Perspective from a Non-Medical PINCC Volunteer, 2009

Perspective from a Non-Medical PINCC Volunteer, 2009

(excerpts from a summary report)

By Talia Kostick (age 22)

As a member of the support staff, I was responsible for helping to set up and restock the exams rooms, keep the medical supplies organized, unpack and repack the medical supplies at the beginning and end of each day, and make sure that the medical staff had everything that they needed. Additionally, due to my fluency in Spanish, I had a number of language related responsibilities. These responsibilities included registering patients and helping them complete patient questionnaires, translating for non-Spanish speaking medical staff during examinations and procedures, translating during physician and nurse trainings, and conducting group discussions and educational lectures for patients waiting to be examined.

Registration and Questionnaire Completion

PINCC requires each patient to complete a registration form and questionnaire before she can be examined. The questionnaire solicits information concerning the patient's sexual and reproductive health, exposure to domestic abuse and sexual violence, general physical health, and family health history. The questionnaire helps the PINCC staff to identify a patient's exposure to various HPV and cervical cancer risk factors and to determine what type of examination is necessary.

Many of the Salvadorian women who came for PINCC exams were unable to read or write. The literate patients found the medical vocabulary and content of the questionnaire extremely difficult to discern. On the first clinic morning, Maggie Shushan (the only Spanish speaking support staff other than myself) and I were overwhelmed by the dozens of women asking for help with or clarification on the questionnaire. We decided that it would be most effective for us to hand out numbers, instead of the questionnaires, to the women and interview the patients one at a time in the order in which they arrived at the clinic. Each morning, before the physicians started seeing patients, Maggie and I took a few minutes with each waiting patient, individually reviewing the questionnaire and writing in the patient's responses. Once Maggie or I finished a questionnaire, we passed it off to a non-Spanish speaking support staff who registered the patient in a computer spreadsheet and placed her forms in a pile to be reviewed by a PINCC medical staff person.

Patient waiting areas were limited and we often had dozens of women seated and standing in extremely close proximity to one another and to the exam rooms. There was often no room to spare and I conducted many questionnaire interviews squatting in front of a patient who was squeezed onto a bench, surrounded by her family and neighbors.

The interview process was difficult not only due to its public and slightly chaotic setting. Many of the women came from extremely rural areas within El Salvador. Some women even walked across the border from Honduras to receive a gynecologic exam from PINCC. With Spanish being my second language, I found the accents and vocabulary of the rural women to be challenging to understand. Even Maggie, to whom Spanish is a first language, shared that she had a difficult time understanding some of the patients. Furthermore, a lot of the medical vocabulary that I was using was relatively new to me. I had some previous exposure to medical vocabulary in Spanish, but not specifically gynecologic terms. I was forced to learn a lot of new vocabulary very quickly and I kept a long list of translated terms by my side at all times.

Carol Cruickshank, the third PINCC staff who spoke Spanish, was generally occupied translating for Dr. Taylor and overseeing the logistics of the medical mission. This left only Maggie and myself to greet and direct the dozens of patients who arrived for examinations. A large number of the patients had to be interviewed and registered before the medical staff could begin the examination process. Maggie and I felt a tremendous amount of pressure to quickly organize and interview the arriving patients. Due to this pressure and the over-stimulating clinic environment, conducting patient interviews was by far the most stressful part of my day. I was often interrupted by women who wanted to know when they would be seen or if they could cut in line for one reason or another. I found myself answering the same questions over and over again and negotiating difficult subject matter in a secondary language.

However, as stressful and chaotic as the mornings and interviews could be, I found this part of the day to be the most rewarding. I provided the initial contact that the patients had with PINCC and offered them valuable and reassuring information about what they could expect during their exams. I found it extremely satisfying that the personal interactions I had with the patients enabled the medical staff to more effectively conduct their examinations. Additionally, no matter how long the patients waited or how overwhelmed I seemed by their many questions, the women were consistently gracious and appreciative.

Exam Room Translation

I spent the majority of the PINCC mission serving as a translator during patient examinations. I worked with a PINCC medical staff person as she trained and supervised a Salvadorian nurse or doctor in the visualization technique. Either myself or the nurse in-training called a patient into the exam room and asked her to remove her clothing from the waist down and to get situated on the exam table. While the medical staff reviewed the patient's forms, I chatted with the patient and explained in detail how the exam would proceed.

The patients often disclosed more specific information or details about their health once they were in the exam room and in the presence of a physician. I was responsible for translating anything that the patient said that pertained to her health or the exam. The patients frequently talked about non-medical topics, such as their bus ride to the clinic or how someone cut ahead of her in line. It was important to filter out impertinent information, as the translation process can be time consuming and we wanted to limit the amount of time that the patients spent exposed and half-dressed on the exam table.

During the examinations, I facilitated any questions or explanations the PINCC staff had for the patient. I also facilitated discussions between PINCC staff and the Salvadorian staff-in-training. The Salvadorian staff completed the exam and then stated if the visualization of the cervix was adequate or not and if the cervix was positive for lesions. I relayed this information and any other observations the Salvadorian staff had made during his/her exam to the PINCC staff. The PINCC staff would then take a look at the patient's cervix and either concur or disagree with the Salvadorian staff's diagnosis. If there was a discrepancy between the two diagnoses, I facilitated the discussion as the PINCC staff explained why the Salvadorian staff was incorrect in his/her observations or diagnosis. All exam room communications were extremely time consuming: every question and explanation had to be repeated by me in the other language from which it was asked or made.

