The ability to communicate is a miracle that allows connection with others. Communication comes in many forms. I learned this again over the last few weeks from a patient and from a sea turtle. I realize this sounds strange. Let me explain.
I met Mr. DJ last week. He came to see me for his newly diagnosed locally-advanced pancreatic cancer. He brought his wife and his nephew to his first appointment.
Mr. DJ presented to medical attention in June of 2022 with a two-month history of abdominal and back pain. He had lost approximately ten pounds. An abdominal ultrasound showed a pancreatic mass concerning for cancer. A CT of the chest, abdomen, and pelvis confirmed the presence of a mass and that there was no cancer spread outside of the pancreas yet. A biopsy of the mass proved poorly differentiated pancreatic ductal adenocarcinoma, the most common form of pancreas cancer. He saw a hepatobiliary surgeon who told him his cancer was unresectable because it involved blood vessels and nerves at the back of his body. The only chance he had at cure was if chemotherapy could convert his cancer from its current “unresectable” state to a resectable situation.
Mr. DJ is an otherwise well man. He is sixty-one. He is physically fit. He continues to work in the construction field. He has no other medical illnesses. He is on no medication. His physical exam was normal.
When it came time for us to talk about the nitty gritty details of what chemotherapy can and can’t do, I asked Mr. DJ what his understanding was of his situation. He told me he was aware he was sent to me to talk about chemotherapy to try to shrink his cancer so that his surgeon could cut it out. He was aware a surgery was the only potential curative path. He was not, however, aware of the unfortunate odds he faced.
In my attempt to be transparent with Mr. DJ and his wife, I told him down-sizing pancreas cancer to the point that it becomes cutout-able is a near impossibility. In all the years I have been treating pancreas cancer, only two of my patients have ever had a reduction in the size of their tumour to allow for a potentially curative surgery. One of these patients is still alive and cancer-free five years after his surgery. The other patient died; her cancer grew in her liver almost immediately after her potentially curative surgery. Despite the odds, we still try in appropriate cases. Every patient wants to believe they might be the lucky one; every doctor wants that luck for their patient.
We then talked about two chemotherapy regimen options, one more aggressive than the other. “More aggressive” in the pancreas cancer world usually means a higher percentage of tumour shrinkage but at the likely cost of more side-effects. We discussed how the drugs were given and how often he would have to be at the cancer centre. We discussed possible toxicities. We talked about average length of life with chemotherapy and without.
There was a lot for me to explain and a lot for Mr. DJ to take in, digest, and ultimately decide upon. We talked about so many different aspects of his care – chemotherapy, side effects, cure versus no cure, length of life, and goals of care. This was a very difficult, complicated discussion to have. There were a lot of “what if’s” and “if not, then what’s”. Even in a best-case scenario situation, it is hard to deliver and receive all the pertinent information.
Mr. DJ told me he understood what I was telling him. In his case, with our goal of making his cancer smaller, the more aggressive option is the best choice. This is what Mr. DJ wished to do. His treatment will start in a few weeks. He wants to be my third patient to get to a potentially curative surgery.
Now, what I have not yet said is that Mr. DJ and his wife speak and understand Korean. They do not speak or understand English. I speak and understand English and un petit peu français. I do not speak or understand Korean. Yet, the information exchange I just described had to occur to ensure adequate understanding of treatment risks and benefits so that Mr. DJ could make a proper informed decision.
When I started my career as a medical oncologist, in-real-life/face-to-face translators existed. We would book the translator ahead of time for a particular language. That translator would be physically present at the appointment with the patient. I thought it was effective. Several years ago, that service morphed into a call-in translating service. Currently, whenever there is a need for translation, we call a phone number, state the language we need translation for and get hooked up with a human translator in that language. The voice of the translator comes booming into the room over a small speaker connected via Bluetooth to the phone to amplify the sound. In my opinion, it is still wonderful that we have a human on the other end of the phone providing this service, but it is quite awkward to talk about life and death issues into a black box which usually sits somewhere between my patient and me.
Every now and then we have a family member or family friend who can do the translating. If the translation is good and trustworthy, this situation is ideal. The tricky part is knowing if the translating is reliable. Fully knowing this is impossible because if we could understand the language we are getting help with enough to know what the translator is saying, we would not need the translator to begin with. Concerns about transparent translation can be especially difficult in cultures where it is not common to tell those who are sick, particularly elders, their medical diagnoses. Informed consent and safety then become a concern for the responsible physician.
