Cano R EDIT AY Undergraduate Journal of Service Learning and Community-Based Research, Volume 2, Fall 2013   Intercultural Communication: Do You Know What I Mean? Dulce Aída Cano University of Texas-Pan American In order to provide excellent service, an interpreter not only has to translate from one language to another, but must also have knowledge about cultures, communication, and the basis of the language. Translating is something not many can do – it is one thing to be able to speak more than one language and another to translate between two languages. Interpreting is an asset that people don’t typically think about when they picture a hospital scenario. The Medical Spanish Minor Program I participated in was created when the language barrier became a dilemma for health professionals in the Rio Grande Valley (RGV) of Texas. Because of the large number of immigrants from Mexico, the majority of the population in the Rio Grande Valley is Hispanic. The Valley is composed of four counties: Starr County, Hidalgo County, Willacy County, and Cameron County. The U.S. Census Bureau (2013) calculates that 88.4 percent of Cameron County is Hispanic, along with 90.9 percent of Hidalgo County, 95.6 percent of Starr County, and 87.3 percent of Willacy County. The health professionals of the RGV must be prepared for the barriers that this may cause. Of course, the service provided by health professionals is different all around the world, and ultimately it is up to the health provider to adapt to the situations presented. The provider’s goal is guaranteeing that the patient is given the care that will benefit his/her health, though achieving that goal may be difficult. Nonetheless, efficient communication guarantees physicians and nurses are able to provide more professional services. When the barrier of communication is placed between patient and doctor, endless amounts of distress and miscommunication may ensue. That’s when an interpreter steps in to overcome that communication barrier. An interpreter has to make a connection between two languages so the translation will flow smoothly. In my experience as an interpreter during my Spanish 3199 Internship, I learned the art of how two people are able to communicate with the use of a third person and the importance of accurate communication in a healthcare setting. The patient goes to the doctor to tell him/her about his/her symptoms and worries, but if the doctor does not speak the same language, the sole purpose of seeking medical attention may be rendered useless. The interpreter has to be able to translate what the patient wishes in the way he/she expresses it, so that the doctor will know the intensity of what the patient is trying to communicate. I attended Med High my sophomore, junior, and senior years. It is located in Mercedes, Texas and is a high school focused on preparing students for the medical field. Most of the students who attend have aspirations of being a nurse, therapist, physician, or other healthcare professional. The University of Texas-Pan American offers the Medical Spanish program to Med High students, and anyone who wishes to apply may do so if he/she meets the criteria. I aspire to be a cosmetic dermatologist, and in the fall of 2013 I will begin my undergraduate studies at the University of Texas-Pan American. Due to the concurrent hours given, I graduated from high school with a minor in Medical Spanish from UT-Pan American and will begin my university career with 52 credit hours completed. I was born in Monterrey, Mexico and practically learned English and Spanish at the same time. I speak Spanish with my entire family and we have very family-oriented customs. My classmates at Med High all spoke Spanish; most of them were raised in a Hispanic home and Spanish is part of their heritage. Seniors who attend Med High are able to enroll in a class called Clinical Practicum; it involves a hands-on experience in chosen Cano 2   Undergraduate Journal of Service Learning and Community-Based Research, Volume 2, Fall 2013   clinical sites. These clinical rotations formed the basis of my Spanish 3199 Internship class that was also part of the minor. I found it very helpful to include the course at the end of my classes because this experience gave me a chance to try out what I learned in the classroom. I had the opportunity to choose which hospitals and clinics I could visit. Many of the sites interested me, but I picked the ones where I thought I would have the opportunity to do the most interpreting. I picked Respiratory Therapy, Physical Therapy, Rainbow Pediatric Clinic, the Emergency Department, the Nursery, and Wound Care. During my experiences in my clinical rotations, I learned how physicians and nurses strive to keep their patients as healthy as possible, and I observed the local dynamics that are obstacles to achieving that goal, particularly the language barrier. In my point of view, getting a patient healthy is the most important issue that needs to be addressed. In Respiratory Therapy, I shadowed the therapists whose jobs consisted of monitoring the function of the patient’s respiratory system. Most of the time the patient’s respiratory therapist, doctor, and nurse met to discuss the patient's symptoms, changes, and improvements. When they accumulated sufficient information, they stepped into the patient’s