Although the doctor and the patient had developed rapport early on in their relationship, a much deeper trust had developed over the years. Nevertheless, Janice could not launch straight into her fundamental agenda item. She brought with her an ‘entry-ticket’ to the consulting room (requests for lancets) and then proceeded to introduce the hidden agenda with a general question about another problem which she clearly realized was only secondary to the main item. This case illustrates that success often occurs after a series of contacts which make up the overall consultation.
What about looking at the notes? It is conventional good practice for doctors to try to be well-briefed about the patient sitting before them. Could perhaps this process prevent one from seeing this person with a fresh eye and encourage one to prejudge the person’s character, or focus in on previous events which are not on the patient’s agenda that particular day? It is tempting to make assumptions about the patient’s agenda particularly at a follow-up consultation brought about at the doctor’s request.
*342/197/1*
Anxiety about a contraceptive method may be a reasonable, logical result of some adverse or misunderstood publicity. Any change in the perceived harm/benefit ratio may cause an inappropriately large shift towards disuse or change. Adverse effects are always more newsworthy than benefits. For example, articles about possible links between oral contraceptives and breast cancer received prominent publicity in all the main newspapers, but other articles showing that a link could not always be shown received little or no mention. The perception of the public who only obtain their information from the media is always slanted towards the dramatic presentation of bad news. So they come to believe that the Pill causes breast cancer, that the intrauterine device gives people infections, that spermicides make babies deformed, that sterilization leads to hysterectomies, and that sheaths are faulty and have holes in them. These misunderstandings need to be understood, not just refuted, otherwise doctors invite the response, ‘Well, they would say that, wouldn’t they!’
*303/197/1*
Women and men throughout their lives have to face changes, from babyhood to childhood, from childhood to adolescence, and then to adulthood. The changes appear less for men though this may not be entirely so. For women, the physical changes are more dramatic and more visible. For men, once adulthood has been attained the body does not change much until old age really sets in, unless accident or over-indulgence intervene. Women have to cope with the changes brought about by pregnancy and later the menopause. Such changes are not under their control and although the body is not abnormal, it is not as it was before. Their adjustment to these changes affects their approach to life on the whole and to contraception and sexuality in particular. For women who have previously been in control of these areas of their lives, this phase can be difficult. Doctors are sometimes consulted by patients who have been well settled on their contraception for some time. A request to stop the method or change the method when there are no side-effects or difficulties should make one stop and think about the feelings behind the request.
*265/197/1*
The importance of communication skills as a component of clinical expertise has been accepted without question by the health professions. They are never more bereft, therefore, than when they lose the opportunity to use those skills because of an inability to speak the language of their patients. Translators alone cannot retrieve the loss when a cultural difference between doctor and patient is seen, by one or other of them, to prevent a shared perception of the matter in hand. If an interpreter is available much more can, of course, be done to bridge the gap. Before discussing the pitfalls and problems of different sorts of translators, it is worthwhile recording this author’s local experience, which is that doctors and nurses underuse translation services because they have become so used to working to a lower standard without them.
*227/197/1*
Doctors are often diffident when dealing with matters relating to sexuality and disability. The two words do not sit comfortably together. So where does the unease arise? Is it due to some uncertainty in the doctor as to how to cope with what seem to be major problems, and to the difficulty in adapting well tried techniques and skills to meet new and less familiar situations? Perhaps the problems are just too overwhelming. On the other hand, the sense of unease may stem from preconceived ideas held by the doctor which relate to society’s view that ‘disabled people do not do that sort of thing, or if they do they shouldn’t’.
One cannot assume that people with disabilities will have more psychosexual problems than the so called ‘able’ whose disabilities do not show. There may, however, be a sexual difficulty in the capacity to perform due to a physical disability which handicaps the person. The doctor needs to feel comfortable talking about the practical aspects of sexual activity, while at the same time being aware of the interactions in each doctor/patient relationship. In general, there may be a tendency for the doctor to be protective and ‘mothering’ towards the patient, whose greatest need is to be allowed to be his (or her) adult self.
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