Direct Approach

The manner in which a physician speaks to patients affects how they will respond and how open they will be to disclosing the truth about their situation. An abrasive and pushy manner can lead a patient to close up and not share important information regarding his/her symptoms whereas a nonjudgmental and empathetic manner can make a patient open up and reveal details to help in diagnosis. The doctor-patient relationship is an integral part of patient care and not only helps the physician in treating the patient but also can help the patient in adhering to the treatment plan.

Introduction and Question
While watching the videos, several issues come to mind. It becomes apparent that the patient’s boyfriend had suggested that she get checked out, but they never go into detail why he suggested she get check out.
 * Is he experiencing symptoms he’s not telling her? Did he himself test positive for an STD?  Did a previous or current other partner let him know that she/he tested positive?

These are only some of the questions that come to my mind when Tammy answers Dr. Creed’s questions but I wonder where the line is drawn for many practitioners for how deep they will delve into their patient’s personal endeavors.
 * Is there a greater benefit in patient care when forcing patients to think about how their partners may have contracted the disease and passed it onto them?
 * Also, Tammy states she doesn’t think her partner will get checked out but little education was placed on the potential for him to keep passing on this STD. With the concern for antibiotic resistance and potential allergic reactions, are there any instances when you would provide Tammy with a prescription for her partner, so that he could be treated as well?

Discussion
One thing that has been really eye-opening during this rotation (as well as my M1 family practice preceptor) is the fast pace. We are constantly overbooked and are running behind schedule. In this setting, I just don't think that it is realistic to spend the necessary time on patient education. For example, today we had a similar case and one of the family med guys said, "I try not to be a social worker... I just don't have the time".

The physician's role to dig deep and treat. When it comes to STDS, it's community health issue. I believe physicians should ask why would the partner ask the patient to get checked. All of Marie's questions are valid to raise so that the patient can thinking about those as well. Trust and communication are important part of every relationship. As physicians, we must educate how you can get the disease/illness. The way I found that is effective (not to mention faster) is to ask the patient how much he/she understand about the disease/symptoms of concern. Usually, we would quickly realize that pt. is well informed and all we have to do is reinforce, or pt. believes in myths and we must educate and address those myths. Either way, we are empowering them as well as finding out what myths they are believing.

I think it's good practice to give prescription for the partner because there's risk of reinfection for YOUR patient. But then, what if the partner is allergic to the meds?

Physician’s time. It's amazing how a physician can see 30 patients between 8 and 4:30 which included initial checkups. I'm sorry to hear that comment about being a social worker.

What I found out, especially last year, is that when the physician has long-term relationship, he/she does not need to spend time to address all the chronic problems or discuss preventive measures every time the pt. is seen. I used to get so irritated when I observed a follow up visit does not include physical exam. But, this does not mean that physicians cannot talk about the concerns or behaviors that may affect pt's health. It's our duty to address it.

I do agree that when we have more pts than physicians available, physicians must effectively use their time. What I found at one of the practices was having educators in the office. So, when there was concern from the physician, the pts were directed at the educators. That team approach seemed to work well. I have seen others making appointments for the education only, or education group. I was told that most of the preventive education pieces are not reimbursable; maybe that has something to do with physicians not willing to take time?

Sometimes with younger women I may take a more directive approach, especially if it appears that the boyfriend gave the patient a sexually transmitted infection.

I may say something like, "It is important to make sure that you do not get an infection like this again because it [Gonorrhea or Chlamydia] can cause damage to the Fallopian tubes. This can result in pregnancies in a tube or difficulty getting pregnant.  That is why the Centers for Disease Control recommends limiting the number of lifetime sexual partners and always using condoms if you are sexually active.  Only you can protect yourself.  Is your boyfriend willing to use a condom?  If not, he is not considering what is best for you.  In that case you would have to decide whether he cares enough about you to let him have sex with you.  In some cases, women decide that they need to get a different boyfriend."

Of course, I would pause for responses from the patient, and try to answer any questions along the way, rather than doing the whole thing as a monologue.

Have you seen or used a more directive approach with patients who appeared to be in a dangerous situation? How did it go?

I've only seen a few sexually related complaints in preceptorships, but I've had good luck with making clear a desire to fix the problem straight from the outset. That often makes it a bit easier to gather the needed information as you go along... odds are that they want the problem fixed, too.

Teenagers get plenty of the statistics and platitudes in health class and are often disinterested or put off by hearing more of them. Personally, I have found it better to demonstrate genuine concern about them, and about the direct tangible consequences of risky behavior. That tends to hit a bit closer to home.

A 30 yo patient I just saw in the clinic with severe pelvic pain made me think a little bit about the thought process of a sexually active female.

Upon questioning, the patient stated that she had been with her current boyfriend for 5 months now. Of course for the first couple months they used condoms, but no form of protection after that. And since she had no symptoms initially, her symptoms certainly have no connection to this boyfriend. She had never had STD screening herself. I found her reasoning pretty faulty.

Yes, there is often faulty reasoning that goes into patient's decisions about sex, use of protection, and sexually transmitted infections. It is good to let patients know that they need to take all of their medication, to wait until both the patient and their partner have finished their medication before having sex. (I tell them to wait a week after single-dose treatments like ceftriaxone and azithromycin.) I tell them that if they choose not to wait they are taking a chance of getting reinfected, and they should definitely use a condom. I am surprised at how some patients do not finish their course of treatment for various reasons, but do not come back to get a complete course of treatment until weeks or months later.

I think that there is a lot of denial surrounding sexual issues. Some patients feel that they could not have given/received a sexually transmitted disease (STD) to/from their partner. Some contacts to STD's who are coming in for treatment want to be tested too, which is OK. But I tell them that regardless of the results of the test they need to be treated as contacts, because sometimes the tests will not be able to detect the disease yet. Otherwise some patients who get a negative test result will assume that their partner got the STD from someone else, and so will stop their treatment.

I was reminded today of how patients sometimes "fall into" sexual encounters, that perhaps they did not intend to experience. My first patient today was a man who started off very haltingly, explaining that he was embarrassed by what had happened. He was studying with a female friend, and the study date had led to sex. He had used a condom, but the condom had broken. A few days later, he was experiencing dysuria. On exam, he had a thin, clear penile discharge. I diagnosed him with urethritis, likely Chlamydia, and treated him with a 7-day course of Doxycycline, with tests pending on the discharge for Chlamydia and Gonorrhea. He was given a handout on Chlamydia and a contact card to give to his partner. I gave him some verbal educational information, similar to that we have discussed above. He also accepted some condoms from a container we have in our exam rooms. I was reminded how easy it is for our patients to contract a sexually transmitted infection (STI), and hoped that this patient would not return later with another STI, especially one that was not so straight forward in its treatment and eradication as Chlamydia.

Directive approach with patients who appeared to be in a dangerous situation. I have seen and certainly used directive approach as described in many of the situations from STDs to uncontrolled DM,HTN, etc. However, I always feel like walking on the thin line. From experiences, I know that as soon as the pt is turned off by my comments, what is said after is no longer effective. As in the last video, I usually try to educate gently without making it sounds like a lecture. I personally don't want to be someone who scares pt. by focusing on the most negative parts of the disease.

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