room and gave their insight about the situation. For the most part the patient’s respiratory system was compromised, so the patient was either intubated or on a ventilator. The communication between patient and doctor was very limited because the patient simply could not communicate or was not even conscious for that matter. A family member usually received the analysis of the patient. In this department, the head pulmonologist was from Africa and his English had a very pronounced accent. His responsibilities revolved around the Intensive Care Unit. The majority of the nurses were from the Philippines and did not speak Spanish fluently enough to communicate with the patients and their families. The therapist I shadowed was Hispanic, and she had the greatest ability to communicate with the patients. When the health professionals stepped into the room to speak to the patient, the pulmonologist would ask the therapist to interpret for him. I noticed that this type of interpreting was different from what I had previously experienced because the doctor did not directly communicate to the patient and wait for the therapist to translate. Instead, he briefly summarized how the patient was doing and then the therapist translated. She would modify the summary with words that adapted to the knowledge of the patient, as well as explain different procedures. In my medical Spanish classes, we did not discuss this form of interpreting. We have to think about how miscommunication may occur in this situation. The communication between the pulmonologists and the therapists has a greater chance of being accurate because they are both professionals and have sufficient knowledge to understand each other. Now, what happens when the patient wishes to know about the situation? Can the therapist and the pulmonologist expect that the family member will retain all the information that was given and communicate it accurately to the patient? If the family member happens to be in distress, he/she might only pick up on the most important points that the therapist communicated, such as how the patient is doing. Miscommunication may occur when the family member misses details that could be very crucial to the patient’s health. It is always best to make sure the therapist speaks to the patient before leaving the hospital to make sure that he/she understands the situation to ensure a better outcome. Also, it is common to give out written instructions, especially when it comes to prescribed medication. Prescriptions are now given in the language that best suits the patient’s needs. This way the patient has at hand what it is he/she has to take and do for quicker, more efficient results. Cano 3   Undergraduate Journal of Service Learning and Community-Based Research, Volume 2, Fall 2013   Physical therapy consisted of many patients that sought therapy post surgery and the therapist's objective was to better the patient’s movement. The contact between the therapists and the patients was very close because plenty of communication was needed in this type of therapy. In this department I did not get to interpret very much because most of the patients were our beloved Winter Texans. Winter Texans are senior citizens that live anywhere in the northern part of the United States and move down to Texas during winter (hence the name “Winter Texans”) because of the milder weather. Even though interpreting was not needed, I learned that communication is essential because the therapists have to know what is working. The environment in this department was very light because the therapists were very open to the feedback of their patients. In a way, I saw a different communication perspective because there never seemed to be language barriers. Noting how the ambiance of the room seemed to change when there were not any language barriers gave me insight into how it should feel if an interpreter is present. If the interpreter really does break that language barrier then this is the way it should feel. During the following phase of my clinical rotations, I learned much from Dr. J. Kutugata. Dr. Kutugata is the owner of a small clinic specialized in pediatrics. Having completed rotations there, I noticed that many of the patients had insurance provided to them by the government. The insurance issued in the United States is given to those who have a low enough income that requires the help of benefits. In class we discussed the perspective of low-income families in relation to their health. Benefits encourage low-income families to seek medical attention more frequently instead of only seeing a medical professional when something serious occurs. Encouraging families helps to teach them about seeking preventative medical attention and also gives them financial help. Parents brought their children of all ages to be checked by Dr. Kutugata; some were check-ups, some were follow-ups, but most of the time they complained of sore throats and fevers. I did not have many opportunities to interpret in this setting because many of the patients spoke Spanish and the doctor’s Spanish was excellent. Most of the patients were Hispanic, but it was hard to ignore how their Spanish was more like Spanglish. Spanglish is the name given to a hybrid combination of English and Spanish. It surprised me that even Dr. Kutugata used Spanglish with his patients. Even