it to me. I can’t learn the language in the pauses between your words.
When I do step in and translate, or even when I step in to have a primary bilingual encounter with a patient, I always do so with a disclaimer to the patient that my Spanish isn’t perfect, but I’m going to try and if they ever are confused by what I’m saying or feel I’m misunderstanding them, they should stop me and we will wait for the translator. I often repeat back to patients what I think they’ve said to me to ensure I’ve gotten the right message.
I am a very cautious translator.
What always fascinates me is how quickly I find myself editing what’s said. I find myself unable to grab for the exact translated word in Spanish, so I walk around what was said in English using two or four or six words to get there. Sometimes words are traded out for synonyms. Idioms are lost. It’s what I can do. This is likely most often a failing of my own language skills, but sometimes the result of an idea or phrasing that simply does not exist in one language or the other.
I try to be as faithful as possible to the intention of what was said, even when the words themselves don’t always seem to come out identical.
But no matter how much double checking I do, how simple the encounter, serving as the translator, the go-between, always makes me nervous.
How much did I lose?
How much slipped past me unsaid?
Did I fail to really express the doctor’s concern? Did that really come across as a joke?
Did I fail to communicate the patient’s fear, their anxiety?
Was I wrong to have switched out the patient’s choice of “tube” for the more medical “drain” when she was speaking?
How much is lost on my lips?
All of medicine is a translation game because medicine itself speaks a language that often bears little resemblance to English, with most of its being composed of a bastardized Latin or Greek. Half of its thoughts are shortened into acronyms or nicknames, and a portion of its terms are archaic references to things long since forgotten. We spin together sentences full of lab values and statistics and the names of tests that we don’t even know what all the letters stand for anymore.
How can you expect someone who speaks a traditional American-idiom to follow a conversation filled with words like “hyperplastic,” “myeloma” and “choledocholithiasis?” Three years into my medical training and sometimes the details, the nuances of these conversations, slip past me. I should keep a list of the strange abbreviations or words I’ve looked up. Surgery seems especially bad at this, just squishing together all the words we want to say into one big mess and adding a suffix (pancreatoduodenectomy, esophagogastroduodenoscopy, choledochojejunosotmy).
Sometimes, I’ve wondered if doctors use this language to keep themselves at arm’s distance from the patient when things are uncertain or terrifying. Is medical jargon some sort of clinical coat that we wear, not only to distance ourselves from the reality of suffering all around us, but also to evade the painful realities of medicine?
Certainly medicine is an imperfect and unpredictable science. Perhaps we use medical jargon to hedge our bets. We’ve all seen ninety-year-olds come back from multi-organ failure while nine-year-olds die on the table with nothing more than acute appendicitis. We’ve seen poly-trauma victims recover completely normal function and simple fractures lead to lifetimes of disability and pain. We’ve seen non-treatable, 90 percent dead-in-a-year cancers turn to no evidence of disease, while 99 percent survival at five years end up in the one percent. We’ve seen the amazing turnarounds, the long shot winners, and the miracles. But we’ve also seen the nasty shocks, the one in a million, and the impossible heartbreaks.
We say “the CT was concerning for distant metastasis” instead of “your cancer will kill you before Christmas.” We say “the speed of resuscitation was inadequate and it appears your loved one no longer has higher cortical functioning” instead of “your husband bled out too quickly. We couldn’t stop it, and now he’s dead. His body just doesn’t know that his brain isn’t functioning anymore.”
Do we simply talk this way because the cool, clinical language of science is the one we have grown so accustomed to speaking that we forget many people are not as fluent as we are? We forget that many people have barely enough competency to know when to nod along.
Do we say these things because we’re hoping that what we know to be true is wrong? We’re hoping for the miracles, knowing they won’t come, but not wanting to take that hope away from those people who still believe in them.
Do we say these things because if we dared to say “will be dead,” “will not recover” or “permanent pain” it might burn us to sit so close to the fire of day-to-day suffering?
Or do we simply say it because we have not been taught the ability to translate our medical language into English? We are not certified translators; we are human beings with some bilingual proficiency trying to step around the sentences, and trying to hold onto the concepts and feelings. And sometimes we fail.
It’s probably, on any given day, any or all of these things.
Eddy used to listen to Jimi Hendrix or the Grateful Dead. He’s probably got Jefferson Airplane vinyls hidden in the dusty corner of some closet in his house. Now, even well past his bell-bottom pants and flowered shirts, he still retains some of that same vibe. I might walk in one morning and have him hand me a flower and tell me about how nuclear disarmament is the most important political issue. After free love, of course.
Eddy was admitted to the hospital for emergency surgery and it was during that emergency that he was first told he had end-stage cancer. Up until that point he’d been feeling fine, maybe a little bit more tired than usual, but his wife had been sick recently and it was probably because of that.
I remember the first time I saw him in the emergency department. He was wearing the same look as a student who thought he had sat down in his English class only to find himself in Japanese 201. He looked so overwhelmed, lost, and very small in that bed. He was thin, certainly the result of the all those years of cancer left festering deep inside his body unknown to him. But the smallness was greater than that, as though the cancer had eaten away more than just tissue, but part of his substance.
I think of Mark in the kitchen moving his hand up his arm.
