Map of life expectancy at birth from Global Education Project.

Tuesday, June 29, 2010

It's just so embarassing . . .

... to talk about sex. At least that's what I found out when we analyzed a whole bunch of audio recorded routine outpatient visits of people living with HIV. This conference is quite interesting and there's a lot to report on, but in the few moments I have right now I'm first going to tell you about my own presentation.

We happened to have these transcripts that we first collected for a different study and then I said, what the heck, let's look at physician counseling of patients about safe sex. According to consensus guidelines by all of the major organizations in the U.S. concerned with HIV care, docs are supposed to do a quick screen in every visit for sexual risk, and provide a brief behavioral intervention. The idea is, over time, to reduce people's risk of transmitting the virus to others, and of becoming re-infected with a strain of HIV that might be resistant to the meds they are taking, or of acquiring a sexually transmitted infection.

Nice guideline, but docs don't do it. Out of 118 visits in our database, only 10 featured any discussion of sexual risk behavior at all and only four of those included any sort of counseling to reduce risk. Using our super duper special coding system, when there were conversations about sexual risk, patients made many fewer reports about their own behavior than when discussing diet and tobacco use; and physicians gave more information, but fewer instructions. Mostly, they just asked, "Do we need to talk about safe sex?", the patient said no, and that was that.

Appallingly, we had patients who came in with sexually transmitted infections, and/or actually told the doctor they were engaging in unsafe sex with multiple partners, and the physician did not respond with any counseling to reduce risk behavior. One guy even said that there were men who were actively trying to become HIV infected, and wasn't that strange? The guy apparently obliged them. But the doctor just choked, and changed the subject.

There are a few problems here. One is that doctors aren't trained to do this kind of counseling. They don't know what to do, so they just avoid the subject. They are afraid the patient will feel judged, and their relationship with the patient will be harmed. And they are just uncomfortable with the whole subject. We live in a very repressed society and doctors are a part of it.

It's not enough to promulgate guidelines. You need to equip the providers with the skills and self-efficacy to follow them. There are plenty of other examples but this one is quite compelling.


Anonymous said...

I was just whining to a friend today about how you don't get discharge instructions until you're discharged. So if you have some kind of surgery for which you really aren't going to be able to lie flat after surgery, you usually don't get that instruction until the few minutes before they discharge you. In one case, this led a friend of mine, who owns a perfectly good recliner at his home, to arrange fore someone to come to his house to feed his cat while he stayed with his mother, who didn't have a recliner. As a result, he spent two weeks in a lawn chair, when he could have just as easily arranged for the cat to stay with a friend and for his mother to stay at his house for a couple of weeks. He didn't know and he didn't know to ask.

My point is that you're fighting a very important and losing battle. Doctors really don't seem to do a very good job of communicating information in a useful manner to the patient. Add to that a taboo subject such as sex, and you have a recipe for ... well, nothing at all, no matter how much is needed.

I know you know how important your work is. I'm just rooting for you finding some way to make a difference.

kathy a. said...

anonymous has a great point about discharge instructions.

i imagine that with questions and counseling about safe sex, doctors feel like they are on a tightrope -- part of that might be not wanting to sound condemning or undermine whatever trust has built up. plus, it's just an awkward conversation, they're in a hurry, yadda.

lawyers often have to have conversations with clients about delicate subjects, too. one thing that helps is role-playing and practicing techniques that usually [or might] work. i know that sounds goofy to a lot of professionals, but it's been some of the most useful training i've ever had. my own area of practice pays a great deal of attention to attorney/client communications, because we need clients to be as forthcoming as they can about what might be painful or embarassing matters.

another thing is actually spending time on the trust relationship -- so the client knows the lawyer is behind him/her even when those more difficult topics are addressed.

Cervantes said...

Yes, even doing some role playing to overcome the discomfort would help. But more in-depth training is also possible. The trouble is, physician training is all about the knee bone's connected to the thigh bone, not about the actual practice of medicine.

kathy a. said...

get your people with the times!