As long as we communicate

Alan Xie

During the first week of my third year rotations, my internal medicine attending asked me, “What languages do you speak?”

Mrs. Q, a Mandarin-only speaking middle-aged woman, had just been transferred to our team from the Emergency Department for high fevers, and most of her history was taken from her husband using an iPad to translate. She had a history of metastatic uterine and ovarian cancer, and the emergency team discovered her blood was growing bacteria. My attending wondered if I could help translate for her.

At home, my family speaks Cantonese, a Chinese dialect that is mutually unintelligible to Mandarin speakers. Although I’m more comfortable in Cantonese, I had been studying Mandarin since my senior year of undergrad. From my rotation the previous summer at Chengdu’s West China Hospital, I knew I could hold a conversation. Trying not to raise too many expectations, I cautioned my attending, “I speak Cantonese, Mandarin and a little bit of Spanish, but I’m not certified to do any interpretation.” The attending reassured me that if we needed to, we could get phone interpreter services. This was my first week in medicine, my first week of rotations as a third year medical student, and although I felt overwhelmed and confused about my role at first, I figured that maybe this could be a chance to help the team. Suddenly, I felt a strange sense of excitement in being involved in her care.

When we came into the room, Mrs. Q looked lethargic in her bed. Her husband, a bespectacled man, perhaps in his early sixties, did most of the talking in her place. We exchanged introductions. I gave them a disclaimer that I was a student still learning both Mandarin and medicine. Because I wasn’t certified to translate, we asked whether or not they would prefer to wait for an official interpreter to translate over the phone. He had a northern Chinese accent, which at times made him a little difficult to understand. At the same time, I spoke with a thick Cantonese-American accent, something that often prompted locals in Chengdu to ask me where I was from. He smiled and simply responded, “As long as we communicate, it will be fine.”

At first, the attending asked me to translate basic questions such as, “Can I listen to your lungs and heart now?” or “Can you show me your belly?” or “Where is there pain?” Mrs. Q promptly responded to her requests. I found myself scrambling for the right words, however, when my attending asked me to tell them that the urology team would come by to talk to her. At that moment, I forgot how to say “urologist” in Chinese, so I was forced to think about how I could communicate with simpler words. I started saying things like “urinary tract doctor” instead, or “your blood has bacteria” instead of “bacteremia.” It had been a while since I had to speak to anyone in Mandarin, and I felt self-conscious that my first attempts appeared rusty. Before we left the room, I apologized to them for my poor Mandarin. Mr. Q reassured me, “Ni de zhongwen hen hao,” meaning, “Your Mandarin is very good.”  To smooth our communication, we exchanged ID’s over WeChat (a messenger app commonly used in China), since it was sometimes easier for me to read and write than to listen and speak Mandarin.

Most of the day on the floors, we were doing something: pre-rounding, morning report, rounding until noon conference, and calling consults in the afternoon. When I had a free moment, however, I came into Mrs. Q’s room and saw her husband lying with her on the hospital bed, quietly holding her. It struck me as kind of sad and endearing at the same time. I imagined them as a lost couple in a world they couldn’t fully understand, and all they had right now were each other.

I said hello, and the husband turned his head to me and got up. I asked him how they were doing, and again he seemed to have that strange, quiet smile. He told me Mrs. Q did not eat last night. They weren’t used to the hospital food, which mainly caters to a Western palate. They wanted to know if it’d be possible for her to have xifan, plain rice porridge, something my parents often made me when I got sick as a child. He said he could make the xifan at home and bring it over. I was curious, however, wondering what kind of transportation they used to get around Worcester.

“How exactly would you do that?”

He looked straight at me and quipped “Uber.” He pulled out his smartphone and showed me maps in Chinese. He didn’t speak much English, but he knew his way around here. They were savvy people, not a simple lost couple as I naively imagined them. As I talked to them more, I learned they were middle school math teachers in Hubei, China. They had come to Worcester six months ago to visit their son, who was finishing his doctorate degree in engineering. However, the son had recently gone out of state and could not come back to see her. Mr. Q told me they kept in touch over the phone.

Mrs. Q also told me she had been frustrated to receive only cold or iced water; she felt as if her body was freezing, and she wanted something hotter to warm herself. Again, this reminded me of my own relatives’ predilection for drinking hot water — according to Chinese medicine and modern Chinese culture, hot water is better for your health and helps the digestive system. In addition, Mr. Q wanted to know how he could fetch the water himself instead of waiting around passively for the nurse. He wanted to participate in his wife’s care as much as he could. I passed the information along to the nurse, who showed him the kitchen and microwave they used to heat up drinks.

Before I left the room to check in with the team, I asked him, “Have you been here this whole time?” He nodded with a kind of steadfast loyalty. Coming from a tight-knit family, I understood where his sense of duty was coming from. I thought of my dad’s lectures when I was growing up, many of which stressed the importance of family. In traditional Confucian thought, people are defined by their relationships to others and the roles they played in society. The family surname came before a person’s individual name. Family was “the great self.” In this couple, I finally understood what that meant.

The next day, Mrs. Q had some imaging done and was found to have a stable hydronephrosis in her right kidney and a new hydronephrosis in her left. After consulting nephrology, we learned that she needed to have nephrostomy tubes placed in her back to drain her kidneys and thus clear the suspected source of her sepsis. Although her husband went through so much trouble to bring her some porridge and chicken soup, Mrs. Q was made NPO; I had to tell them she couldn’t eat or drink anything. The interventional radiology team needed to start the procedure right away. Mrs. Q appeared anxious.

“What kind of procedure is it? Is it invasive? Who is doing it?”

