If you have taken ‘Bridging the Gap’ you already heard of Anne Fadiman’s book “The Spirit Catches You and You Fall Down”. But, did you have a chance to read it? I strongly recommend it.
Originally published in 1997 by Farrar, Straus and Giroux, ‘The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures’, a book recipient of The National Book Critics Circle Award, is a mandatory book for medical students at the University of Michigan.
The Book portrays the story of Lia Lee, a Hmong child diagnosed with severe epilepsy and the youngest daughter of a refugee family from Laos that settled in central California, who was treated for her condition in a small county hospital where no professional medical interpreters were available. More than the language barrier the book emphasizes the importance of the professional interpreter (an in this particular case, the lack of it) in bridging the cultural nuances among different world views and perspectives. It clearly places the interpreter’s role as cultural broker as important, if not more, than the interpreter’s role in bridging the language barrier.
“Dan [Dr. Murphy] had no way of knowing that Foua and Nao Kao [Lia’s parents] had already diagnosed their daughter’s problem as the illness where the spirit catches you and you fall down. Foua and Nao Kao had no way of knowing than Dan has diagnosed it as epilepsy, the most common of al neurological disorders. Each has accurately noted the same symptoms, but Dan would have been surprised to hear that they were caused by soul loss, and Lia’s parents would have been surprised to hear that they were caused by an electrochemical storm inside their daughter’s head that had been stirred up by the misfiring of aberrant brain cells.
Except through surgery, whose risks consign it to the category of last resort, epilepsy cannot be cured, but it can be completely or partially controlled in most cases by anti-convulsant drugs.
The Hmong are not the only people who might have good reason to feel ambivalent about suppressing the symptoms. The Greeks called epilepsy “the sacred disease”.
Although the inklings Dan had gathered of the transcendental Hmong worldview seemed to him to possess both power and beauty , his own view of medicine in general, and of epilepsy in particular, was, (…), essentially rationalist.”
Besides the contrasting visions and ways of approaching a given medical problem (disease, according to the physician’s point of view, versus illness, the patient’s point of view of the disease), the extremely different ways to address a patient or a family member or simply to who address questions and concerns, behavioral attitudes deeply embedded within each interacting culture (the Western culture of medicine and the traditional Hmong society culture), may cause intercommunication to miserably fail.
(…) When doctors conferred with a Hmong family, it was tempting to address the reassuringly Americanized teenaged girl who wore lipstick and spoke English rather than the old man who squatted silently in the corner. Yet failing to work within the traditional Hmong hierarchy, in which males ranked higher than females and old people higher than young ones, not only insulted the entire family but also yielded confused results, since the crucial questions had not been directed toward those who had the power to make the decisions. Doctors could also appear disrespectful if they tried to maintain friendly eye contact (which was considered invasive), touched the head of an adult without permission (grossly insulting), or beckoned with a crooked finger (appropriate only for animals). And doctors could lose the respect of their patients if they didn’t act like authority figures. (…)
Complementing the case of Lia Lee, the book intersperses and discusses other medical interactions where conflicting cultural approaches to medical problems highly influenced the outcomes.
(…) In his opinion [of Dwight Conquergood, an ethnographer sent to Ban Vinai by the International Rescue Committee], the physicians and nurses at Ban Vinai [camp hospitals in Ban Vinai refugee camp, Laos] failed to win the cooperation of the camp inhabitants because they considered the relationship one-sided, with the Westerners holding all the knowledge. As long as they persisted in this view, Conquergood believed that what the medical establishment was offering would continue to be rejected, since the Hmong would view it not as a gift but as a form of coercion.
Only when cultural barriers were tore down the possibility for medical outcomes to become satisfactory both to the medical team and to the patient and family alike became feasible.
Therefore, the book accentuates the importance for professional interpreters in a medical setting in bridging the cultural gap between interacting parties if achievement of satisfactory outcomes is sought. Mainly, because all parties are aiming to the same goal: the well-being of the patient.
In medical terminology, a ‘complication’ is an additional disorder or condition that develops during the course of an existing one (OED). During his training as a surgery resident Dr. Gawande became concerned with the uncertainties and dilemmas underlying within the medical system. In his own words: (…) the medicine that one cannot find explained in textbooks but that has puzzled me, sometimes troubled me, sometimes amazed me, as I‘ve joined the profession’s ranks.
From those concerns, was born in 2002 “Complications: A Surgeon’s Notes on an Imperfect Science”, a book where, with a fluent and engaging narrative, Dr. Gawande weaves, interspersed with a plethora of detailed examples, an engaging discussion on some widespread situations. Homogeneous as a whole, and also within each of its sections, the book can also be read as a collection of unrelated essays where no particular reading order is required; therefore, freeing the reader of any spatial and/or temporal constraints.
