The Interaction of Language and Care: Three Experiences from a Multilingual Med Student

I am a UCSF medical student of Toishanese-Cantonese-Chinese background currently on a research gap year during the COVID-19 pandemic. My research is focused on telehealth, mobile health, and how to best implement them for people who speak little or no English at all. For people with language barriers, the pandemic made providing care to them harder. During shelter in place, many people with language barriers weren’t familiar with using the web, or even the phone. Although technology moves society forward, people like my parents, who came from rural Toishan China, are often left behind.

Despite growing up in NYC, English was my third language (the first two being Toishanese and Cantonese). As the son of non-English speaking immigrants, I was expected to translate things from jury summons to credit card bills. This is why I’m interested in working on language barriers. Here are three experiences during my rotations, research, and community outreach which allowed me to reflect on the power and limitations of language. 

Experience 1: Magical Powers

This first experience showed me that language can have magical powers. This happened in 2019, pre-COVID. One night during my medicine rotation, I overheard a conversation from another that a patient needed an in-person Cantonese translator. It wasn’t something we can use the phone or video translator for because of the urgency of the situation. However, getting an in-person translator on the same day especially at night is extremely difficult. So I volunteered myself to the team.

The attending briefed me on what was going on, the patient was suffering from terminal cancer which failed despite multiple drug treatments. They wanted to talk with the patient herself to know her wishes on proceeding, that is whether to continue treatment or to focus on going home and family. These are difficult decisions and requires her to understand the options and decide for herself. 

I entered the room with the team. Her whole family was in the room with her (this is pre-COVID). I hear from the husband’s tone that he has a Toishanese-Cantonese accent. So I asked the husband in Cantonese “what language does your wife speak, Cantonese or Toishanese or something else?”, he said “She actually speaks better Toishanese”. As I approached her bed, I can see that she was comfortably asleep, I quietly spoke at her bedside in Toishanese “阿嬸你好,我係丐嘅(這裡的)醫學生。” “Hi Aunty, I’m a medical student here” (FYI in Toishan it’s polite to call your elders by Aunty, Uncle, Granny or Grandpa as a sign of deference). Her eyes lit up in excitement and though we never met before, it felt like some we connected quickly on a kindred level. We had some short conversations as  鄉里 (heung lei, xiang li) fellow villagers often do. Topics like, Which village are you from? How long have you been in America? How’s your parents? Is your mom doing okay? When was the last time you went back to the village? 

After exchanging the pleasantries, I redirected her to the somber topic at hand. We wanted to understand her goals for the rest of her care. I explained in Toishanese that all the treatments we used had failed so far and while we wished we had better treatments there was nothing else we could do. We can try continuing with the treatment and some people choose that, or we can focus on bringing her home and focus on making her comfortable so she can spend her remaining time with her family. 

She took some time to think about this. She talked with her husband and her children and decided that she wanted to focus on her family and go home. She wanted to go 飲茶 yumcha (dimsum) and hopefully be well enough to visit her village in China one last time. These weren’t possible if she continued receiving chemotherapy. From the conversation, the team understood the goals and thought about the best step of action to help her. 

As I walked out to debrief with the team, my classmate on the team said “You know she never spoke with us at all, she was too somnolent”. I learned because of the chemo and other drugs she was receiving it was hard for her to hold a conversation with the team during morning rounds, they were lucky if she was even slightly aware they were there. Even though I translated for people multiple times before, I never knew that language can have such an important impact. Perhaps, it was the gravity of the situation that made it feel like I have a special magical power. I was proud that I was able to help this family out. 

This experience also framed what I learned from schools when interacting with all patients. Start with the small-talk before big-talk. And sometimes that small talk is important, from the small talk I was able to understand what she valued in life, so it completely clicked for me when she talked about her goals outside the hospital. Not everyone from Toishan will react the same (and you thought Asian was a monolith!). Different people from the same places will have different values, especially with decisions about end-of-life care, anything that helps with communication is crucial. 

Experience 2: Care can be felt beyond language barriers 

In my first experience, language-concordance helps in complex decision making situations. However, it’s not the only factor in good care. Speaking the same language isn’t the same as communication, and showing care can go beyond language barriers as I will illustrate in this experience.   

I am fluent in Chinese, I read it and write it and I understand some classical Chinese texts. Yet, I don’t consider myself to be “literate” in Chinese. To me when I think of a person who’s literate in Chinese, I’m envisioning a scholar like those in Chinese period dramas who can compose poetry and recite classical text off the top of their head. I don’t know if this is common in Chinese language countries. For context, my parents and most of their siblings weren’t able to go to High School. I have little exposure to people from China with a high school education or greater. So, I’m amazed whenever anyone can do these things

This experience happened during the pandemic. I was interviewing a patient for a telehealth perspective project which recruited patients from multiple language backgrounds. The interview was done on the phone. This patient taught Chinese literature back in China. He spoke fluid Cantonese while adding some poetic prose. So he was someone I considered very literate. One of the topics that came up in our interview was the differences in care he received from a Chinese speaking doctor at a private clinic in Chinatown versus the care he receives now from a provider who only spoke English and communicated with him through translators at a large network hospital. He preferred his current provider who spoke only English.