We then told them the IR team would come over shortly, and they would explain all the risks and benefits with a phone interpreter to obtain their consent and make sure they understand.  

While awaiting the drainage of her kidneys, Mrs. Q became thirsty from being NPO. I contacted the nurse for her who gave me ice chips with some swabs to wet her lips. As this continued, I checked in on them every few hours I was there. Sometimes they would ask questions I didn’t know, and it became a motivation for me to understand her condition, to read up on the physiology of the kidney, to know the management of sepsis, and to find a simple way to explain it. 

Although her right kidney was drained, Mrs. Q didn’t seem to get much better. Instead, her condition suddenly worsened. The next day, her creatinine started rising and her lactate rose to 4.7, a sign of severe hypoxic damage. When I came to see her in the morning, she reported new onset diarrhea and worsening chills. She laid in bed, covered in a winter jacket, looking extremely fatigued. The attending asked where she was hurting, and she pointed to her back where her kidneys were.

“I feel like I’m dying,” she muttered, wrapped in all her layers.

I passed the message along to my attending in the room.

She looked sternly at Mrs. Q and said, “Not on my watch you’re not.”

I couldn’t quite find those exact words to say in Mandarin, so instead I told her, “Don’t worry, the team is going to take good care of you.” 

Looking over her notes, we discovered the left kidney did not get a nephrostomy tube placed. The attending voiced her frustration, saying, “I made it clear that both kidneys needed to be drained.” The IR team did not find any obstruction in the left ureter as evidenced by her recent imaging, and decided not to drain it. In any case, something needed to be done, and my attending started pushing for drainage of the left. After discussing with the IR team, another percutaneous nephrostomy was scheduled for later that evening. When I came by Mrs. Q’s room, I saw plastic containers filled with home-made Chinese food Mr. Q had brought over lined up by the window. By this point, she had met with a multitude of different faces from four different medical departments, stayed in the hospital for almost a week, and now she was receiving another uncomfortable tube inserted into her body. With remorse, I told them that Mrs. Q could not eat or drink again.

During rounds, I missed one of Mr. Q’s WeChat messages, and I found him waving to me right outside of our workstation. I immediately logged off of my Epic account and came out to see him. Using Google translate on his phone, he asked me whether or not Mrs. Q could also have enteritis. I told him I would pass along his message to the team. The attending ordered a stool test for C. Diff, and we assured him we would look into it. Despite his worry, he always seemed to have a half-smile while talking to me. I found it bemusing at first, but I imagined having someone explain to him what was going on gave him a sense of control. 

After she had her second nephrostomy tube placed, Mrs. Q started getting better. My service with the general medicine team had ended, but even so, I found myself coming back to Mrs. Q’s room on the sixth floor just to check in with them. It felt like a personal obligation rather than a professional one. I found out she was switched into a single room, giving her and Mr. Q more space and privacy. More importantly, she was no longer quivering or covered in blankets. She told me she was feeling better, and she looked a lot more energetic as well. At night, I looked up her progress notes and labs and saw her creatinine was slowly dropping back to normal.

On her discharge day, I caught them while the nurse was giving them instructions. The nurse asked me to tell them that Mrs. Q was going to get a visiting nurse with a phone interpreter assistant to manage her nephrostomy tubes at home. The medical team also helped her schedule follow-up appointments with her gynecology-oncologist for her ongoing battle with cancer. At the end, Mr. Q shook my hand and told me, “Xie xie ni de guanxin,” meaning, “Thanks for your concern.” Knowing they were returning to China in a few months, I wondered if I would see them again.

Now that I am halfway through my clerkships, I reflect back on my training and realize how much education has come from my patients, even at the very beginning of my clinical year. From this encounter, I saw the therapeutics of face-to-face communication for both patient and provider. Because of the relationship I built with Mr. Q and Mrs. Q, I felt more motivated to check in on them just one more time before the day ended and make their requests heard. When patients come to the hospital, they want to have their questions answered and their feelings acknowledged. Attempting to speak in a patient’s native language, regardless of proficiency, shows empathy and a willingness to slow down and listen. Being shown that their medical providers care helps ease patients’ discomfort when facing a new illness in a foreign hospital.  

Although providers need to be empathetic when they listen to their patients, good communication also requires humility and critical self-reflection. I initially saw this couple as simply lost foreigners in need of help, but they were also experienced elders who knew each other well and had their own ways of dealing with illness. As I tried to imagine their experience navigating a foreign medical system, I also needed to have a willingness to interrogate my own tentative narratives. It was not enough to care and simply feel sorry for them. If there was something they could do, like bringing food or water palatable to their diet, they wanted to be able to do it. Because being hospitalized can often take away one’s autonomy, it’s important for providers to restore as much of it as possible. This makes it especially important to explain to patients the rationale of their management plan. In maximizing patient autonomy, care can be properly balanced with respect.

When I started my third year, I thought I was helpless and asked my resident what my role was on the team. He told me curtly, “Your job is to learn,” and indeed, the best learning comes from talking to patients. Seeing Mr. Q’s courageous love for his wife, I understand better the bonds of family and culture in my own life. When I tried to learn for the patient rather than my shelf exam, the knowledge stuck to me better because I could put a face to a medical condition and remember the story of a patient’s management. I cannot make orders as residents do, administer medicines as nurses do, but I can listen to patients. Learning how to care for patients begins with communication. As a future physician, that’s something I will always keep in mind.

*Please note that the patient received a professional interpreter when working with specialty teams and always in advance of and during complicated procedures.

Alan Xie is a current third-year medical student and second generation Asian-American. Before going to medical school, he did research on health education in Boston’s Chinatown. He is passionate about the humanities and global health.