The Irish Medical Times - Lost in Translation: Comunication Challenges in Healthcare
In the ED my chesty cough had bought me a one way ticket to a secluded trolly in a room with a view - of a brick wall. A thin partition separated me and my ‘neighbour’ who I decided was an elderly man, by the sounds of his cough, interspersed with shouts of “Mary Mother of Jesus” more coughing “Sweet Divine Mother of Mercy, where’s that bloody doctor?”
The bloody doctor duly arrived.
Doctor: You have Covid
Man: No
Doctor: You do. You tested positive.
Man: Who did? You did?
Doctor: No. I don’t have Covid. YOU have covid.
Man: How do I have that? I don’t have that!
Doctor: Do you know what Covid is?
Man: No
The doctor started talking about a treatment plan and nurses came to hook the patient up to drips, etc. The elderly gent was clearly somewhat confused and perhaps this confusion was an ongoing problem, or maybe it was a symptom of the illness. It is possible the man may never fully understand his predicament. Had I witnessed a gap in communication that can’t be closed? An understandable occurrence in the urgent setting of an Emergency Dept.
When I won the hospital lotto and eventually got moved to a ward, the man in the cubicle next to me whipped the curtain back with delight. “So, g’wan,” he asked me, “what are you in for?” I was tempted to respond “Murder. Yourself?” but instead I coughed out an incoherent response which said it all.
He told me he’d had a massive stroke, it hit him while he was in the pub, a terrible headache, he’d staggered all around the pub pulling at people, getting his hand caught in some young woman’s hair extensions as he fell to the ground roaring in agony. An ambulance was called and it took 6 men to carry him on their shoulders to the paramedics. A full blown stroke at age 40, he concluded, with more than an air of pride.
I was transfixed, I’d never heard of anyone having such a dramatic and painful stroke experience. I also didn’t fully understand why anyone, perhaps outside of a funeral march, would be carried on people’s shoulders, and don’t the paramedics come to you, not you to them?
I thought strokes were synonymous with more debilitating presentations with sudden paralysis, facial droop, difficulty speaking. Not groping your way around the pub bellowing in agony, but everybody's experience is their own. And it made for a great story.
I expressed surprise that he wasn’t in the dedicated Stroke Unit, instead of this hodge-podge of a ward with all sorts of delightful diseases. He said they were waiting for his pain to stop, and his bowels to move. As a commode wheeled up, I pulled the curtain and thought about bellowing in pain myself as my senses were assaulted by the sights, sounds and smells of a curtain shivering while unspeakable explosions occurred behind it.
Some time later (I couldn’t say exactly as I had retreated deep inside to my happy place) the explosions stopped and a doctor arrived. The patient's wife suddenly appeared, perhaps she had been hiding under the bed away from the commode. I couldn't help but overhear the conversation, I was about 3 feet from them, separated by a half pulled curtain.
The doctor seemed kind, and listened to the charismatic patient tell the wild story for probably the umpteenth time, but she was very clear with the patient that the diagnosis hadn’t changed from day 1, it was a migraine, now that the bowels were moving the patient could go home.
When the doctor left, the wife turned to the patient and said “There ya go, it’s a migraine not a stroke”. The patient was livid, “Ah Deirdre, you haven’t a clue, the stroke caused the migraine.”
Either the patient misunderstood the doctor or preferred the stroke narrative, which had probably already been communicated to friends, family, and the pub dwellers who witnessed the dramatic event. I wondered how far this miscommunique could go, would the patient join a stroke support group? Would they look for services allocated for stroke victims? Would they relay it to another doctor in the future thus informing how that doctor treats them? Could they end up on blood thinners that they don't need which could have a detrimental impact down the line?
While I was pondering all this I noticed that the man in the bed across from me was staring right at me. In fairness, there was nothing else to look at in the room. He was munching his way through his 3rd bag of sweets of the day.
