Communication (from Latin “communis“, meaning to share) is the exchange of thoughts, messages, or information, as by speech, visuals, signals, writing, or behaviour.
For two people to fully understand a conversation that has taken place, as well as words and actions, there needs to be a rough awareness of the cultural and social context of the other person.
One of the big challenges in doctor-patient communication is that doctors tend to ask about objective symptoms, trying to sort and sift problems in order to formulate diagnoses. Patients, on the other hand, want to tell you about their illness and its effect on their life. Communication breaks down if the doctor doesn’t understand the patient’s world, and the patient doesn’t understand the doctor’s question.
Here in Zambia, I am trying to learn the the local language (Chichewa) and using translators in the meantime… However, translated words can only get you so far if you don’t know your patient and their everyday life.
As well as spending my time reading up about the million causes of splenomegaly, learning how to draw up chemotherapy drugs (because the nurses aren’t allowed to administer them), and trying to memorise the 3 letter acronyms for the many HIV medicines (TDF, FTC, 3TC, NVP, ABC, AZT…), I also have to spend a lot of time in these early weeks trying to learn the local psyche.
I have found that greetings are very important in Zambia and should be the first part of any conversation. Therefore, for every patient on a ward round of 50 patients, whether they are septic, in pain, or even dying, you start something like this:
Me: ‘Muli bwanji?’ [How are you?]
Patient (or relative if the patient is too sick to talk): ‘Ndili bwino, bwanji?’ [I’m fine, and you?]
Me: ‘Bwino, zikomo…’ [I’m fine, thank you…] before proceeding with the real questioning.
Simple questions thrown into a history such as ‘how far have you travelled to get here today’, ‘how did you travel here today?’ and ‘what work do you do?’ can be really helpful in painting a picture. It can be quite humbling to hear that a Farmers wife from a village far away has travelled on the back of a truck for 5 hours, and slept under a tree on the hospital grounds in order to see you.
A big frustration for me is not being able to know the exact words a patient has said. This problem can occur at home too, but most translators in the UK are trained specifically in medical translation and try to repeat words verbatim. Here, that is not the case. I saw a patient who had taken cotton insecticide (organophosphate) deliberately with suicidal intent. Several doses of Atropine and several days later, when the patient had regained consciousness, I tried to do a psychiatric assessment of ongoing suicide risk. I asked the translator if the patient could tell me about their mood. The patient spoke for a good 30 seconds. The translator thought about what had been said and reported only this: ‘her mood is a bit fine’.
Even when you do know the meaning of a word, there can be an element of lost in translation. The most popular answer to questions such as how are you feeling, do you have any pain or are you feeling better is a word that translates roughly to ‘at least’. I struggle to know what this really means… At least I am still alive? At least my pain isn’t as bad as yesterday? At least I am a bit better? At least I still have my marbles? At least I don’t look like that guy?
For me, by far the most confusing interaction that has taken place was when I told a woman (via a translator) that she had Hepatitis B with severe cirrhosis of the liver. This is a bad thing to find out, and doctors receive specific training on how to break bad news such as this. I sat on the end of the bed and using a soft voice explained things slowly and carefully. She had a beaming smile throughout the conversation and when we finished she took my hand and shook it vigorously saying ‘zikomo, zikomo dokotolo’ [thank you, thank you doctor]… baffled and exhausted, all that I could think of to say was ‘yewo’ [you are welcome].
My Chichewa should improve over the course of the year, but I think that gaining more insight into the lives and psyche of the local people will be the most valuable thing I can do to improve communication with my new patients.