Introduction to Sensitive Topics

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Introduction to Sensitive Topics
Sean Reed, M.D. Assistant Professor Department of
Family Medicine
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Sensitive Topics
Death and dying Family interactions
(spanking) Racial and ethnic experiences Bowel
and bladder function Physical deformities Sensory
deficits (blindness, deafness) Mental
illness Prison Literacy

• Sexual orientation and practices
• Illegal drug use
• Alcohol use
• Spirituality and religious beliefs
• Violence/Abuse

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OBJECTIVES

• Describe a rationale for asking people questions
  about sensitive topics
• 2. Be more aware of your own attitudes/biases
• 3. Review barriers to addressing these issues
• 4. Describe a general approach to sensitive
  topics

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19 y/o woman with a sore throat

• College student
• Sore throat for 5 days
• Fever 101
• Strep test negative

Gonorrhea
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Leading Causes of Death, Youth Ages 10-24
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Rationale Nosey or Necessary?
vs.

1. Helps expand/develop the differential diagnosis
   (Ddx)
2. Predicament (patients plight / coping
   mechanisms)
3. Builds rapport
4. Opportunity for education / prevention (safe sex,
   healthy lifestyles)

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Change can make a difference
50 of health problems are caused by behavioral
risk factors
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The Envelope Please
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Personal Biases / Attitudes

• We all have biases. We need to be aware of them
  and make sure they dont get in the way of our
  patient care.

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Barriers

• Physicians own discomfort/biases/beliefs
• The patient doesnt want to talk about it
• Jargon
• Lack of specificity
• Time

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Patients Dont Want to Talk About it
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Patients ready and willing to talk!
One study involving 1900 patients (mean age of
40) found that 97 of participants were
comfortable discussing questions regarding HIV
risk behaviors, domestic violence and drug and
alcohol use with their doctors.
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Metacommunication
To communicate about your communication to help
overcome barriers or resolve a problem

• If a patient raises an issue - GO FOR IT
• If you think something needs to be addressed GO
  FOR IT
• When in doubt, anxious or lost GO FOR IT

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Jargon
I did not have sexual relations with that woman
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Vol. 281 No. 3, January 20, 1999 Would You Say
You "Had Sex" If . . ?
Results  Individual attitudes varied regarding
behaviors defined as having "had sex" 59 (95
confidence interval, 54-63) of respondents
indicated that oral-genital contact did not
constitute having "had sex" with a partner.
Nineteen percent responded similarly regarding
penile-anal intercourse.
FIRED!
When Dr. E. Ratcliffe Anderson, the American
Medical Association's executive vice president,
announced on January 15, 1999, that he had fired
the editor-in-chief of the Journal of the
American Medical Association (JAMA), he said that
an important factor in his decision was the
publication of a research article on the sexual
attitudes of college students. It was not just
the content of the article that was at issue, he
said, but the fact that the article had been
advanced for publication ahead of schedule with
the intent of influencing a major political
debate. In this case, the issue studied was
whether people consider oralgenital contact to
be "having sex."
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Lack of Specificity / Time
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(No Transcript)
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Structured Approach

• Comfortable setting
• Relaxed style
• Routinize questions
• Language
• Confidentiality
• Empathy
• Avoid assumptions
• Ask patients permission - Is it OK?

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• 1. Comfortable setting
• - private, quiet area, sitting
• 2. Relaxed style
• - how many voices do you have?
• 3. Routinize questions
• - dont overdo it
• 4. Confidentiality
• - perhaps best done at the beginning of the
  interview or even the relationship
• - you might choose to re-emphasize this concept
  (adolescents)

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• 5. Language
• - consider this patients educational level,
  cultural background, etc.
• 6. Empathy
• - taken too far this can work against
  routinizing and a relaxed style
• 7. Avoid assumptions
• 8. Ask patients permission/Allow the patient to
  prepare
• - Is it OK?

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Note Taking
When a patient divulges some highly personal
information consider not writing it down
immediately
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Summary

• Take note of your own biases and attitudes
• Patients do want to talk about sensitive issues
• Be specific / avoid jargon
• Develop a relaxed routine
• When in doubt, metacommunicate

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Thank You
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