During my last visit home, my mother waited less than an hour before showing me her medical records. She offered them up the way I’d once presented my middle-school report cards, steering the papers across our kitchen table between bowls of peppercorn chicken and eggplant until they slid to a stop in front of me. Looking at them made my head spin, as they were written almost entirely in Chinese.
They were from the National Taiwan University Hospital, where my mother had been undergoing treatment for breast cancer for the last two years. She discovered the lump the summer of 2015. A month later, she moved into my grandparent’s house in Taichung, leaving my father and me to worry from our house in New Jersey. When asked about her reasons for seeking care outside of the United States, my mother always cites Taiwan’s single-payer, nationalized health care system, widely acknowledged to be one of the best in East Asia. She notes that her co-pay for office visits never exceeded twenty dollars, and her paperwork was minimal despite numerous referrals. She’s too pragmatic to discuss anything beyond the logistical benefits of her choice.
Still, I think she was also motivated by her desire for caregivers who wouldn’t judge her for her accent and her beliefs. She wanted nurses who would recommend congee for her lost appetite instead of cereal and doctors who wouldn’t balk at her cupping marks. After having faced everything from casual bigotry to English grammar during her thirty years in the United States, she wanted care from those who were fluent in her language and culture. When her cancer went into remission and she decided to return to America for her follow-up care, I assumed the hard part was over. I was wrong. Transferring care from an international hospital to an American provider was — and still is — a painful process, driven by a patient’s skill at jumping through bureaucratic hoops. This became clear when my mother’s medical records stumped doctor after doctor.
Too many clinics and hospitals did not have a Mandarin interpreter on staff. One oncologist simply returned her photocopies; another asked if she could send in her biopsy. Several doctors wanted her to simply repeat, at great personal cost, every lab test and scan she’d undergone in Taiwan.
Finally, an uneasy solution was found: my mother was asked to translate the Chinese portion of her records into English and submit those instead. My mother, who was already anxious about finding an American doctor, who asked me what neuroscience meant when she saw the word on my diploma, had to translate her own medical records — which meant so did I.
It’s true that my mother’s diagnosis has improved my Mandarin by leaps and bounds.
“Isn’t English the universal language of medicine?” she demanded. “And isn’t English your first language?” Implicit in these questions was another: “Have I raised you in America and tolerated your strange bicultural ways for nothing?”
She couldn’t believe that medical English was so different from American English. Months into medical school, I was still struggling to use, understand, and even spell terms like orthopnea and dysmenorrhea. Every time I described a patient as sweaty instead of “diaphoretic” in front of my doctor-mentor, I felt the flushed embarrassment of a child who’s forgotten their talent show routine.
At first, my fresh-off-the-boat confusion about medical terms seemed fine, even funny. The impenetrable nature of medical English was a matter of no urgency. It wasn’t until my mother’s return to America that I realized how frighteningly tall the language barrier looks when one’s well-being is at stake. It wasn’t until I started interviewing patients that I realized how ubiquitous this language barrier is.
During my time in the emergency room and primary care settings, I’ve met a number of non-English speaking patients. I meet younger relatives who translate for older patients and it reminds me of my family. When the interview balances, precariously, on the use of simple English, I leave feeling queasy. Once, I joked to a patient that the only Spanish word I knew was the word for flooding: inundación! I’d learned it at a medical school language class that felt like a small solution to a systemic problem. The joke was meant to be self-deprecating, and to put her at ease. But when she frowned and told me I should practice my Spanish, I felt a wave of shame. Of course, self-deprecating humor was scary when her caregiver’s ignorance had consequences for her care.
Luckily, most of the doctors I’ve met have been kind, if ineffectual, about language barriers. They’re game to use devices to improve their patient encounters: inarticulate translating computers and interpreter lines reminiscent of a grade school telephone game. But, other physicians are impatient, bordering on cruel. A teacher of mine once complained that having to use an interpreter delayed her entire day’s schedule and slowed down her thought processes.
While she was the most dismissive example, I’ve seen other physicians — kind, well-meaning ones — make other assumptions of non-English speaking patients. They speak to them as if they’re deaf, dumb or indigent. The assumption, I suppose, is that patients who struggle to speak English will also struggle to understand medical concepts.
So, as a solidly mediocre medical student who has tried scaling the language barrier from both sides, I’ll expand on that assumption: everyone struggles to understand medical concepts. Regardless of cultural context, medicine is itself a foreign language that no one is born into. I’ve met patients, brilliant and resilient, who cannot understand words like benign and screening. No matter how fluent they are in any language, medicine plays by its own linguistic rules — not to mention that stress and bad news short-circuit communication skills in the best of us.
Not everyone needs an interpreter, but almost everyone needs interpretation — of test results, medical terminology and esoteric hospital policies. The further I progress in medical school, the further I stray from being able to fulfill this need. I’m much better now at understanding the things that doctors tell each other outside of the patient rooms. But each day I’m in school, listening to lectures and highlighting packets, is time spent in an immersion program. I default to acronyms and complex scientific explanations. The longer I spend listening to lectures, the worse I become at speaking plain English or even bad Chinese.
Even before my mother became furious and disappointed at my inability to help her translate, I knew my education would distance me from my family. We were already separated by cultural, generational and linguistic gaps: I speak to my parents in stilted Mandarin and they reply in limited English. Medicine was yet another language barrier — how would I even begin to explain to them the smell of formaldehyde, or the contents of my classes?
However, I never expected my education to distance me from my patients, as well. But, every time I’m in a care setting, I have to remind myself to put aside the jargon and the casual tone with which lecturers refer to debilitating illnesses. Even as someone who has had to balance two cultures my entire life, the transition between patient interaction and physician discourse is the most challenging code switch I’ve ever experienced. Yet my education has done little to teach this transition, let alone acknowledge it.
People — and especially doctors — will always struggle to communicate across cultural differences. What we fail to realize is that medicine, in and of itself, is a foreign country with its own tongue and customs. If its visitors, our patients, are struck speechless and lost, it should not reflect poorly on them.
And, if those visitors are non-English speaking, they have to contend with infinitely more strife: a sociopolitical climate that is hostile to them; a country in which power is inversely correlated with accent. If those visitors are like my mother — or, as is often the case, less financially and socially privileged, by the time they arrive to our clinics and hospitals, they are already exhausted because they’ve had to carry the burden of communication for as long as they’ve been in this country. They’ve had to navigate American signage and systems because health care is not the only field with a shortage of linguistic inclusion. This navigation is draining, and being ill is draining. Yet we still expect these patients to communicate their medical needs by wrestling with an uncooperative language. We are the ones who have had the privilege to spend our days studying jargon. We should be responsible for bridging the communication gap intrinsic to our profession.
Writer-in-Training
Warren Alpert Medical School
Emily is a medical student, crossword fiend, and backpacker. She likes reading poetry, cleaning her bicycle, and talking about medical education. Email her! She'd love to chat.