Telling strangers not to shave: not everyone speaks English

Going on elective wasn't all fun for Layla McCay. She didn't have a clue what was going on, though she wouldn't have been able to tell her Japanese hosts that. Contrary to the sometimes lazy outlook native English speakers have, maybe you ought to learn the language before going.

Well, there is still something that everyone can understand. Fries to go with that?

When choosing where to do your elective, there are many things to consider: should you go to a local hospital or abroad? How about a third world country? Which specialty? Should you go alone? I recommend adding a further consideration to your list: should you go to an English speaking country? As someone who did not, I feel qualified to describe some of the pitfalls, as well as the potential benefits.

My decision was largely due to having recently read Memoirs of a Geisha, as well as my interest in nephrology. With the opportunity to spend a month anywhere in the world, I decided upon Japan. I secured a place at Osaka University Hospital, and found three “homestay” families to live with.

I thought I had better learn some Japanese. I bought a Teach Yourself guide and progressed slowly. I wasn't too worried, however; having visited several other non-English speaking countries, and having a somewhat inaccurate view of Japan, I naively assumed that I would be able to get by without knowing much Japanese. And besides, the doctors assured me that language would not be a problem.

I had only to set foot in Osaka Airport to realise language was going to be a problem. I was all alone in a country where everyone spoke a language I could not begin to understand, and all writing was in kanji characters: I was unable to communicate and unable to do the most simple things without help.

Reading does not seem so important until you suddenly can't. You realise there are no legible signs in the hospitals, no patient notes, no numbers on the lifts, no names of train stations, no toolbars on the computer screen, no menus in restaurants, no signs on toilet doors, and no instructions for anything: remote controls, mobile phones, showers, etc. It is a daunting prospect.

More daunting is the lack of verbal communication. English is an obligatory part of the Japanese school curriculum but the focus is on writing, not speaking. The minimal Japanese I learnt was useless. My vocabulary for the entire month consisted of: good morning, goodbye, please, thank you, excuse me, and kidney.

“Excuse me,” or “sumimasen”, got me into trouble. When I made a mistake or bumped into someone, I would forget and automatically say “sorry”. Then I would remember and tack on the “masen” ending, hoping nobody had noticed. On my last day in Osaka I was informed that instead of excusing myself, I had been telling everyone “don't shave.”

The families with whom I stayed spoke little English. We spent the evenings eating unidentifiable Japanese food and watching Japanese television in awkward silence, occasionally getting the dictionary out to communicate something essential to each other, such as a somewhat belated “I am allergic to peanuts.”

Sightseeing was difficult because of the lack of English descriptions. The families were wonderful, taking me to see the sights of Osaka, Kyoto, and Nara, but often I was obliged to simply gaze at buildings and imagine why they might be important. It surprised me that even in the most touristy of locations, a person who spoke English could rarely be found.

It was better in the hospitals. Although I could only find my way about the unmarked labyrinth-like corridors using my precious hand drawn map, some of the doctors could speak English, and a few were not too shy to do so. I was based in the nephrology department and stood quietly in a corner while medicine went on around me. It was surreal. I attended outpatient clinics conducted entirely in Japanese. I went on ward rounds, where a doctor would sometimes stand with me to translate. One day all of the junior house officers were required to present their patients in English for my benefit. I felt terrible at the stress I was causing as they struggled with the language in front of their professors.

Nephrology is a particularly bad choice of specialty for people who cannot communicate because there are so few visual signs. I was unable to examine patients myself, as I could not communicate with them, and there were so many doctors available that my assistance was never required. My presence was a novelty, which began to wear thin after the first couple of weeks.

I learnt to talk slowly and clearly, however, and to use only the most simple words. I learnt the value of body language in a way any number of vocational studies sessions could never teach me. I learnt to cope with the temporary disabilities of being unable to talk, listen, or read. I learnt to use the public transport system, I got myself to the hospital every day, and home again at night. I managed to use shops and restaurants by myself. I learnt to guess patients' diagnoses by their signs, body language, and tone of voice and to communicate by these methods myself.

At the end of my time in Japan, I went alone to Tokyo and managed to sightsee; travel by trains, buses, and subways; stay in a Japanese guesthouse, and get the correct bus back to Osaka Airport (this one was a close call). I even learnt which were the female toilets.

I recommend choosing an elective in a country where people can understand you. It is surprising how much communication is superfluous and it is interesting to pare it back to the bare essentials. A language barrier does not make for the most productive of electives, however, especially when your assistance is not required. Think about what you want to get out of your elective. If you are going to a non-English speaking country, consider how much you will be able to participate and learn from your chosen specialty. Maybe something more visual than nephrology would have been more useful for me.

Remember you will have to get along by yourself outside of the hospital, and consider the sanity of going alone. In retrospect going to Japan was a fantastic experience. But at the time it was daunting, exhausting, stressful, and slightly mad. It was difficult to learn much medicine with such minimal communication, but I did learn a great deal about Japanese people and culture in a way I could never have done as a tourist.

My elective was not very useful for learning clinical skills. In terms of communication, living in a foreign culture, and general survival skills, it was invaluable. An elective is not just about learning medicine. Cliché though it is, I think mine will actually make me a better doctor.

1. Memoirs of a Geisha, Golden A. London: Vintage, 1998