Greetings from the desert!!! I had a great walk around the neighborhood this morning. A gentle breeze shifted the warm around, giving a cooling effect. The sun was rising beyond the rocky peak. A few other men were out leisurely strolling to unknown destinations. An occasional bird announced its presence. Cars rumbled along the border roads occasionally, but for the most part I enjoyed the quiet. I returned home to my morning duo of iced water and hot coffee. My ‘lounge chair’ awaited my presence for a time to read and to think. Every day it is my custom to set aside some time where the busyness of the day’s events cannot enter. This time allows my remaining day to flow much better. When I face a particularly challenging day, rather than omit this time and start work earlier I often arise earlier and add time on this end. This habit is one method I alluded to earlier as “Filling my tank.” For you it may be another method or practice. For many, I am sure, my early morning routines are crazy; for you, early morning is meant for sleeping.

Seeing patients in the clinic this week, I was struck by how many differences there were represented. Sure, there were the common age, height, and weight differences, but I was most struck at the fact of the number of translators I had to call in to assist me. I had patients arrive who spoke different styles of English (I did my own translation for these!), Urdu, Pashtu, Arabic, Pakistani dialects, Afghani dialects, languages from regions of India, Sri Lanka, Philippines, Sudan, and others. Sometimes the translator would need to search out a language both they and the patient knew. Language differences make work difficult at times.

One of my biggest concerns is connecting with and understanding my patient’s needs. When I speak to someone, I try to look them in the eye; I was raised that way. So enter a patient. I look at them and ask what brings them into the office. They look to the translator who makes my words understandable. The patient usually shakes a head and starts talking and turns to the translator. Round and round we go. I find myself facing the translator instead of the patient more often than not. Sometimes the patient will go on and on talking, and I need to break in and stop wandering. Other times the translator will listen for several minutes yet give me a sentence summary. Really? Do I really have all I need? Examination is limited culturally as well. Clothing is a protection that must be dealt with as I check what is wrong. As an orthopedist, I can often get to understand the problem through motions that challenge joints. Swollen joints are usually fairly obvious. Watching a person walk often gives major clues as to the problem the patient has. X-rays, CT scans, and MRI pictures probe and penetrate to look within.

But tests only assist with caring for the patient. For example, I can tell you if the patient has advanced arthritis of his knee, but I need to know more. Many men present with advanced arthritis of their knees and pain. Advanced arthritis, generally good health otherwise, significant pain, and disability can lead to total joint replacement and restoration of function. I am an example. Simple choice? Nope. Advanced arthritis, generally good health, pain, disability, and total joint in this case means loss of job, visa, and return to their home country. Their family, living in their home country and surviving on this man’s income, now face economic hardship. Understanding this fact, I must see what else I can do to improve their function; the choices are limited.

Language barriers must be bridged if I am to help. Even when I understand their words, I sometimes miss the real purpose of the visit. I saw a woman with back pain and went through a history, exam, and looked at her x-rays she had. I went through the findings and proposed a plan. She started to quietly sob. Being a sharp clinician, I suspected I missed something. Duh, you think?

So we started again. Eventually, I found a close friend had breast cancer that spread to the spine. This woman was sure her pain was breast cancer in her bones. I only told her the bones looked healthy; I did not say, “I see no evidence of breast cancer.” Once we got past this, her back pain became minimal and she did not think she needed the plan I proposed; we treated her problem through reassurance and a referral to women’s clinic for a mammogram. My plan would have failed her need.

Communication is a vital part of our society. How often do I not really hear what someone is saying to me? If you are married, you know this happens way too often with your spouse. When you are asked a question, are you really expected to answer with a solution or not? Is there really an answer to the question, “Do you think I am too fat?” What exactly does a politician mean when he is the candidate who is “for the people”? Do all other politicians hate people yet enter a service job? When the company president names you a valuable employee, what is he communicating to you? What if his words and your perception of his action are in contrast; do the words mean the same thing?

Communication is just not words. Communication relies heavily on nonverbal attributes. That is one reason I find Skype much more valuable than email. If I write, “Yes, right,” you make take it as supportive. If you see me arms crossed, a frown or a smirk on my face, and I say the same words, the communication is totally different. I may have decided to disagree is too costly as far as risks exist. I may disagree because I decided history shows it does not matter. Communication carries along with it the importance of trust. Can you trust what you hear? Do this person’s actions align with their words? That is, do they “walk the talk”?

Integrity is an important component of trust. I must trust my translator will work with integrity to communicate my words with my patient. I must trust that if the translator or patient does not understand me, they will ask and not be hesitant to do so. The patient must trust I have their best interests in front. They must trust that if I do not know, I must admit so rather than create a fictional story. For example, say I explain,”My right hip went bad because I was a jogger for years.” Really? Only my right hip? Not my left hip or knees? Maybe a sometimes humbling “I don’t know why this happened, but it has” is best. Why? That is a difficult question to answer. A whole legal system has grown over this question of why and who is responsible.

My clinic situation experiences lead my mind into many regions and questions this week. Communication is one aspect of my morning thoughts. I think next week I will look at another. We all rely on communication in our lives. To have meaningful communication, we must have trust and understanding. To have trust, we must walk and talk with integrity. To understand, we must listen more than we speak. Good communication is necessary for life in His grip.