Eddy’s ribs poked through his chest, his sternum dipped slightly. Hands, chest, face: pale. That his H/H (blood numbers — there I am, speaking medicine) would show severe anemia was a surprise to no one. Every time I see him, I feel helpless. One of my attendings on surgery likes to say “a chance to cut, a chance to cure.”
Here there is only a chance to cut.
Over the course of the next couple of days, Eddy underwent a very long series of surgeries. After one of many, we go see him on rounds.
My resident flicks the light on without warning, without introduction. No “hello,” no “good morning,” just bright lights and “Surgery team here.” He does the quick incision checks required: incisions clean, dry, intact, wound edge non-erythematous without drainage.
Just as we’re about to step out, my resident drops that someone will be coming by today to take him for the CT.
“What CT?” Eddy asks. He’s slightly slow to speak. My resident had almost made it to the door by the time the question leaves his lips.
“To see if the cancer has any more sites in your liver.”
“But I thought you took that one out when you did the surgery.”
“No, we just biopsied one of them. We’re not going to remove them.” My resident says and then he hits the door.
I can see it on Eddy’s face. He has more questions. He hasn’t understood even though it’s been said to him half a dozen times in strange, clinical sentences. The fact that his cancer has metastasized to his liver means he’s stage four, it means he’s going to die, it means there’s not much more to do now, maybe some palliative treatment, but no chance of cure anymore. I know I’ve heard a dozen different people in a dozen different white coats tell him these things, but it was all in these unclear, roundabout ways.
I should say something, I should call my resident back. But he’s already on the phone to the operating room; first case is already asleep in the room. He’s gone. He’s already half scrubbed.
But I say nothing.
“What would you do?” Eddy asks me the next time I go by to see him, this time alone. “Why should I even bother? This has been hard enough on my wife figuring out that I have cancer. If she knew that it was in my liver too I think it would kill her. I don’t think she could handle it. Would you have the CT? I don’t know if I want to know. Does that make sense?” I’m not sure he’s talking to me or just to himself or to the universe, but then he looks at me with his eyes large in their hollow sockets and waits for an answer.
And oh God, I wish that he hadn’t asked. I don’t know what I’m supposed to say. Should I tell him what I know about the numbers and the survival rates? Should I tell him that no matter what the CT shows, he’s not going to ever get to be a cancer survivor? Should I do what everyone else has done and dodge the question with more numbers, more big words, so as to not have to be the one to hand him the finality of his diagnosis? Should I escape the conversation with an answer that he will be unable to translate?
I start to. I start to give him the same information he’s been handed a dozen times, but the words die in my mouth. That’s not what he needs.
Should I just tell him the truth — that if it were me, I’d check myself out of the hospital right now, fly to the Caribbean and spend the last six months of my life on the beach?
That’s not what he needs either. This isn’t about me. He just needs a translator. Someone to translate his emotions into a medical response that the doctors will understand. He needs someone to translate his “I need time to think about this” into medical speak.
“You don’t have to have it done if you don’t want to,” I say, finally. “It’s okay if you need to think about what you want. It’s okay if you tell them that. They will understand. They were just trying to expedite things for you by having it done now, but they can always do it outpatient after you get discharged.”
He says nothing for a long time. He looks up at the ceiling above him, a ceiling he must have been staring at for the last several days. I’m sure he is incredibly familiar with the place where the ceiling meets the lights, the place the paint is cracked. He’s memorized the details of it all but this time I think he’s looking for the answers. I don’t think he’ll find them.
“Thank you.” He says at last and turns back to look at me. It’s a soft, genuine “thank you.” One that curls up the corners of his lips as it leaves them behind.
I’m certain I’ve said the wrong things, just as I do in Spanish. I’m certain I’ve failed to communicate appropriately what I mean to say, but I hope that he’s heard the intention in there somewhere and that it’s a comfort to him for me to speak the same language he speaks in lieu of the medicine he’s heard too often.
Medicine permeates our speech. Being a doctor is much like being bilingual in a country that speaks predominantly a language that is different than the one you speak at home. You go to work and speak Medicine. You text it to your colleagues. You converse in it while you wait in line for coffee. You write it. You dictate in it. Then you come home, switch back to normal English, and your partner stops you halfway through a sentence because you’ve lost him or her down the rabbit hole of shortened words. You send an email to your mother with “s/p” and “2/2” found in the body and she thinks they’re typos.
We speak Medicine and we do it so easily, so quickly, and so completely that we fail to recognize that someone else might have trouble understanding the tangled idiom of our sentences.
What I’m learning in the third year of medical school is that as doctors we have to wear a very large number of coats. Sometimes we’re healers, sometimes counselors, sometimes teachers and sometimes translators. And sometimes we’re especially bad at wearing that last coat enough. I don’t know whether we just have to learn by experience, or this is something that we should be teaching our doctors to do.
I don’t know if it’s something I’ll ever be good at it, or if I will always feel like I do when I try to translate to and from Spanish: like there’s a chance I’m missing something, like there’s a chance something is being left on my lips.
I do know that I must always strive to ensure the meaning is heard and the intention understood even when the words themselves are clumsy. Because Mark is right: not everything translates.