Visualization Technique Translation

I often translated as one of the PINCC medical staff conducted an initial training in, or review of, the visualization technique for a group of Salvadorian nurses or doctors. These trainings involved a great deal of medical terminology relating to the cervix and precancerous lesions. A PINCC medical staff, the nurses/doctors in training, and I would sit around a table and review the visualization technique using various diagrams and charts. We then used a set of training cards with photographs of different cervices to quiz those in training. The back of the cards revealed whether the visualization of the cervix displayed on the card was adequate or inadequate and if the cervix was positive for precancerous lesions.

Patient Education

After the majority of the patients were registered, and if I was not translating in an exam room, I would conduct a short informational lecture for the waiting patients. At the time of registration, each patient received an HPV/cervical cancer information sheet (in Spanish) from the PINCC staff. The sheet reviewed the cause of cervical cancer (HPV infection), how HPV is transmitted, the clinical progression of cervical cancer, what to expect during the physical examination, the various treatment methods, and ways to prevent further transmission of HPV. As many of the patients could not read, I gathered small groups of women together and read the information sheet out loud. This insured that all of the women could access the important information conveyed on the sheet and provided a forum for the patients to ask any questions that they might have before they went in for their examination.

The patients were generally very enthusiastic about receiving a copy of the information sheet and reviewing it with me as I read out loud. However, the women were much more timid about asking questions. I periodically paused while reviewing the information to make sure that everyone was following along and understanding what I had explained. The women rarely interjected to say that they didn't understand or to ask questions. I encouraged questions and often repeated the information on the sheet in a variety of ways and with less medical vocabulary to increase their understanding.

For women who are not confident in the fidelity of their sexual partners, condom usage is highly recommended to prevent HPV transmission. It is also necessary for any woman who has received treatment for a precancerous lesion to use condoms during intercourse for a month following the procedure to ensure that the cervix heals properly and fully. The PINCC team brought hundreds of condoms on the mission and distributed them to the patients who received treatments. Because condom usage is stigmatized in Salvadorian society (over 60% of the population is Catholic), the majority of the patients were reluctant to talk about condom usage and even fewer were willing to take the condoms home. While talking with the nurses at the Alcaldia Clinic, it became evident that few of them had experience using condoms and that none of them felt comfortable demonstrating to a patient the proper technique in condom usage and disposal.

In the back of the Alcaldia Clinic, cloistered away from the patients, I used a Coca-Cola bottle to conduct a condom demonstration for a group of seven to ten nurses. After the demonstration, I encouraged each nurse to take a turn and practice putting a condom on the bottle. A couple of nurses admitted that this was the first time they had ever touched a condom. The age of the nurses participating in the condom demonstration ranged from early twenties to mid-fifties. Although they laughed a good amount throughout the demonstration, which I attributed to their unfamiliarity with condoms and timidity towards the general sexual subject matter, the nurses were extremely enthusiastic about learning the correct technique in condom usage.

The patients, however, were entirely unwilling to participate in or even watch a demonstration. A few of the waiting patients accepted a condom or two when I offered, yet none were willing sit and watch me conduct an educational demonstration. I believe that this seeming disinterest maybe have been due to a discomfort with my age. By happenstance, the women waiting to be seen when I came to conduct the demonstrations were all over forty. I speculated that they felt uncomfortable having someone half their age advise them on their sexual practices.

Conclusion

Give a man a fish and he will eat for a day. Teach him to fish and he will eat for a lifetime. ~ Confucian Proverb

I believe that PINCC's work is a modern expression of this age-old proverb. The mission of the organization is based on providing medical education and skill facilitation, instead of direct medical care, which empowers physicians to maintain the health of their own communities without reliance on foreign medical aid. It is this aspect of PINCC that I find to be extraordinary. PINCC's goal is that someday the organization will be superfluous.

PINCC not only combats the spread of cervical cancer, the organization works to narrow the divide between the 'First' and 'Third' worlds and the discrepancy in healthcare between the two. In the 21st century, when thousands die of preventable ailments each day, it is inexcusable to simply combat the cause of these deaths without addressing the various infrastructures that permit these causes to fester in the first place. PINCC demonstrates that the cause of cervical cancer is much more than a virus by confronting poverty, sexual and physical abuse, human trafficking, sexism, inadequate access to education, and other factors that can increase a woman's exposure to HPV. This aspect of PINCC is just as, if not more important than, the gynecological services it provides.

I am extremely proud to support PINCC and to have participated in this spring's Central America mission. I feel that my contribution to the PINCC team was crucial in the success of the mission, which gratifies me deeply. The translators on the mission not only facilitated the training of the Salvadorian doctors and nurses: we provided a human connection between doctor and patient. In situations that proved to be trying for many of the patients, the presence of someone who could speak Spanish and offer reassurance made the uncomfortable process of cervical cancer screening and treatment all the more humane. Providing this throughout my two week with PINCC was immensely rewarding and inspiring.