When seeing patients, physicians often develop a list of questions and possible diagnoses prior to even seeing the patient based on the chief complaint and other factors known about the patient including demographics such as race, sex, and age. The counseling techniques physicians implement are influenced by these factors and in turn influence the outcome of the patient's visit.
Introduction and Question[]
Based on Tammy's diagnosis, it seems that she is a candidate for counseling on safe sex practices. How would you approach her in a non-judgmental, non-threatening manner? Do you think your approach would change if she was of a different culture or race?
Discussion[]
How should the questioning change based on race. This is a tough, thought-provoking question. On the one hand, they say if you assume you only make an ass out of u & me. On the other hand, in the case where conditions occur much more frequently in one race than another, why not let that information aid you in making the diagnosis? An obvious non-OBGYN example is if you have a patient of Sub-Saharan African descent with Si/Sx of anemia, you'd be more likely to think sickle cell, and I don't think anyone would argue that it's OK to use race to help lead you down the right track. But I think that for conditions such as teen pregnancy and STD's even increased rates for a particular race represent more gray-area information that you might not want to assume applies to the particular patient you are with. Just FYI, here is a link to data on teen pregnancy rates by race 1986-2002:
http://www.guttmacher.org/pubs/2006/09/12/USTPstats.pdf
When it comes to sexual practice issues, whether it be suspected std or even ed in males, I often feel uncomfortable asking these questions. I think it's also because I don't know how the patients feel about it when I ask them. But as far as approaching these patients in nonjudgmental way goes, I try to think of it as any other medical problem. Tammy obviously needs professional care and you are there to provide it. It can be compounded by mistrust towards the physician, however, our job is to give the best care at the given moment. Some of it may be the culture in medicine or something we pick up along the way, call it experience or callousness. Bottom line is you have to maintain and treat the patient like all patients. I'd still respect patients’ privacy, listen to them, explain with their best interest in mind. As a student, I feel grateful at times when they are willing to tell their stories however sensitive issue they may be. Someone told me before you have to treat it like how the patients treat it. Some people are more matter of fact about it than others. Some people may feel uncomfortable, then you should be more careful to not make them more so.
I think that’s an interesting issue. I think that part of the issue can also be based on the physician's comfort or ease. If we as physicians become more comfortable asking these questions... and we start to think of these questions truly in terms of a critical part of the patient's health... then I think that empathy comes across to the patient.
I recently asked that question to one of my patients. And I was so caught up in trying to figure out what was going on with him, that I asked him about sexual history without necessarily prefacing the question. At that point, I had already developed a pretty good rapport with him... but I saw him kind of startle to the question, and I caught myself. And I touched his arm and said, "Oh, I apologize, sir, this is just a question I would normally ask to anyone in order to best assess their health." And we had a good moment.
I think technique is excellent... but I also think that sooner we get comfortable talking about these same issues, the easier it will be to effectively handle these situations.
One other thing I wanted to comment on since we're talking about sensitive sexual practice issues: we need to educate ourselves on LGBT issues. I read a great book on healthcare delivery to the LGBT community about 5 years ago (this may be the name of it, I'm not sure, but the idea would be to read something like it):
Health Care for Lesbians and Gay Men: Confronting Homophobia and Heterosexism
http://www.amazon.com/Health-Care-Lesbians-Gay-Men/dp/156024772X/ref=sr_1_1/104-0334816-2167954?ie=UTF8&s=books&qid=1194027909&sr=8-1
It really opened my eyes to how I should ask questions to not alienate people right off the bat (i.e. men, women, or both?). If you're straight, or used to dealing with people who are, it can be really hard not to assume your patients are as well. For example, if you're dealing with a man who writes on his form that he has a girlfriend and has only had sex with her in the last month, you might miss the fact that he has anal sex with men (but doesn't consider this sex because he is not the receiver). This would mean he's got risk factors that you need to address. I would encourage everyone to read a book like this also to become familiar with sexual practices different from your own, so you can not seem shocked when you hear about them for the first time.
Recommended Resources[]
Data on teen pregnancy rates by race 1986-2002:
http://www.guttmacher.org/pubs/2006/09/12/USTPstats.pdf
Health Care for Lesbians and Gay Men: Confronting Homophobia and Heterosexism
http://www.amazon.com/Health-Care-Lesbians-Gay-Men/dp/156024772X/ref=sr_1_1/104-0334816-2167954?ie=UTF8&s=books&qid=1194027909&sr=8-1
Links to Cases[]
Back to Tammy or Case studies.