The book is structured in three distinct sections: (1) fallibility, where issues involving medical providers, mainly doctors, are discussed; (2) mystery, devoted to themes that puzzled and still puzzle the medical profession; and (3) uncertainty, on rare medical cases where apparently obvious evidences might be conducive to misdiagnose a particular disease.
Insightful as those essays are, they are not merely to be read passively but to be taken as a starting point for deeper discussions on the subjects they bring up. I found especially interesting those chapters where ethical dilemmas arise from given situations that prompted the author to reevaluate cases and the parties involved, putting everything in perspective to allow a discussion from a detached a point of view as possible.
Especially poignant, particularly regarding to surgery, is the need to balance medical training of new surgeons with the patient’s consent to be cared by a trainee, even under the attending’s supervision; mainly when the author himself admits that: One reason I doubt that we could sustain a system of medical training that depended on people saying “Yes, you can practice upon me” is that I myself have said no. (…). On the other hand, it appears that positive outcomes in teaching hospitals tend to be higher than in non-teaching hospitals because in them there is always more than one medical provider evaluating, checking, and rechecking every step in every single case. A chance for errors is always at hand.
Three decades of neurophysiology research have shown us numerous ways in which human judgment, like memory and hearing, is prone to systematic mistakes. The mind overestimates vivid dangers, falls into ruts, and manages multiple pieces of data poorly. It is affected by the order in which information is presented and how problems are framed.
The fact is that virtually everyone who cares for hospital patients will make serious mistakes, an even commit acts of negligence.
Operations like that (…) have taught me how easily error can occur, but they’ve also showed me something else: effort does matter; diligence and attention to the minutest details can save you.
Statements as those made me consider our profession as medical interpreters in similar parameters. As all we are aware of, there is a strong need for continuous evaluation. An assessment that should be performed in each and every encounter and not as a detached testing set up; thus, prompting a strong need to conscientious and continuous self-evaluation. This evaluation should entail not only our interpretation performance in itself, but our role as a bridge between provider and patient to facilitate the crossing as easier from one side as from the other. As interpreters, we aim to be considered as part of the caring team, to gain recognition from the medical staff. However, we should be asking to ourselves: Is this recognition going to enhance or jeopardize the benefits a patient might gain from our presence in the encounter? Is this going to favor or endanger the patient’s trust?
There is the interpreters’ need to be friendly enough to be trusted by the patient. To generate a warmth ambiance where the patient can feel at ease to ask questions, and as many questions as needed, to clarify issues without having the feeling of becoming inconvenient or even intrusive. And at the same time, detached enough from the patient for self protection (too much empathy can be detrimental) without giving the provider a false impression (i.e., that we teaming with the patient against the medical establishment). Therefore, there is a strong need for balance if we aim to succeed in our communication endeavors, both as language and cultural barrier breakers.
I would like to end these thoughts with some of Gawande’s comments on handling doctor-patient interactions as well as in addressing medical decisions. I believe it might as well be convenient to us, interpreters, to bear them in mind during the encounters in which we assist:
(…) I had come into residency to learn how to be a surgeon. I had thought that meant simply learning the repertoire of moves and techniques involved in doing an operation or making a diagnosis. In fact, there was also the new and delicate matter of talking patients through their decisions – something that sometimes entailed its own repertoire of moves and techniques.
(…) As one surgical professor told me, when you sit close by, on the same level as your patients, you’re no longer the rushed, bossy doctor with no time to talk; patients feel less imposed upon and more inclined to consider that you may both be on the same side of the issue at hand.
(…) The doctor should not make all these decisions, and neither should the patient. Something must be worked out between them, one on one – a personal modus operandi.
Children need a healthy environment so they can grow to become healthy and productive adults. Lacking in an attachment, negligent caregivers, physical and/or sexual abuse, are all hard experiences that can affect a child’s lifelong health. As medical interpreters, it is important to know what child abuse and neglect is and what signs and symptoms to look for. In fact, every state establishes its own definitions of child abuse which has to meet the minimum Federal standards. Many reasons contribute to an increased risk for abuse and neglect. Identifying the symptoms of abuse is the first step toward helping these children.
The abuse or neglect almost always takes place at home and the perpetrator is typically well-known by the abused. Every state has its own rule to typify the abuse, and most of them include: neglect or failing to provide the basic needs for a minor; physical or injury abuse; sexual use; indecent exposure; rape; or sexual exploitation (prostitution or pornographic); and emotional abuse such as rejection, criticism, or threats. Child abuse is a lifelong damage, and the impact is critically significant, until an intervention occurs.
Many situations have been identified as risk factors for abuse. Studies show that emotional immature parents can’t take care of their offspring in a healthy way. Parents with unrealistic expectations who don’t know about or understand normal child development, stress, poverty, divorce, substance abuse, inter-generational patterns of abuse and negligence are contributing risk factors. Around 3.4 million reports were placed in child protective services in 2012. (Statistics are from U.S. Department of Health and Human Services. (2013). Child Maltreatment 2012.)
