2. Introduction to Sensitive Topics Sean Reed, M.D. Assistant Professor Department of Family Medicine

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

4. 1.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 OBJECTIVES

5. 19 y/o woman with a sore throat College student Sore throat for 5 days Fever 101 Strep test negative Gonorrhea

6. Leading Causes of Death, Youth Ages 10-24

7. Rationale: Nosey or Necessary? 1.Helps expand/develop the differential diagnosis (Ddx) 2.Predicament (patient’s plight / coping mechanisms) 3.Builds rapport 4.Opportunity for education / prevention (safe sex, healthy lifestyles) vs.

8. Change can make a difference 50% of health problems are caused by behavioral risk factors

9. The Envelope Please

10. We all have biases. We need to be aware of them and make sure they don’t get in the way of our patient care. Personal Biases / Attitudes

11. Physician’s own discomfort/biases/beliefs The patient doesn’t want to talk about it Jargon Lack of specificity Time Barriers

12. Patients Don’t Want to Talk About it

13. 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.

14. Metacommunication 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 To communicate about your communication to help overcome barriers or resolve a problem

15. Jargon “I did not have sexual relations with that woman”

16. 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 oral– genital contact to be "having sex." 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. Vol. 281 No. 3, January 20, 1999; Would You Say You "Had Sex" If.. ? FIRED!

17. Lack of Specificity / Time

19. Comfortable setting Relaxed style “Routinize” questions Language Confidentiality Empathy Avoid assumptions Ask patient’s permission - “Is it OK…?” Structured Approach

20. 1. Comfortable setting - private, quiet area, sitting 2. Relaxed style - how many voices do you have? 3. “Routinize” questions - don’t 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)

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

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

23. 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

24. Thank You http://www.random.org/