though it did not seem very professional to me, using Spanglish seemed to allow for better understanding. There were certain words and ideas that the patients and their families did not know in English, but could relate it well to specific words and cultural terms in Spanish. Slang in Spanish is very prominent when referring to medical terms. There are medical rituals involved in certain cultures that do not have a specific word in English, such as a “barrida” or “mal de ojo.” A “barrida” is when a bundle of herbs that are said to have medicinal benefits are swept around a person and it is believed that the herbs relieve pain and cleanse the soul. “Mal de ojo” is a type of curse, per say, that is transmitted to a person when a person who wishes evil stares at him/her. The person may come down with multiple symptoms and usually “mal de ojo” is blamed when the symptoms are sudden. Since these beliefs are part of certain cultures, there are no actual words in English to translate them to. Using Spanglish helped in the transmission of these messages to the doctor. In cases where the doctor is not familiar with these kinds of beliefs, it is always important for the interpreter to let the doctor know what the patient is referring to. Any other words that the patient just is not sure how to say in one language can easily be said in the other. The patients find it easier to just refer to a different language than to think of a synonym of the word they want to say. The doctor would also ask the child’s parent if he/she preferred he speak English or Spanish. In my opinion, that was a small, essential step that very much benefits the Cano 4   Undergraduate Journal of Service Learning and Community-Based Research, Volume 2, Fall 2013   communication because there are people that prefer a certain language. If the doctor understands the patient then it doesn’t matter what language he/she is speaking. The doctor thought the same way and did not mind the Spanglish; his goal was to get to the root of his patient’s problem. In these consults, the patient did not do much talking because it was always the parent that was anxious about getting answers to his/her questions about the child's health. As parents, they know their children and notice more of the child's symptoms. Dr. Kutugata was very efficient in communicating with the parents to try to get as much information as he could so that he could make a diagnosis. The emergency room was my fourth site in my clinical rotations. It was the place where I had the most interaction with patients and opportunity to interpret due to the foreign doctors that practiced there. In this department there were foreign doctors from India and Austria. The doctors did not speak Spanish at all and interpreters weren’t present in the department. Scribes helped the doctors document the information during the interview between the patient and the doctor; they doubled as interpreters on occasion. I thought this was unprofessional because they are not trained to interpret at that level. In my previous courses in Medical Spanish, I learned that many factors go into interpreting, especially in the case of an emergency. When a certified interpreter is not available, communication is risked. The consequences of inadequate communication in a clinical setting can lead to inaccuracies and is definitely not recommended. There was a scenario where I helped an Austrian doctor interpret the symptoms of a patient that included chest pain and nausea. He came into the emergency room with his wife who was very worried and upset. She was not able to communicate with the doctor very well because she was under a lot of anxiety and her English language skills were not very strong. The doctor stepped into the interview with the scribe and asked her to interpret what the wife was saying. The wife told the scribe that her husband was having chest pains and she gave him some ibuprofen. The doctor asked the patient’s wife about other symptoms and if he had chronic diseases like diabetes or hypertension. At this point I was only taking the role as a student interpreter. I recalled having talked about self-medication in my medical Spanish course. I thought about how ibuprofen can interfere with platelets, reducing blood’s ability to clot. Typically, ibuprofen is taken to relieve pain but if the wife was unsure of where the pain was coming from, self-medicating is not something to experiment with. A nurse who I occasionally shadowed told me that an interpreter is a great asset in the emergency room, but sometimes having so many people in the room is a disadvantage. At times, this makes the patient feel uncomfortable. The nurse mentioned that the rooms are small and that having more people in the room is the last thing the patients want. I thought it would be a great idea to just have the doctor and the interpreter record the interview and later the scribe could document the information. Honestly, I loved this department because there are so many different aspects of medicine being analyzed and the experiences are unforgettable. I got a rush whenever a case came in. It was always a surprise; I never really knew what was going to come through the door so it kept me on my toes. In the nursery I was curious to see how the nurses interacted with the brand new mothers. The communication was