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Approach to the Patient
Saturday, August 16, 2008
An effective relationship between health care provider and patient is based on the knowledge and skill that qualify the provider for effective communication between the individuals, and for the ethical standards that govern the conduct of the participants in the relationship.
THE KNOWLEDGE BASE
The health care of women encompasses all aspects of medical science and therapeutics. Physicians in the practice of obstetrics and gynecology are called upon as consultants, and in addition, they frequently act as primary care providers for their patients. Internists in general practice and family practitioners often find that a major component of their clinical activities involves the special needs of women. These special medical needs and concerns vary with the patient's reproductive status, her reproductive potential, and her desire to reproduce. Certainly the diagnostic possibilities and the choice of diagnostic or therapeutic intervention will be influenced by the possibility of, or desire for, pregnancy, or in some cases by the patient's hormonal profile. In addition, the gynecologic or obstetric assessment must include an evaluation of the patient's general health status and should be placed in the context of the psychologic, social, and emotional status of the patient.
History
To offer each woman optimal care, the information obtained at each visit should be as complete as possible. Whether the contact is a routine visit or is occasioned by a particular problem or complaint, the woman should be encouraged to view the visit as an opportunity to participate in improving her health. The clinical database should include general information about the patient and her goals in seeking care. The history of the present problem, past medical history, family history, medications used, allergies, and review of systems should be concise but thorough. Portions of the history provided by questionnaire or by other members of the health care team should be reviewed with the patient, in part to verify the information, but also to begin assessing the patient's personality and to determine her attitude toward the health care system. The menstrual history and developmental history may provide a background for presenting complaints in subsequent years. The menstrual history, sexual history, and obstetric history obviously assume central importance for the gynecologic or obstetric visit. In addition, the habit of systematically categorizing the nature of such complaints as pain, abnormal bleeding, or vaginal discharge will usually narrow the differential diagnoses. For example, the categorization of a complaint of pain should include its onset, duration, frequency, and associated behaviors, as well as a description of the nature or type of pain and its location. Such thoroughness will permit assessment of change as well as determination of the appropriate mode of investigation or therapy.
The initial contact with the patient, made while she is fully clothed and comfortable, may be useful in decreasing her anxiety about the physical examination; concerns about the examination may be elicited, and a history of previous unfortunate experiences may alert the examiner to the need for extra attention, time, and gentleness.
Physical Examination
The second component of the patient assessment, the physical examination, should also be directed toward evaluation of the total patient. The patient should again be encouraged to view the examination as a positive opportunity to gain information about her body, and she should be offered feedback regarding the general physical examination and any significant findings. The examination should always include a discussion of any concerns expressed by the patient. The breast examination provides a good opportunity to reinforce the practice of breast self-examination. The pelvic examination is usually an occasion of heightened anxiety for the patient, and every effort should be made to make the experience a positive one. The physician should give the patient as much control over the process as possible, by asking if she is ready, asking for feedback on whether the examination is painful, and seeking her cooperation in relaxation and muscle control. Information about each step of the examination can be provided so the patient is involved and appropriately aware of the value of each maneuver.
Inspection of the external genitalia is followed by the gentle insertion of an appropriately sized, warmed speculum to permit inspection of the vagina and the cervix. For patients with pain or increased anxiety, their cooperation must be continually reinforced by slow, gentle placement of the instrument, maintaining downward pressure against the relaxed perineal body and away from the urethral and anterior vaginal areas. Some women may wish to watch, by the use of a mirror, as the genitalia are inspected and may gain confidence from visualizing the cervix and vagina. The Papanicolaou (Pap) smear may be uncomfortable for some women, and they should be alerted when the test is being done. The bimanual examination should also be explained to the patient. When the uterus is anteflexed, the woman may want to appreciate the size and location of her uterus by feeling it with the guidance of the examiner. The rectovaginal and rectal examinations, if performed while the patient relaxes her anal sphincter, provide additional information and can be another source of reassurance for the normal patient or a means of diagnosis for the patient with disease. If an ultrasound is indicated as part of the gynecologic or obstetric examination, additional participation by the patient in the evaluation can be obtained by explanations of the visualized anatomy.
