Clinicians talk with patients about various subjects that are emotionally laden or sensitive. These discussions can be particularly difficult for inexperienced clinicians or during evaluations of patients clinicians do not know well. Even seasoned clinicians have some discomfort with certain topics: abuse of alcohol or drugs, sexual orientation or activities, death and dying, financial concerns, racial and ethnic experiences, family interactions, domestic violence, psychiatric illnesses, physical deformities, bowel function, and others. These areas are difficult to explore in part because of societal taboos. We all know, for example, that talking about bowel habits is not "polite table talk." In addition, many of these topics evoke strong cultural, societal, and personal values. Race, drug use, and homosexual practices are three obvious examples of issues that can raise biased attitudes and pose barriers during the interview. This section explores challenges to the clinician in these and other important and sometimes sensitive areas, including domestic violence, the dying patient, and mental illness.
Several basic principles can help guide your response to sensitive topics. The single most important rule is to be nonjudgmental. The clinician's role is to learn about the patient and help the patient achieve better health. Disapproval of behaviors or elements in the health history will only interfere with this goal. Explain why you need to know certain information—doing so makes patients less apprehensive. For example, say to patients "Because sexual practices put people at risk for certain diseases, I ask all of my patients the following questions." You should use specific language. Refer to genitalia with explicit words such as penis or vagina and avoid phrases like "private parts." Choose words that the patient understands. "By intercourse, I mean when a man inserts his penis into a woman's vagina." Find opening questions for sensitive topics and learn the specific kinds of data needed for your assessments.
Other strategies for becoming more comfortable with sensitive areas include general reading about these topics in medical and lay literature; talking to selected colleagues and teachers openly about your concerns; taking special courses that help you explore your own feelings and reactions; and ultimately, reflecting on your own life experience. Take advantage of all these resources. Whenever possible, listen to experienced clinicians, then practice similar discussions with your own patients. The range of topics that you can explore with comfort will widen progressively.
Cultural Competence. Developing the ability to interact and communicate effectively with patients from many backgrounds is a lifelong professional goal. The following examples illustrate how communication barriers, cultural differences, and unconscious biases can influence patient care.
A 28-year-old taxi driver from Ghana who had recently moved to the United States complained to a friend about U.S. medical care. He had gone to the clinic because of fever and fatigue. He described being weighed, having his temperature taken, and having a cloth wrapped tightly, to the point of pain, around his arm. The clinician, a 36-year-old from Washington, DC, had asked the patient many questions, examined him, and wanted to take blood—which the patient had refused. The patient's final comment was "... and she didn't even give me chloro-quine!"—his primary reason for seeking care. The man from Ghana was expecting few questions, no examination, and treatment for malaria, which is what fever usually means in Ghana.
In this example, cross-cultural miscommunication is understandable and un-threatening. Bias and miscommunication, however, occur in many clinical interactions and are usually subtler.
A 16-year-old high school student came to the local teen health center because of painful menstrual cramps that were interfering with school. She was dressed in a tight top and short skirt and had multiple piercings, including in her eyebrow. The 30-year-old male clinician asked the following questions: "Are you passing all of your, classes?" .. . "What kind of job do you want after high school?" .. . "What kind of birth control do you want?" The teenager felt pressured into accepting birth control pills, even though she had clearly stated that she had never had intercourse and planned to postpone it until she got married. She was an honor student, planning to go to college, but the clinician did not elicit these goals. The clinician glossed over her cramps by saying "Oh, you can just take some ibuprofen. Cramps usually get better as you get older." The patient will not take the birth control pills that were prescribed, nor will she seek health care soon again. She experienced the encounter as an interrogation, so failed to gain trust in her clinician. In addition, the questions implied incorrect assumptions about her health. She has received ineffective health care because of conflicting cultural values and clinician bias.
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