crucial because moms had to pay attention to the nurses to be able to care for their babies. It was up to the mothers to retain all the information that the nurses shared with them, such as methods of breastfeeding and signs that the baby was uncomfortable. At the nursery, an array of ethnicities was present, but all the nurses spoke English and Spanish. Some of the nurses told me they hardly spoke any Spanish when they first started, but they had picked up enough Spanish to help them explain instructions and precautions. No matter what the language was, the information explained to the mothers had to be consistent. The nurses Cano 5   Undergraduate Journal of Service Learning and Community-Based Research, Volume 2, Fall 2013   followed a curriculum and had to explain important steps to the new mothers. By following a standard procedure, the same education was given to all mothers. Lastly, Wound Care was very exciting because I had a lot of hands-on experience. I shadowed the nurses and assisted them in dressing and cleaning wounds. A lot of the wounds that were treated were pressure ulcers. Pressure ulcers are caused when pressure is applied to a particular part of the body. When pressure is applied it interrupts blood supply and can cause tissue damage and ultimately gangrene. Ulcers can be caused by diabetes type 1 and type 2 because the disease causes high levels of blood sugar that disrupt normal blood flow. It just so happened that my Clinical Rotation supervisor used to work at a diabetes clinic and informed us of the high rates of diabetes in the Valley. She told us that the diabetes rate in the region is almost three times the rate of the whole U.S. She blamed poor eating habits. She insisted that healthy eating habits should be taught to the younger generations because they have a more probable chance of changing them. Even if the patient did not change his/her eating habits, it was always good to have the wounds taken care of to avoid amputation. The job was very basic, but nonetheless it was a great experience. There was not much interpreting involved in this department because the nurses were bilingual and could communicate without a problem. Also, the doctors spoke with the patients directly because the doctors managed the wounds more than the nurses. I definitely gleaned insight about healthcare issues in the Valley in this rotation, but this information was not attained as an interpreter. Service learning is always a prompt way to test your skills and knowledge learned in the classroom. Hands-on experience is obtained in an effort to develop critical thinking skills. Service learning provides many great opportunities for a student to learn about his/her community and learn how to maintain the wellness of it. The most useful information that this experience yields is getting to know one’s self better. This service-learning experience impacted me because I learned the importance of human interaction and that everybody in the health profession has a very important role. I have always heard that doctors need better people skills than other career professionals. The doctor has to communicate with families in times of crisis. Likewise, all the "non-doctors" are part of a critical concept. Any health professional will understand that the patient comes first and his/her health is of utmost important. Personally, this experience has taught me that not only can illness be a barrier, but language, in this case, is also a barrier. Patients transmit messages very differently because of cultural differences. First and foremost there should always be the promise of good service, and hospitals are most impactful when they understand the culture and customs in the surrounding area. Working in the health field requires comprehending various levels of understanding to be able to put one’s self in the position of the patient. The experiences I had during my internship taught me a little bit of everything, including the importance of effective communication between patient and health care provider. I used all the knowledge I gained in my courses to help me prepare for the National Board for the Certification of Medical Interpreters examination. The exam is composed of two parts: the oral and written part. The classes I took were a strong reinforcement for the written part because it tested to see if I captured those important aspects of interpreting. The oral part tested my knowledge on syntax and accurate translation. Even though I had studied communication in my Medical Spanish courses, before this internship I never really imagined that so much goes into being an interpreter. I always knew that when I grew up I wanted to help others and I was very blessed to have the opportunity to learn two different languages. The Medical Spanish minor is a Cano 6   Undergraduate Journal of Service Learning and Community-Based Research, Volume 2, Fall 2013   great addition to my medical studies and is definitely just the first step of so much more that I aspire to be. ~ A big "thank you" to my amazing professors, Dr. A. Stachura, Dr. H. Castro, and Dr. G. Martinez from UT–Pan American for helping me throughout this amazing experience. References United States Census Bureau. 2013. “State and County Quick Facts: Texas.” United States Census Bureau. http://quickfacts.census.gov/qfd/states/48000.html.