Vol. 40, No. 1
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Lessons From Our Learners
William D. Grant, EdD Feature Editor
Editor’s Note: Submissions to this column may be in the form of papers, essays, poetry, or other similar forms. Editorial assistance will be provided to develop early concepts or drafts. If you have a potential submission or idea, or if you would like reactions to a document in progress, contact the series editor directly: William D. Grant, EdD, SUNY Upstate Medical University, Department of Family Medicine, 475 Irving Avenue, Suite 200, Syracuse, NY 13210. 315-464-6997. Fax: 315-464-6982. grantw@upstate. edu.
Tell Me, Doctor, What Is It That You Really Need to Know?
Florence Gelo, DMin, NCPsyA
Dottie, a client of 5 years, arrives for her weekly psychotherapy appointment. She has finally taken action, after years of procrastination, to identify a primary care physician and to make an appointment. She is determined to report her experience. Fifteen minutes early for her initial visit with a family physician, she was handed an initial intake form. She answered all the routine questions. Though memory and tedium caused some impatience in completing the form, she reported not being surprised by most questions. She had little resistance to answering questions about alcohol intake, past and present smoking habits, and history of drug use. She laughed as she recalled her father’s outbursts after every visit to his doctor. Not wanting to be told what he already knew, he would say that the doctor “sounds just like your mother—nagging me about my smoking. He worries about my lungs and my heart—your mother complains about my breath.” Then her mood rapidly changed, and the tears started. She was surprised that she had experienced a variety of viscerally emotional responses to the form’s questions about her experiences of physical and emotional abuse, domestic violence, and sexual abuse: relief, fear, shame, and humiliation. Yes, it had been a long time since she had visited a physician, but she clearly recalled never being asked such sensitive questions. She admitted that she answered these questions reluctantly; she was aware that she was revealing intimate and painful information about herself for the first time and did so only because she half-heartedly believed that this information must obviously be valuable to the doctor who would be treating her. Why else ask? As she continued her narrative, her anger rose. She was called to follow the nurse, was weighed on a scale outside an examination room, and then directed to the room where the nurse checked her temperature and blood pressure. At this point, a young man entered the room, introducing himself as Dr C. He asked her what brought her to the office and then explained that he was going to review her intake form and then Dr Z would be in shortly after. Dottie summarized the young doctor’s questions to her and opined that he had generally been very thorough. He asked her to clarify several answers but then he “bypassed the section about physical and emotional abuse.” She admitted she felt relief about never anticipating anyone reading her history of sexual abuse other than her “real” doctor. Later when she met with Dr Z, she felt annoyed that neither did he ask questions related to her responses to the violence and abuse questions nor did he even acknowledge that she had responded to them. What made this all the more painful for Dottie is that she is an incest survivor, information that before this visit remained undisclosed to any physician. Yet, when she finally revealed this, its existence went unacknowledged. For several months in therapy, Dottie talked about her visit with Dr Z, who behaved as if her experience of incest had not existed, just as her mother had. Exploring the culture of silence about her experience of incest, one that she too had
(Fam Med 2008;40(1):13-4.)
From the Department of Family, Community, and Preventive Medicine, Drexel University.
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January 2008 sions that may be uncomfortable for them or for which they feel less capable of addressing. The physician may have even perceived information about a patient’s history of incest or sexual abuse as personal information irrelevant to the current visit. The intake form is a ritual in every practice. Information related to insurance coverage, home address, emergency contact information; how innocuous can you get? Yet the degree of distress that can be caused by well-intended questions is often not considered in form design and implementation. A patient has now put in writing an aspect of personal history that may feel humiliating and afterward, once divulged, may also create feelings of anxiety. The patient may realize that others have access to her patient record and may read what has been documented.
Family Medicine Rational or otherwise, this fact may create a profound sense of vulnerability and surface concerns about personal safety. The assumption is that when a question is placed on an intake form, the information is actually needed for the benefit of the patient. Patients reasonably assume that they will be invited to discuss this important information, especially when questions require a patient to disclose sensitive information and, as in this case, the patient is new to the practice. Absent a needto-know analysis, how can we be certain that patients are being best served?
Correspondence: Address correspondence to Dr Gelo, Drexel University, Department of Family, Community, and Preventive Medicine, 2900 Queen Lane, Philadelphia, PA 19129. 215-9918464. florence.gelo@drexelmed.edu.
participated in, she was now ready to discuss these years in greater detail. Dottie did not to return to Dr Z’s office to complete her second of the customary two recommended office visits but, instead, decided to talk with friends and family to identify a communicative and compassionate physician. Months passed before Dottie was ready to schedule an appointment with another primary care physician—one who, it turned out, reviewed the intake form comprehensively and with interest and who inquired about Dottie’s history of incest with the same level of interest and directness as with all other areas of evaluation. It is easy to rationalize Dottie’s experience. The limited time allotted for patient visits may have contributed to this oversight. Physicians may choose to avoid discus-