Implications of Technology
The scientific knowledge base for obstetric and gynecologic care has grown in parallel with general medical advances. In some cases this proliferation of information and technology has profoundly altered the relationship between health care providers and their patients. For example, the change from an intuitive management of labor and delivery to active monitoring and subsequent interpretation of data has provided a more rational basis for decision making. This change of management style has also created a potential for conflict or confusion in the relationship between patient and physician. In seeking to obtain additional information, the physician can be perceived to be intervening unnecessarily. More than ever before, issues of consumerism and participation in decision making require an understanding of the expectations of each individual woman. Whether a woman perceives herself as a “client” or as a “patient,” and the degree to which this perception coincides with the views of her physician, may alter her acceptance of recommendations for care. The fact that several options are available in the management of many obstetric or gynecologic situations may further complicate the relationship. However, this situation provides an opportunity to allow the patient to participate actively in choosing the best therapy for her particular circumstance.
COMMUNICATION
If the first foundation of a strong therapeutic relationship is knowledge, the second is communication. The ability to establish trust, to obtain and deliver complete and accurate information, and to ensure compliance with recommendations depends in large measure on the health care provider's communication skills. In some individuals these skills are innate, but for most the ability to become an effective communicator in a variety of settings requires an active process of learning and a willingness to be evaluated by peers. The information communicated in each encounter, whether by written material, in face-to-face discussion, or by telephone contact, extends beyond the factual content provided to include a demonstration of the provider's willingness to be available to answer questions and to encourage patient involvement in decision making.
One common barrier from the patient's perspective is that medical information is communicated via a foreign language to the layperson. This foreign language is often spoken in a hurried fashion and the listener is not given the opportunity to ask questions for clarification. The patient may also find it difficult to voice her concerns within the traditional doctor-patient relationship. She may be embarrassed to reveal intimate details of her personal life to a provider who does not take the time to show interest in her story. By not allowing the patient to express her fears, concerns, or questions, the provider can miss valuable clues to diagnosis and formulation of a treatment plan.
Solutions to these communication barriers can be found by educating patients and providers. The physician should provide a comfortable environment, encourage the patient to ask questions, listen carefully both to her story and the way she tells it, and explore with her the goals and expectations she has about the treatment. Videotaped interviews are a very effective means of educating providers about these skills. The patient should be asked to repeat instructions, and written material should be provided whenever possible. For her part the patient can be asked to take notes and keep a diary for review at subsequent visits.
Enhanced communication has been shown to dramatically increase compliance. A striking example of lack of compliance occurs with prescription of hormone replacement therapy (HRT). Overall compliance with HRT is approximately 30%. Patients either do not fill or renew their prescriptions because of fear of cancer or due to inadequate or inaccurate information regarding risks and side effects. Long-term continuance rates are highest among patients with the greatest understanding.
For the health care practitioner, the counterbalance of a litigious society that may hold the physician responsible for treatment outcome places a high premium on documentation and scientific justification for each intervention or nonintervention and can place the physician in an adversarial position with respect to the patient's desires. The obligation to inform the patient, to obtain surgical consent, or to advise about choices regarding pregnancy outcome, is becoming in some instances a matter of law rather than established medical practice. These legislative initiatives, while offensive to many, are signals that the public feels it requires protection from manipulation at the hands of those who have the power of knowledge and training not available to the layperson. Regardless of the validity of this perception, it can only be countered by efforts to establish and maintain the trust of each individual with whom the physician has a medical relationship. This trust is rooted in the physician's medical knowledge and is maintained by conscientious structured lifetime learning, the frank assessment and acknowledgment of areas of ignorance, and the willingness to discuss with the patient what is known and what is uncertain.
ETHICS
If the bricks of the foundation of the relationship between physician and patient are knowledge and communication, the mortar that forms the basis for trust is the integrity and ethical behavior of all participants in the relationship. Ethical dilemmas in obstetrics and gynecology are receiving increasing recognition, particularly as they deal with the provocative issues surrounding the beginnings of life, the nature of parenting, and the control of individual patients over their own destiny. Ethical dilemmas only arise when there are conflicting obligations, rights, or claims. Since the delivery of health care involves multiple participants, a consensus of values must often be sought when the patient is cared for by a team, even when significant pluralism of views might be represented. To minimize potential ethical conflicts, to anticipate potential areas of difficulty, and to achieve consistency in behavior, individuals may avail themselves of a number of resources for ethical decision making. In addition to the growing literature in the field, many hospitals and practice settings have formal consultation services for resolution of ethical dilemmas. Before seeking an external framework, however, the practitioner should be aware of his or her own values and understand the basis of these values. The values of the medical profession and of the institutions in which the physician practices, as formulated by codes and standards, but also as expressed indirectly through past actions, are usually then helpful in providing a decision-making framework. Finally, a familiarity with ethical theories may permit decision making that achieves an acceptable consensus in the face of conflicting values. Discussions based on consideration of the ethical principles of patient autonomy (respect for persons), beneficence (doing good), nonmaleficence (refraining from doing harm), and justice (consideration of resources and fairness of opportunity) will prevent capricious and arbitrary decisions.
