Afe Alexis
Published April 13, 2019
That afternoon, halfway through my intern year, I had been assigned to the outpatient clinic. My first patient of the afternoon was new to the clinic. Unsurprisingly, there were no antecedent data in her chart, no forewarning of the ensuing events: a blank slate of sorts. Armed with only her name, I walked into the waiting room and called, scanning the half-filled room of expectant and attentive faces. Her head jerked up, eyes large and wary. The reciprocal discontent that arose within me was foreign, so unaccustomed was I to being on the receiving end of unprovoked mistrust. Nevertheless, I, ignored my internal discomfort, performed the customary welcoming introductions and ushered her into the office.
Before sitting, she hesitantly asked, "Do you speak Spanish?" To this, I offered my usual apologetic response, "Lo siento, poquito" (I’m sorry, very little), and suggested that we use the translator phones: those blue devices that turn ignorance into understanding. She agreed, albeit reluctantly. I dialed the language line under her watchful gaze and, after brief introductions and assurances of confidentiality from the interpreter, the three of us proceeded to conduct the interview. "What brought you to the clinic today?" I asked and waited for my question to assume relevance to her through the translator. As she began to speak, the words tumbled out as though eager to escape from the confines of her mouth. Even though in a language not my own, her halting, tearful speech and agonizing tones were portents to the grave content of her account.
In response to her narrative, even the human desire to give comfort was too great for the interpreter. Generally trained to be impervious to emotion, this particular interpreter became less of the passive neutral conduit and more of an active medium capable of providing emotional support, by, as he later told me, offering sincere apologies in Spanish before proceeding to translate the account so that I too, could be enlightened. Understanding descended like a dark, foreboding cloud; the horror of the narrative, palpable. She had been a victim at the hands of another, and the aftereffects of that event had been the impetus for this current clinic visit. By this time, my patient, well into her second tissue of the afternoon, was sitting in grim silence, waiting for the translator to break down the impenetrable wall of words created between us and illuminate the unintelligible.
I knew comfort and support were necessary through that difficult account, and I was a ready agent- my provision of tissues, the tilt of my body towards her, the concerned expression on my face, the gentle tone of my voice were all demonstrations of the empathy I desired to convey. But despite these actions, I wondered: How comforting is comfort when delayed and transmitted through a remote third party? Additional questions crossed my mind: Is the vulnerability that results from self-disclosure intensified by the inadvertent isolation felt in the momentary but seemingly prolonged silence of incomprehensibility as the words are conveyed from the interpreter to physician? How cathartic is verbal expression when it must be punctuated by awkward pauses and anticipatory silence as the words transition from babble to meaning? Is it irrational to think that, in those unavoidable moments, waiting for the back and forth of translation, the comforting effects of the subsequent spoken words become attenuated? Could that pause, though momentary, though understandably unavoidable, be agonizing enough to cause further harm through its ability to isolate at this, a significantly vulnerable point? Could a silence charged with the ignorance of meaning at one instance facilitate solace in the next? Would the compassion surrounding, and not just the literal meaning, of my words also be translated? As these questions floated to the surface of my mind, the accompanying doubts, in my own ability to provide effective comfort under the circumstances, also arose.
That afternoon, the language barrier became a significant constraint to our therapeutic physician-patient relationship, impeding the subtlety of the communication, risking full situational disclosure and frustrating my ability to provide immediate comfort through words. It appeared that the shift from a dyadic to triadic interaction had disrupted our verbal dynamic.
In my estimation, the situation demanded an immediacy of verbal response, independent of a conduit, in order to provide the most effective form of emotional support. Silence, as a means to convey emotion and solidarity, seemed inappropriate for this interaction.
Did my patient share my opinion? Were similar questions swarming in her mind? Were the delays in transmission as noticeable to her as they seemed to me? Were her needs for comfort and reassurance being adequately addressed in these moments? I'm not sure. I didn't ask her. Instead, I peered into her pained, tearful face, looking through my own eyes of empathy and imagined how I would want to be regarded if the roles were reversed. I would want, not only a concerned ear, but immediacy of response. I would want to be certain that the pain of my testimony would be transmitted directly, without deviation, towards its intended recipient. I would want the nuance of my language to be captured. With that revelation, I preempted the interpreter and asked my patient if she preferred a native Spanish speaker to continue the interview. Thankfully, that option existed, if only for that day. In that moment, I absolved the interpreter from the potential role performance confusion that could arise from his desire to provide comfort, a possible contradiction of the neutral role that one in his position was usually required to adopt. In addition, I confronted my own sense of futility in my attempts to express immediate verbal empathy, while contending with the delays generated by the physician-interpreter-patient conduit.
She readily agreed, gratitude etched in her expression. I had given her the choice to be heard, unfiltered in her own language; a choice that may not always be present for non-English speaking patients. I had confronted the undeniable reality that a remote interpreter, while essential for safe patient care when a language barrier exists, was, regardless of expertise, limited in conveying the many aspects of conversation that are independent of words: the nuances, the context beyond the diction. Ironically, these are often the parts of the conversation wherein many of the expressions of empathy unrestrictedly abound.