Like many immigrants when he first arrived in the USA and got health insurance, he picked a Chinese speaking male doctor at a local Chinatown clinic. It was close to where he lived and they spoke the same language. However, his experiences there were dismal. He remembers waiting for the doctor 30 mins - 1 hr past his appointment time to see the doctor, and the actual time spent with the doctor was only 5 minutes. While they spoke the same language he didn’t feel they had any semblance of communication. He felt rushed in and out the door. 

Eventually when he got a different insurance plan, he switched to a provider at a large network hospital. He chose a Caucasian female doctor who was accepting patients at the time. At every visit she utilized translation services to talk about his health and care. Despite the language differences, his experience with her felt much better. He never felt rushed from her and really appreciated that she always ended the conversation by asking him whether there was “anything else you want to talk about”. He felt cared for. During the pandemic, as his care was moved to telephone, he still felt cared for - all from the tone of her voice and questions she asked. “She genuinely cared for my well being. I will give her 100% and more if I could!”

This conversation with him gave me hope for patients with language barriers. While it’s helpful if providers can speak the same language, this advantage is lost if they don’t communicate. As his experience in the private clinic showed, he didn’t feel like he spoke with that doctor at all. Showing that you care can go beyond language barriers. There are common themes in communication skills which every person appreciates and that gives me encouragement to work with diverse communities outside my own and learn from them. 

Experience 3: There are some things language can’t translate, the social experience

I signed up to be a volunteer contact tracer in San Francisco during the surge months in October - December. Although I was busy with multiple projects at the time, I felt compelled to do it because the SFDPH only had 2 Toishanese (a Chinese dialect) speaking contact tracers at the time compared to over 17 Cantonese tracers. While many younger Toishanese like me speak Cantonese and sometimes Mandarin a lot of older folks such as my mom and my girlfriend’s mom cannot speak Cantonese fluently, even though they can understand it Cantonese speakers may not be able to understand them. So it was a gap I felt personally obliged to fulfill. 

During one shift, I was assigned a mono-lingual Toishanese speaking lady to contact. She reminded me of my mom in a lot of ways, she worked as a home health aide, a caretaker who is hired through insurance or with personal funds to take care of elderly. I called and spoke to her in Toishanese, informing her that I was a contact tracer as part of the San Francisco Department of Public Health and that she had a recent COVID exposure. 

Although I felt I spoke clearly to her. She didn’t understand my explanations about what a contact tracer is, and what the department of public health was. She asked if I can speak with her employer instead. I felt offended given that we spoke the same language but didn’t voice that to her, instead I confirmed whether she agreed with her employer being part of the phone call which she affirmed. I told the same thing to her employer who relayed the same information back to her and she seemed to understand the situation better.

It was a complex situation because she was a live-in caretaker for her employer’s 90+ year old mom and stayed in the same bedroom as the mom - it was unsafe for the mom to be alone at night. While the city offered a shelter-in-place hotel for her, there was nothing we could do for her employer’s mom. Both she and her employer were hesitant because of the care the mom needed, which at the time was more important to them than the risk of COVID-19. So they needed time to think about the options. 

As we ended our call, the contact and I engaged in some small talk. She asked me how long I’ve been in America, “30 years”, and I asked her the same to which she responded “2 years”. This was the one major difference between her and my mom and when things began to make sense. My mom immigrated to the USA for over 30 years now, so she is familiar with the resources offered by an urban environment. As she is a monolingual Toishanese speaker from rural China there was a sharp learning curve during our early years in the USA. The feeling that struck me then was fear and suspicion, every time I helped my mom fill out any form that had some sort of government seal she told me not to fill anything out incorrectly because we might get arrested - sometimes even an ad with some official looking logo on it looked scary. It took us a while to learn the city environment and which services we can trust. Nowadays my mom knows what forms are more official and which are just advertisements, and before 2017 and after 2020 she’s also less worried about the government’s treatment of immigrants like her. “We have rights and we have protections'' she would say. 

Thinking back to the contact, it might have been that she’s not accustomed to an urban environment and may have some suspicions which are all normal reactions. Based on their interaction during the call, I also felt that she and her employer trusted each other. Her employer was her supporter in this phone call; an emotional or social pillar to let her know that things will be alright, this person calling you is here to help us. Reflecting on this, I’m grateful her employer was there to support her, because it would have been hard for me to connect to a level of trust. 

While speaking the same language may help build trust it doesn’t automatically guarantee you trust. Her employer was a necessary mediator of trust for her, and something that I cannot replicate from language alone. 

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