There are typical symptoms of abuse. Neglected kids may have signs of malnutrition, lack of hygiene, and unattended medical problems. Physical abuse could be identifying if a child has bruises, burn marks, etc. Sexually abused children present physical signs in the genitalia area and emotional signs such as mood changes (aggressive to overly passive) and physical, emotional, or intellectual delayed development.
Finally, it is important to know that child abuse and neglect have a huge impact on the families and community. Child abuse traumas have been associated with depression, suicides, substance abuse, teen pregnancy, and a host of other problems. Support of healthy, stable relationships between caregiver and a child must be encouraged, and don’t forget there are many social services and nonprofit organization that can help.
by Chi-Wei Chang
This was my first time going to a national conference for interpreters. My goal was to be there and learn about simultaneous interpreting and how to teach simultaneous interpreting. Unfortunately the speaker for that specific topic was missing in action! What a disappointment!
Nevertheless, this conference was packed with workshops. One of them in particular drew a huge crowd of interpreters: Becoming an expert interpreter. As any medical interpreter can tell you, every interpreting encounter has its own challenges. How can a novice interpreter advance to be an expert?
Mr. Ryan Foley spoke about many tips for interpreters to improve their skills. Among those, three are fundamental and should be remembered:
1. focus on the techniques: the example he gave us was figure skating (which I can relay really well). How a skater improves on making a perfect axel not only requires repetitions but more importantly, using the right techniques. The same principle can be applied to interpreters who want to improve themselves and become better at interpreting.
2. goal oriented: set goals for oneself. Whether they are weekly goals or monthly goals, it is crucial for medical interpreters to learn more about medicine and look up information about illnesses or procedures that one has come across at an appointment.
3. look for constant and immediate feedback. Always seek direct and indirect feedback from patients, providers and peers. Based on clients’ feedback, interpreters can better prepare him/herself by identifying and correcting his/her own mistakes right away as well as gaining new ideas.
The conference’s hospital tours also offered an invaluable experience. I signed up for a tour that took us to MD Anderson, one of the hospitals that is part of the Texas Medical Center. The scale of this medical center is enormous. The interesting aspect about these tours is not just getting first-hand experience about the size or the appearance of the hospitals but how their language assistance program is run. As expected, Spanish is the most requested language. Yet to my surprise, the Vietnamese patient population is more than Mandarin Chinese here in Houston. The manager of the program explained to us that they use two schedulers to schedule all interpreters, temp and staff alike. What intrigued me the most was that their interpreters are sent to appointments when providers are ready to see the patients. And when interpreters are done with one job assignment, they are obligated to call their schedulers so they can be deployed to other available jobs. This way they do not have to keep a huge staff of interpreters. Wow! I would love to learn more about their model and how it can be applied to our own.
One of the best parts of going to a national conference is networking with other interpreters. It offers a great opportunity to learn from one another and to build one’s contact network. I was fortunate to be able to form on day-one a small group of interpreters from Asian countries. We went to most of the workshops together and shared our thoughts and experiences. All of us are now friends on social media and we provide resources and support to each other on a regular basis!
Depression is a persistent brain disorder, component of various psychoses that interferes with the patient’s everyday life. Its symptoms can include: sadness, loss of interest or pleasure in activities one used to enjoy, change in weight, difficulty sleeping or oversleeping, energy loss, feelings of worthlessness, and thoughts of death or suicide.
There is no single cause for depression, among them genetic, environmental, psychological, and biochemical factors. It is estimated that in the United States alone 20 million people suffer depression with feelings that do not go away, even though antidepressants and talk therapy have been considered effective treatments.
William Styron, an American writer best known for his novels The Confessions of Nat Turner (1967) and Sophie’s Choice (1979) had his worst bout of melancholia in 1985; a bout so severe that provided him with a seven week stay in the psychiatric unit at Yale –New Haven Hospital. Out of his experience with depression he wrote an article that appeared in the magazine ‘Vanity Fair’, which was later expanded and published as a book: Darkness Visible: A Memoir of Madness (Random House, 1990). There, he reflects on his knowledge of the malady acquired as a long-sufferer of this incurable and recurrent illness.
Here are some very interesting issues as expressed by him in regarding the illness and his own experience of it (underlined are mine). I trust that some of his comments about the malady are largely self-explanatory:
- Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self – to the mediating intellect – as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode (…)
- My acceptance of the illness followed several months of denial (…)
- A disruption of the circadian cycle (…); this is why brutal insomnia so often occurs and is most likely why each day’s pattern of distress exhibits fairly predictable alternating periods of intensity and relief.
