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Open to Interpretation

For much of my career, I have cared for patients who need interpreters when they come to see a doctor. Now at the site where I practice and teach, most of the patients speak Punjabi and Bengali. The elderly people are mostly Greek and Italian. Working with interpreters is an everyday occurrence and has its own challenges. Family interpreters will often massage and edit their loved ones’ content until I am unsure whether I actually get the story the patient is telling.  Some of the professional interpreters we know well and work with are real collaborators with our team, not only translating language but also bridging cultures.

After the LMCC examination one year our Residents were laughing. One of their OSCE cases was about working through an interpreter. “The Residents from other programs found it really hard,” said Janel, “but for us, it was just another day at the office.”

I first became aware of the difficulties of working with interpreters when I was a rotating intern. I was on my gynecology rotation and doing an intake interview in the infertility clinic. The patient was a shy woman from Tibet. The Interpreter was her sister-in-law. Some of the questions in an infertility questionnaire are very sensitive and not what you would like your husband’s sister to know, such as: how often you are having sex and what you are actually doing. When I got to the question about sexually transmitted infections, the sister did not quite understand me. Once I made it clear what this meant, she looked me in the eye and said firmly “Tibetan people do not do that!” Somehow I did not think that I was getting a complete and unbiased report of the patient’s issues. 

The strangest Interpreter-mediated patient encounter happened years ago when I worked at the Herzl clinic in Montreal. The patient was a recent Russian Immigrant. Her chief complaint was she thought that she had worms coming out of her body. To complicate matters, the patient was deaf and was communicating through a sign language interpreter. She was using a Russian or European version of Sign. The interpreter understood and used American Sign Language and spoke to me in French (I am an Anglophone), and I talked to the interpreter in French. This triple translation was very confusing, and the opportunities for “Broken Telephone” seemed enormous.

At first I thought she had pinworms, mainly when she told me that she had been treated in a walk-in clinic and that they had gone away for a while. Then she told me, through the interpreter, that the worms were coming out through her skin, rising up like little spikes at night and crawling all over her body, making her unbearably itchy and making her masturbate to relieve the discomfort. I became a little bit suspicious. Then she told me that she could see the worms wriggling in front of her eyes. Could she have some strange parasite, I wondered, vaguely remembering something about Loa Loa worms, but weren’t those in Africa, not Russia? This was probably delusional parasitosis, I concluded, but how could I be sure?

I turned to the interpreter and asked, “Does she sound rational to you?”

The interpreter looked at me, shocked. “You know I can’t comment on that!” She said.

I was stymied. There is so much information in how people communicate; their speech’s pace and pattern, idiosyncrasies that can give you hints that the patient is psychotic and delusional. All this was missing through the three layers of translation and interpretation. I stared at the patient. I examined her, and all I could see was pickings, scabs, and excoriations. Nothing was definitive either way.

The patient’s fingers started to fly. The interpreter, despite her insistence on professionalism, could not hide the look of disgust and incredulity on her face. “She says,” the interpreter said to me, “that at night she can hear the King Worm and the Queen Worm in her head as they discuss how they are going to eat her alive.”

“Aha!” I thought, “You have been defined!”

“Are you sure that is what she is saying?” I asked her, not wanting to make an error.

“I’m pretty sure that is what she is saying.” The interpreter looked shaken. The patient’s fingers were still moving. “Now she says, the worms are having sex in her head, and little baby worms are going to come out through her eyes.”

I was almost ashamed at how relieved I felt at this statement. At least now I knew what the diagnosis was. The negotiation to start an anti-psychotic to “put the worms to sleep so we can get rid of them” was much more complicated since the patient absolutely refused to see psychiatry. However, at least we found a way to communicate across the divides. I never saw that patient again, so I don’t know how things worked out. It is hard to communicate with parasites once they get in your brain, no matter what language they are using.