Sojourner in a foreign land

A question our field must consider is whether our work as medical geneticists should be restricted to domains that are (more or less) purely medical or do we have a responsibility that encompasses also the human/emotional side of a genetics consultation [Resta and Kessler, 2004]. If it is the former, then it should be relatively easy to switch countries and languages. If it is the latter, then we must address how significant is our choice of language and the consequences of working in a language that is not our mother tongue. Shortly after arriving in Switzerland and before having time to refresh my French language skills, I was called upon to discuss a prenatal diagnosis of trisomy 21 with a young couple. An amniocentesis had been performed after a positive first trimester test and the couple was coming for the FISH results. The announcement of the chromosome abnormality was met with tears from the woman while her husband displayed little emotion. There followed a relatively standard counseling session with a discussion of the medical and clinical implications of Down syndrome, options for the pregnancy, and social and emotional aspects surrounding the diagnosis, and the stress of making a decision regarding the pregnancy. At this point, the husband stated that prolonging the appointment was a waste of time, clearly termination of pregnancy was the only sane option, and there was really no need for his wife to make a fuss. I said that it was not unusual for partners to have differing views and asked the wife “Est-ce qu'il y a quelqu'un qui peut vous supporter?” I thought I was asking her if there was someone to whom she could turn to support her in her distress but I had made a translation error and had in fact asked her if there was anyone who could tolerate (stand) her. “Supporter” and “support” are actually false friends; I should have used the verb “soutenir.” Luckily, there was a young resident with me who quickly provided the correct word. Twelve years later though, I can still see the surprised look from this woman (even if it only lasted a second or two) and the smug look from her husband who seemed to believe that finally here was someone who understood how difficult it was to deal with this crying woman when really there was no need for tears. I think this is the type of nightmarish misunderstanding is what we worry about when considering counseling in a language that is not our mother tongue. There are clear disadvantages to counseling in a foreign language. They include the limited ability to choose just the right word or phrase, lack of knowledge concerning social and cultural norms, and a fear of not understanding the patient. I would argue though that there can be advantages to counseling in a foreign language. When using English, I am not obliged to consider my words before speaking but in other languages I must have a moment of reflection before speaking. I find this pause of reflection often more than makes up for a narrower vocabulary. When you are speaking in a second language, you also have a tendency to use shorter phrases and you avoid slang (because if you do not know the slang, it can not slip in accidentally). This can be crucial for good communication and is often part of the advice we give to genetic counseling students and medical residents. I have also learned to use my accent as a method for allowing the patients to pose questions that puts the fault of a potential misunderstanding on me rather than on their ability to understand. Before I explain genetic concepts, I will signal that I know that I have an accent and if there is anything that I say that they do not understand, they should please stop me and I will find another way to explain. When I first started working in Germany, my language skills were limited. I did not want patients to worry that we wouldn't be able to communicate so at the beginning of every session, I would acknowledge my poor German and say that if there were problems I would go and get a native speaker to help us. It seems natural that if a patient detects that their language is not your mother tongue that they may worry about communication problems. If you address this at the beginning with a proposed solution if necessary, it can deflate the anxiety of the patient. I gave my regular spiel about my German skills, or lack thereof, to a woman of Turkish origin and she said to me “Wir Ausländerinnen, wir verstehen uns.” Loosely translated this means “Us foreigners, we understand each other.” It gave the entire counseling session a better dynamic: we were in this together. It also meant that the doctor was not someone on a pedestal separated from the patient, but just another regular person struggling with über-complicated German grammar and those 20-syllable-long words. It can be more difficult communicating with your colleagues than with your patients when working in a second language. They are frequently more impatient and definitely prone to use multiple and complex abbreviations. In reviewing the chart of a child, I was to see with developmental delay and epilepsy, I read that his cerebrospinal fluid was “edr.” I could not come up with anything for that. This abbreviation means clear as the “eau de roche”; that is, clear like water from the source (but only if one knows that in old French “roche” which means “stone” today used to mean cave or source and that this water was supposedly the clearest). This metaphor is easily decipherable now (thanks to Google) but at the time it left me scratching my head. In rounds and seminars, if I was unsure if I had understood, I usually kept quiet and asked my husband for help when I got home. In counseling sessions, if I was unsure if I had understood, I took the time to repeat what I thought I had heard and make sure that I had understood. This is not a bad practice even if you are working in your mother tongue but we often do not make the time for it. This re-phrasing of what a patient has said may be a well-known interviewing technique for genetic counselors but may not be a part of medical training. Working in Germany and Switzerland, there are some clear societal differences when compared to my native country but the culture shock was perhaps less in moving to Europe than it was moving from New Brunswick to Toronto. As a young physician from the Maritime Provinces, I arrived in Toronto armed with English and French, only to be faced with patients on a general medical ward who spoke only Portuguese, Hindi, or Mandarin. Making the effort to learn a few words or phrases in the patient's language was greatly appreciated. One of my fonder memories of that year in internal medicine was looking after a 91-year-old Portuguese woman who was dying of a nasty thyroid tumor. I learned a few basics in Portuguese—good morning, how are you doing today, and the like. My chief tried to arrange a transfer to palliative care but the lady and her son both requested to stay with me until she died. My daily visits to her room were sometimes brief, and hardly ever medical, but they were appreciated and gave me a sense of purpose. In hospital rounds, be it in pediatrics or genetics, it is not unusual to hear younger colleagues apologizing for incomplete history taking on the grounds that there was a “language barrier.” While it is true that communication is difficult when there is not even a small common linguistic ground, I would surmise that in more cases than not, the language barrier is not the main reason for the communication block. Interpreters can help, but communication through interpreters may not always be precise and does not favor the communication of empathy. Overcoming the “language barriers” will become even more important as numbers of foreign immigrants and refugees to Europe are increasing. No matter where you work, even if it is your hometown, you will be faced with people from different backgrounds. Being overly sensitive to cultural differences can be detrimental to the counseling process [Browner et al., 2003]. If you can make the time and effort to communicate, this will be so much more essential than simply being of the same culture. While in Germany, I saw a young Jordanian family who had a child with glutaric aciduria type 1. They requested prenatal diagnosis in their second pregnancy and sadly the fetus was predicted to be affected. For a variety of reasons, including that they felt they would be unable to visit family in Jordan with two affected children, the couple chose to terminate the pregnancy. I had to appear before a committee of gynecologists/obstetricians to justify this decision before they would accept to perform the procedure. The committee refused. They felt that the severity of the disorder was insufficient to warrant termination. I have rarely been so angry and it remains the only time I have stormed from a room and slammed the door on the way out. Here we were, a Jordanian Muslim couple and a Canadian Jewish geneticist, all immigrants to Europe, being turned down because of a culturally different perception of the consequences of a genetic disease. An approach that favored empathy, and not paternalism, would have been required. In summary, there are disadvantages to working in a foreign tongue, but it can also be a good way to learn some essential interviewing skills: short simple sentences, no slang, speak slowly. You should take time to listen to your patients and be aware of non-verbal cues in any language. I would also add that empathy is a value that reaches across all cultures. Thank you to my husband, Andrea Superti-Furga, for his patience in listening to me and in helping me to decipher the varied tapestry of clinical interactions; as well as suggesting that I write this article in the Festschrift for our colleague and friend, John Carey.

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