- (…) never let it be doubted that depression, in its extreme form, is madness. The madness results from an aberrant biochemical process. (…) such madness is chemically induced amid the neurotransmitters of the brain, probably as a result of systemic stress, which for unknown reasons causes a depletion of the chemicals norepinephrine and serotonin, and the increase of a hormone, cortisol. With all of this upheaval in the brain tissues, the alternate drenching and deprivation, it is no wonder that the mind begins to feel aggrieved, stricken, and an organ in convulsion. Sometimes, though not very often, such disturbed mind will turn to violent thoughts regarding others. But with their minds turned agonizingly inward, people with depression are usually dangerous to themselves. The madness of depression is, generally speaking, the antithesis of violence. It is a storm indeed, but a storm of murk. Soon evident are the slow-down responses, near paralysis, psychic energy throttled back closed to zero. Ultimately, the body is affected and feels sapped, drained.
- (…) certainly one psychological element has been established beyond reasonable doubt, and that is the concept of loss. Loss in all of its manifestations is the touchstone of depression – in the progress of the disease and, most likely, in its origin.
- (…) The pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come – not in a day, an hour, a month, or a minute. If there is a mild relief, one knows that is only temporary; more pain will follow.
- A phenomenon that a number of people have noted while in deep depression is the sense of being accompanied by a second self – a wraithlike observer who, not sharing the dementia of his double, is able to watch with dispassionate curiosity as his companion struggles against the oncoming disaster, or decides to embrace it. (…)
- (…), the hospital was my salvation, (…) – I found the repose, the assuagement of the tempest in my brain, that I was unable to find in my quiet farmhouse. This is partly the result of sequestration, of safety, (…) the hospital also offers the mild, oddly gratifying trauma of sudden stabilization – a transfer out of the too familiar surroundings of home, where all is anxiety and discord, into an orderly and benign detention where one’s only duty is to try to get well. For me the real healers were seclusion and time.
- Save for the awfulness of certain memories it leaves, acute depression inflicts few permanent wounds. There is a Sisyphean torment in the fact that a great number – as many as half – of those who are devastated once will be struck again; depression has the habit of recurrence.
Quite recently, Alexandra Styron, one of his daughters, has reflected on her personal father-daughter relationship and how this relationship has been, over the years, shaped by her father’s illness; personal impressions and thoughts made public in Reading My Father: A Memoir (Scribner, 2011). Therefore, father and daughter provide the public with a rare case, in which the interested reader can somehow experience firsthand the effects of a given mental illness from two different perspectives: that of the patient himself and that of one his most direct (though not quite sure if close) family members. Some of her impressions follow (underlined are mine):
- (…) He was also praised, perhaps by an even larger readership, for Darkness Visible, his frank account of battling, in 1985, with major clinical depression. A tale of descent and recovery, the book brought tremendous hope to fellow sufferers and their families. His eloquent prose dissuaded legions of would-be suicides and gave him an unlikely second act as the public face of unipolar depression.
- (…), he flatly refused the two forms of treatment universally acknowledged as beneficial for the maintenance of a mind inclined to melancholia: talk therapy and antidepressants. (…)
- (…) Wretched and panic-stricken, Daddy began suddenly clinging to my mother as if she were the last raft on the Titanic. He’s spent more than twenty years pushing her away. Now he wouldn’t let her out of his sight. (…) If she did manage to sneak away one hour, a passing rain shower was enough to convince him she and her car were wrapped around a tree.
- (…) His voice all but disappeared, his gait slowed to a palsied shamble. The fantasies of suicide he’d harbored through much of the fall turned still more lurid – although, institutionalized as he was, he did grow resigned to the fact that the option was probably out of his hands. (…) His hyperreactive system – hitched to his chronic hypochondriasis (…); every “possible side effect” tried out its routine on him. Electroconvulsive therapy (ECT) was suggested as a possible option, having proved to be a particularly efficacious treatment for unresponsive, older patients.
- Watching Daddy go insane was tough on all of us but utterly devastating for my mother. His obsessions were endless and exhausting. (…) But sometimes it looked at her and it seemed as if she could not breathe, as if the whole unbearable situation would literally suffocate her. (…)
- Some days I just looked at my father and thought: Are you really going to die of depression? (…) He knew he was losing the fight, but he drew the line at being forced to feel better. No trying was his toehold on personal dignity, his last stand.
Although depression affects everybody in a different way and degree of intensity, it is noticeable from both Mr. Styron and her daughter’s comments that depression is a difficult to accept long-standing illness that strongly affects both patients and family alike. However, as with many diseases, acknowledging it is the first step to fighting it. And it is important to keep in mind that in making public a battle such that can only help other affected people to cope and fight against it, while hiding it and denying it not merely delays to the point of suppression the patient’s options for recovery but also prevents fellow patients, caretakers, and medical providers alike to benefit from our understandings.
Medline plus (NIH: National Institute of Mental Health);