Ms. Cole-Kelly is professor of family medicine, director of communication in medicine, and codirector, Foundations in Clinical Medicine Seminars, Case Western Reserve University School of Medicine, Cleveland, Ohio; e-mail: firstname.lastname@example.org.
Empathy is a core clinical skill found in every model of doctor–patient communication. Yet, we as educators must consider how different an expression of empathy might be for a doctor with a different cultural experience and a different ease with the English language.
I was observing Mamta, a gentle, third-year family medicine resident from India, in her afternoon clinic with Ms. Taylor. Ms. Taylor began to cry while describing her unhappiness with the changes that she was experiencing due to menopause. She described how she didn't know how to handle her “new moods,” her sleeplessness and hot flashes, and her husband's dismay with her behavior.
I have shadowed Mamta on multiple occasions and was consistently impressed with her communication skills, but this time something was amiss. Ms. Taylor was emotional, and Mamta followed her emotion with more questions. Tears were slowly crawling down Ms. Taylor's cheeks, and Mamta asked, “Are these symptoms every day, more at night than day time?” Ms. Taylor spoke through her emotion: “They're all the time; I can barely work.” Mamta's information gathering questions seemed uncharacteristic for her in response to her patient's nonverbal and verbal responses. A brief empathic statement would have barely slowed her down. Yet, Mamta continued with her questions.
As we walked out of the room, Mamta almost tackled me with her confession, so full of emotion herself: “I know you wonder why I didn't respond to her tears.” I was relieved that she was aware of the incongruity of the interaction. After affirming my confusion with her behavior, a metaphoric bolt of lightning hit me as she spoke: “When my heart got mobilized, I lost my English.” She continued: “I had a rush of Hindi words that flooded my mind to reassure and offer comfort. By the time I had translated them into English, the moment had passed, and I sadly became mute.”
When her heart got mobilized, she lost her English. What a revelation for her, for me, and potentially for other residents who usually are fluent in English but who, when their emotions get mobilized, think in their mother tongue—a term that calls to mind the rocking and lullabies of mothering. Lullabies, words of comfort, are often embedded in our minds in the language in which we first learned them. Translating them into a second language takes painstaking effort when emotions play a role.
Weeks later, I was shadowing Adira, a gentle, sensitive resident from the Middle East, who was seeing a new patient presenting with itching and irritation in her vagina. The patient had just shared with Adira that her husband had been cheating on her for the last several months and that she was consumed with worry about acquiring an STD. After Adira confirmed and presented the diagnosis of trichinosis, all the patient could do was shake her head back and forth in apparent anger and despair.
Adira initiated a conversation with me the moment the door closed behind us. Again, the mental gymnastics of translating when the heart is stirred presented a challenge for her: “Oh Kathy, I wish in these situations my English was more fluent. I so wanted to comfort her but could not make my English come fast enough in the way I wanted, so I reverted to giving her medical information.”
The experiences of Mamta and Adira demonstrate the challenges for international medical graduates expressing empathy when emotions are mobilized and typical words of comfort can't be easily accessed. Ideally, educators should encourage residents to slow down and pause a moment until those emotions have settled and translation from the mother tongue can occur.
Thanks to Dr. Mimi Singh for suggesting the use of the term “mother tongue” in her review of this essay.
The names in this essay have been changed to protect the identities of the residents and patient.