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Thursday Apr 20, 2017

Speaking Same Language Doesn't Guarantee Being on Same Page

One of the greatest gifts my parents gave me was the ability to speak and understand Spanish. They moved to the states in 1981 for work and school and, like many others, had the goal of establishing a better life for themselves and their children.

Although I was born in the states, my parents spoke only Spanish at home, which meant I learned English from Sesame Street and in kindergarten. However, my Spanish was slightly different from the rest of the Spanish-speaking world's: It was Puerto Rican.

Spanish-speaking countries have their own unique dialects. Just as people in the United States and England (and even Americans in different regions of this country) speak different varieties of English, people in Spanish-speaking countries have different phrases and expressions, different vocabulary, and even different tones and cadences. In larger countries such as Mexico, there are regional language variations.

But I didn't know any of this growing up, and I didn't appreciate my own limitations in Spanish until I started my medical practice. My Mexican patients would look at me quizzically as I'd try to explain something. My Chilean patients would scratch their heads at a Puerto Rican phrase I would use. For the most part, we would all communicate well, but there would often be a moment where one of us said something that would need clarification.

So why is this important to us as physicians? The Latino population in the United States is growing rapidly. It's estimated that by 2050, 30 percent of the entire U.S. population will be Latino, and that Latino population has a heavy disease burden, with higher rates of diabetes, obesity and undiagnosed/untreated mental health issues than the general population.

Furthermore, nearly a quarter of our country's Latino population lives below the poverty level. We also know that the Spanish-speaking population in the United States suffers from a huge disparity in the quality of health care they receive, as evidenced in a 2013 report from the CDC.

No matter where we practice medicine, many of us are going to be caring for Spanish-speaking patients, and we need to be prepared to deliver culturally competent care that incorporates at least some understanding of social and economic challenges these patients struggle with. But as I've discovered, the key to unlocking the best care for my Spanish-speaking patients is to ensure that we are, in fact, speaking the same language.

For example, early in my practice, I had many patients complain to me in Spanish of "fatiga." This looks like "fatigue," right? It even sounds like fatigue, and that's what it often means on its own. So, in my ignorance, my line of questions and workup for these patients was to figure out exactly why they felt fatigued. But on one occasion, a patient corrected me and said, "fatiga de respirar," which in medical terms translated to "shortness of breath."

I realized I was misinterpreting what patients meant by fatiga based on what the word sounded like in English. This kind of misinterpretation, also known as false fluency, is when we hear a word in a foreign language and interpret it to mean what it sounds like in our native language. This is a common mistake, and as I've just shared, even fluent foreign language speakers can err in this way if we're not paying close attention to the context.

Another example is the Spanish word for pregnant, "embarazada," which to an English-speaker may read and sound like "embarrassed." Obviously, these words have two very different meanings. Although such misinterpretations are often benign, they can sometimes lead to dire consequences, as in one case when the Spanish word Cubans use for feeling sick because of something they ate or drank -- "intoxicado" -- was misinterpreted to mean "intoxicated." 

Another challenge is that many Latinos express themselves using only a limited health-related vocabulary. I've had patients tell me they were in the hospital, only to find out they were really just in a clinic that they called "el hospital." Many patients complain of "gastritis," which may or may not be gastroesophageal reflux disease, but in general is just like saying one has an upset stomach. And I've had dozens of patients tell me they have rheumatoid arthritis, only to find after careful history and workup that they really have osteoarthritis, but somewhere in their medical experience, this distinction was confused.

The key insights for me, even as a fluent Spanish speaker, are that I need to have the wisdom to not become anchored to a diagnosis and the patience to ask for clarification. This tactic has now prevented me from going down the wrong diagnostic path multiple times. One word that I always ask to clarify is "tonterĂ­a." The literal translation is "foolishness," but in a medical context, I've heard patients use this to describe ailments ranging from tinnitus to presyncope.

Much the same way that we have to clarify in English what a patient means by feeling "dizzy," we should have the same drive to explore what a patient means if we're unsure or if something doesn't seem to fit in the clinical context. By having this sense of exploration, we can better take care of not only our Spanish-speaking patients, but all of our patients.

Luis Garcia, M.D., is a family physician in York, Pa., working at Family First Health, a federally qualified health center. He focuses on caring for the Spanish-speaking community and is an avid photographer.

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