“I’m diabetic. I’m getting my big toe cut off,” he announced to me from the other side of the room in his strong country brogue. “Ok” was all I could manage back. I was being treated for pneumonia and didn’t feel well enough to get into a chit-chat about toe amputations.
Thankfully, I was saved by the bell as his doctor arrived. She glanced around his bed which looked like Willy Wonka and Mrs Tayto got together and had loads of offspring. His bedside tray was full of fizzy drinks at different points of consumption. She picked one up and told him he shouldn’t drink these things.
“It’s not mine,” he said defensively, crossing his arms, “I’m collecting them so I can return them to Lidl. I’d never drink that stuff. I just drink tea, usually green tea, doctor.” The doctor moved swiftly on past the lie, and asked what his diet was like (“Great” apparently) she asked him if he ate many carbohydrates (“None” was his quick response). Mrs Tayto would beg to differ.
I don’t think the patient was deliberately being obtuse. We all want to put our best foot forward (hopefully with all our toes intact). It can be hard to admit our failings, especially to someone who is going to add them to our permanent file. How do we communicate honestly and ensure we get the correct treatment without fear of reproach? Sometimes the reproach is external, sometimes it is internal.
It wasn’t just the doctors and patients who were out of sync on the ward. There was conflict between patients too. A young Russian drug addict on the ward would start every day begging for his methadone, on one occasion, after receiving it, he marched up and down the ward shouting “Long live President Putin!”. Until a Ukrainian patient jumped out of bed, stood in the Russians way, and said in a gravelly voice “Stop this! Putin is no friend of mine”. They had a fiery exchange in a foreign language.
I was on IV diuretics which would send me urgently to the toilet. Of course my toilet urge erupted as the men were arguing. They were standing right in front of the only bathroom. I had to wheel my drip in the men's direction, and say in my South Dublin accent “Hoi goys, sorry, can I get past you there please?”
My toilet need brokered a peace deal and they retreated to their beds.
While I was in the toilet WIlly Wonka kept knocking on the door and trying the handle saying “Hello? Hello?” So I rushed and ripped open the door thinking he must have been in dire need. He was standing there with a bag of Skittles “I thought you might want some sweets?” he asked. I politely declined, later he would instruct the nurse to leave a bag of sweets on my bed. I’m sure he was just being nice, but ‘No Thanks’ means no thanks, across the board.
Just when I was starting to lose faith in humanity, a young doctor walked in and right up to the Ukrainian patient. The poor patient had been in for days, his English was sporadic, many attempts by doctors and nurses had been made to communicate with him but it was slowly going nowhere. He was clearly unwell and I’m sure tests were showing issues, but it was this medical history they were after. I presume a translator had been requested but I can also presume they are in high demand and short supply. Then in walks the young buck, brimming with confidence.
Even Wonka put down his sweets to see what would happen next. Bucko took out his phone and using a translation app he began a long (albeit halting) conversation with the Ukrainian patient. It turns out the man had a 20 year history of stomach problems, had undergone several surgeries and so on. Bucko was delighted with himself, the correct plan could be formed, and the patient seemed thrilled to finally be understood.
Doctors are not trained communicators, they don’t necessarily have an instinct for how to ‘meet the patient where they’re at’. Similarly patients are from all walks of life, we don’t come with an interaction booklet, and when we are feeling unwell our interpersonal skills may not be at their best. Looking for one solution to close all communication gaps is probably foolhardy.
If not being understood is a part of life, the young doctor using the technology on his phone to converse was an example of a life hack. There are other communication hacks that don’t involve technology, try smiling, make eye contact, face the person you are talking to, nod, take a seat, introduce yourself, use each other's names, use written, digital or visual information if that’s preferred, to name a few.
By fostering a culture of open dialogue, empathy, and using technology or soft skills to bridge communication gaps, we can work towards a healthcare system where misunderstandings are minimized, and patients receive the care they truly need. I would like to see more doctors and patients feeling encouraged to try out their own life hacks to move us to a place where we not only understand, but we feel understood.
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