In Mr. DJ’s case, his nephew, who was thankfully fluent in both Korean and English, interpreted our entire conversation for us. I had evidence that he was doing a great job by the questions that were coming back at me from Mr. DJ and his wife. We were lucky. I really got the sense Mr. DJ and I were having a conversation instead of us each having a separate conversation with the faceless person on the end of a phone line.
If I am being honest, it is often more difficult for me to have a patient who does not speak my language. The visits are more challenging in these cases for sure. It takes longer to do everything with patients when translation is required. Extra time is needed for checking in to the building, being assessed by the nurse, seeing me, leaving with appropriate appointment dates and times. Every single thing takes more time and time is something we are rarely flush with in healthcare. In the case of my job specifically, if I am doing it properly and ensuring my patient understands the information that I present to them, most interactions almost double in length when interpretation is required. This adds stress to our clinic.
Additionally, with translation, it is often hard to know if my patient hears and understands the information as it was intended. I worry that maybe there isn’t a word in my language that translates well in their language, or vice versa. I worry a patient doesn’t grasp the importance of reporting side-effects. I worry the prognosis and the length of time they might have left to live gets lost in the translation of the words I have used, or maybe these words are not said appropriately by the person translating. Further, there are cultural nuisances which, in my opinion, most doctors are not properly trained in. It is so hard.
Plus, that is just my side of things. I cannot imagine the difficulties my non-English speaking patients experience while trying to navigate the health care system. I imagine there is fear and anxiety. There is surely struggle in trying to explain their medical concerns, in expressing themselves so that healthcare personnel can understand. How many times are they not allowed to participate in their care because translation is not handy? How many decisions are made without their input? I wonder how often a non-English speaking patient feels heard and understood.
Before I left the room that morning, I pulled out my phone and swiped over to my “Google Translate” app. I got this app while on summer vacation, mostly to be able to decipher that “Locro de papa” means warm heavenly deliciousness that fills your belly up with happiness (also known as potato soup with cheese, avocado, and roasted corn that surprisingly adds a would-have-never-known-missing-texture and a little pop of excitement to the dish!). In the app, I typed in, “It was a pleasure to meet you and your wife. We will do the best we can for you.” I pressed the “go” button. Like magic, Korean characters and words populated the space below my English words. I then passed Mr. DJ my phone. He took it, showed his wife, and smiled while shaking his head, saying “thank you” several times. We had an understanding. Even without knowing the same language, we had a connection.
I said “you’re welcome” but as I walked out of the room, I couldn’t help but think I should be thanking him – for a lesson in patience and for strengthening my ongoing faith that healthy connection between humans doesn’t have to have language barriers. Respect, kindness, compassion, patience, and caring are equally, or more, important than the language we speak.
I hope Mr. DJ ends up being my third pancreas cancer patient to get to a potentially curative surgery. We will know more in the coming months. For now, we will do the best we can, both for his cancer, and in how we communicate with each other.
Author Notes:
A few weeks ago, I experienced some precious moments with a sea turtle while snorkeling. I was part of a small tour group in a magical place. There were other people around but for a short while it felt like it was just me and a turtle sharing our own little ocean. This turtle and I ended up swimming side-by-side with no one and nothing else in my visual field for a handful of minutes.
The turtle was massive with a greenish-brown shell speckled with a vibrant yellow that looked as if it glowed when the sunlight hit it just right. I observed this magnificent animal flap its flippers in the ocean more gracefully than bird wings in flight. I have no idea if it knew I was there, beside it, swimming and watching in awe. It was so beautiful.
For a few seconds, the turtle and I somehow found ourselves facing one another. I could tell the turtle was going to go up for air and so I mirrored it and poked my head out of the water at the same time. I looked into the dark black eyes of this turtle. The turtle changed the angle its head ever so slightly as if questioning me. I remember hearing nothing but my heart beating louder and harder in those seconds, more blood pumping per beat than usual.
I know I felt a connection in those moments with this giant turtle and with nature. I had an unusual sensation that the universe can connect all living creatures somehow. Afterward, I felt a deep sense of gratitude for the experience of being in that space, with that turtle, in those moments. I will never forget this experience.
The turtle and I didn’t talk to each other. We didn’t make any audible sounds to my ear. But I felt a connection. For a few brief moments in the summer of 2022, I spoke Turtle. At least that is what I choose to believe.
Communicating with Mr. DJ and this turtle over the last few weeks reminded me of the importance connection has in my life. Knowing I have really reached someone or having someone, or something (even a turtle), truly reach me in a more than superficial water cooler conversation type of way is so soul quenching.
I am curious to know, reader, about a time when you experienced a connection with another living being that moved you?
