Tuesday, August 30, 2011

Language Barriers

I run an all-feline veterinary hospital, and we have a fairly large Japanese client base. This is not by accident. One of my technicians, Hiromi, is Japanese, and she made it clear to me when I hired her 8 years ago that she would like to actively help me cultivate a Japanese clientele. In speaking with her cat-owning Japanese friends and acquaintances, Hiromi has heard countless tales of frustration, as they described the difficulty in explaining exactly what it is about their cat that had them worried, as well as their inability to fully understand what the doctor had told them.

Cats are complex creatures, and the physical and behavioral changes that they display when they aren’t feeling well can be rather nuanced. Without significant mastery of English, these subtle but important observations go unreported. Hiromi wanted to help remedy this situation and I was all for it. We advertised in Japanese publications. She translated and transcribed some of the medical articles I had written, and we posted them on our website. Word soon got out, and the Japanese clientele began to grow.

The language barrier, however, operates both ways. Some things are easy for me to explain, and very little additional interpretation is necessary by Hiromi. There’s nothing really esoteric about an upper respiratory infection. “Your cat has a cold, and this medicine should help.” Some illnesses are much more complex, and require more intense translation. Explaining a diagnosis of diabetes isn’t too difficult, because most people have a basic understanding of the disorder. The treatment of diabetes is detailed and complicated, however, and explaining how much insulin to give, how to draw it into the syringe, how to inject it, signs of an overdose, etc. can be daunting.

Of course, the difficulty lies in the fluency of our Japanese clients, both in speaking and in comprehending. In our practice, this varies greatly. Most of our clients have a very good grasp of the language, and Hiromi only really chimes in to clarify the difficult concepts. A few clients, however, speak very little English, and without Hiromi, both the client and I would be totally helpless in the exam room.

Occasionally, I’ll have a Japanese client that speaks English pretty well, but doesn’t understand what I’m saying, especially the medical terminology. Or I’ll have the reverse situation, where the client doesn’t say much, but seemingly understands everything I’m saying, and when I’m done speaking, they’ll ask me a follow-up question (in Japanese, via Hiromi) that impresses me as to how well they understood what I had told them.

I really hadn’t thought too much about the language barrier, since having Hiromi present has always alleviated the problem. Last week, however, I got a poignant lesson on the importance – and power – of language, when dealing with such emotional topics as the health of our beloved pets.

It had been a bad week to begin with. During the week I had evaluated four cats with significant illness, and was in the process of scheduling them for additional diagnostic procedures. In one cat we had narrowed our diagnosis to either inflammatory bowel disease (IBD) or lymphosarcoma. A second cat with chronic vomiting and diarrhea was in the same situation. A third cat had already been diagnosed with IBD over a year ago, but had developed jaundice and elevated liver enzymes and had stopped eating.

The fourth cat was Po, an elderly cat who had lost a lot of weight recently. On physical examination, I felt a mass in the cranial abdomen. I suspected a tumor of the stomach, but couldn’t be certain.

Po’s owner is Japanese, and her verbal skills in English are passable. I think her ability to understand what I say is probably better than I suspect, but I really just cannot be sure. When it comes to diagnosing more obvious things, language is less of a problem. But when I feel a cat’s abdomen and I think I feel a tumor, my English-speaking brain immediately starts formulating the gentle words and sentences I hope to use to deliver the worrisome news. And here lies the problem. I may be thinking in my head, “your cat has a mass in the abdomen, it’s probably cancer”, but of course, I would never deliver this type of news so bluntly. What I’d like to say is, “well, on physical examination, something in the very front part of the abdomen feels a little strange. I think I feel a lump. Initially, I was thinking this was a piece of stool, but this mass is a bit larger than a typical piece of stool. And pieces of stool are compressible with my fingers, but I’m trying to compress this, and it’s not yielding like a piece of poop would. I’d like to take an x-ray to see if I can characterize this mass a little better.”

Will Po’s owner understand “lump”, “abdomen” “compressible”, “yielding”, and “poop”? Probably not. When Hiromi translates what I’ve said to the client, will all of the subtleties be intact, or will they be lost in translation? One reason I really like my Japanese clients is that they are unfailingly polite, and will always smile or nod respectfully when I address them. In many cases, I cannot tell if they’re smiling and nodding because they understand what I’m explaining, or if they’re simply being polite.

I took an x-ray of Po’s abdomen, and I saw what I believed to be the mass that I was feeling with my hands. It looked like it was the stomach. Again, on an x-ray, you can’t be totally certain, but it definitely looked suspicious.

I thought in this situation, perhaps a picture would be helpful. So I showed the client the x-ray, and while I pointed and narrated, Hiromi translated. Then we sat down and discussed the options. I recommended abdominal ultrasound to get a better picture of what this mass was, and to get an ultrasound-guided biopsy to get a definite diagnosis. Po’s owner nodded. I had Hiromi tell her that given the cat’s age, and the fact that I think I see and feel a discrete mass, the likelihood is that this is some kind of cancer. Hiromi translated this. The client nodded, but I could see her eyes welling up. I said that lymphosarcoma is the most common cancer we see in cats, and that there are two types – a milder, less aggressive low-grade type, and a more serious, aggressive, high-grade type. I told her that when there’s a discrete tumor, it’s more likely to be the high-grade type. Hiromi translated. Po’s owner remained composed, and didn’t say much. I told her that if it was indeed high grade lymphoma, surgery wasn’t really an option here. Treatment would be with chemotherapy. She asked about the chemo. I briefly described the medications and the protocol. She asked about the prognosis. I said that some cats go into remission, while others do not. She asked what happens if they don’t go into remission. I said that we would have to put her cat to sleep. Hiromi translated. Po’s owner nodded. A few seconds later she quietly began to cry.

I felt terrible. I felt like the evil messenger. I would say something. Hiromi would translate. Po’s owner would become upset. Then there’d be silence. I’d say something again. Hiromi would translate. Po’s owner would cry. It’s weird to have a profession where you can really devastate someone’s life with one or two sentences.

After all the explanations and descriptions, we decided to go for the chemotherapy. Po will need to come in for medical treatment almost every weeks for ten weeks, initially, and if he goes into remission, we can cut back to an every-three-weeks schedule.

In my profession, it’s important to attend continuing education meetings and to read the journals. We’re always learning; it’s the nature of being a veterinarian. But sometimes, my greatest lessons don’t come from the journals and textbooks. I’m grateful to my Japanese clients for helping to teach me the importance of language and for making me aware of how crucial proper communication can be, when it comes to such important matters as the health of our beloved cats.

Addendum: After 3 weeks of chemo, Po is doing well. In a few days, we’ll give the fourth treatment, and then will do abdominal ultrasound to see if the stomach tumor is shrinking, or (hopefully) undetectable.

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