The principle of autonomy, or respect for each individual person, may form the underlying basis for resolving many ethical questions and will determine appropriate attitudes toward confidentiality, privacy, right to information, and the ultimate primacy of the patient in making treatment decisions. Since caring for women necessarily involves information regarding sensitive and intimate relationships and activities, as well as access to a woman's thoughts, feelings, and emotions, full disclosure of such information by the patient places a burden of trust on the health care provider to protect the rights and privacy of each patient. The relationship established at an initial gynecologic visit between a young adolescent and the physician may potentially extend throughout her adult life and include such major life events as education about reproductive health, assistance in family planning and childbearing, and preservation of physical fitness and well-being through the postmenopausal years. To successfully establish such an enduring clinical relationship requires a sensitivity to the changing goals and needs of the individual patient. Offering care to some patients or providing some types of services may not be comfortable for all practitioners. For example, establishing a rapport with an adolescent seeking birth control or providing health care for a lesbian woman may require a nonjudgmental approach when one is interviewing the patient and a balanced consideration of lifestyle options. The recognition of these special needs has led to a compartmentalization of health care in some regions, so that specialty practices or clinics directed toward adolescent health care, family planning, fertility, oncology, and menopausal care are frequently available. These resources can best be utilized by referral, with guidance provided by a primary provider, so that appropriate use of such resources can be an integral part of the general health care of each woman.
THE KNOWLEDGE BASE
The health care of women encompasses all aspects of medical science and therapeutics. Physicians in the practice of obstetrics and gynecology are called upon as consultants, and in addition, they frequently act as primary care providers for their patients. Internists in general practice and family practitioners often find that a major component of their clinical activities involves the special needs of women. These special medical needs and concerns vary with the patient's reproductive status, her reproductive potential, and her desire to reproduce. Certainly the diagnostic possibilities and the choice of diagnostic or therapeutic intervention will be influenced by the possibility of, or desire for, pregnancy, or in some cases by the patient's hormonal profile. In addition, the gynecologic or obstetric assessment must include an evaluation of the patient's general health status and should be placed in the context of the psychologic, social, and emotional status of the patient.
History
To offer each woman optimal care, the information obtained at each visit should be as complete as possible. Whether the contact is a routine visit or is occasioned by a particular problem or complaint, the woman should be encouraged to view the visit as an opportunity to participate in improving her health. The clinical database should include general information about the patient and her goals in seeking care. The history of the present problem, past medical history, family history, medications used, allergies, and review of systems should be concise but thorough. Portions of the history provided by questionnaire or by other members of the health care team should be reviewed with the patient, in part to verify the information, but also to begin assessing the patient's personality and to determine her attitude toward the health care system. The menstrual history and developmental history may provide a background for presenting complaints in subsequent years. The menstrual history, sexual history, and obstetric history obviously assume central importance for the gynecologic or obstetric visit. In addition, the habit of systematically categorizing the nature of such complaints as pain, abnormal bleeding, or vaginal discharge will usually narrow the differential diagnoses. For example, the categorization of a complaint of pain should include its onset, duration, frequency, and associated behaviors, as well as a description of the nature or type of pain and its location. Such thoroughness will permit assessment of change as well as determination of the appropriate mode of investigation or therapy.
The initial contact with the patient, made while she is fully clothed and comfortable, may be useful in decreasing her anxiety about the physical examination; concerns about the examination may be elicited, and a history of previous unfortunate experiences may alert the examiner to the need for extra attention, time, and gentleness.
Physical Examination
The second component of the patient assessment, the physical examination, should also be directed toward evaluation of the total patient. The patient should again be encouraged to view the examination as a positive opportunity to gain information about her body, and she should be offered feedback regarding the general physical examination and any significant findings. The examination should always include a discussion of any concerns expressed by the patient. The breast examination provides a good opportunity to reinforce the practice of breast self-examination. The pelvic examination is usually an occasion of heightened anxiety for the patient, and every effort should be made to make the experience a positive one. The physician should give the patient as much control over the process as possible, by asking if she is ready, asking for feedback on whether the examination is painful, and seeking her cooperation in relaxation and muscle control. Information about each step of the examination can be provided so the patient is involved and appropriately aware of the value of each maneuver.
Inspection of the external genitalia is followed by the gentle insertion of an appropriately sized, warmed speculum to permit inspection of the vagina and the cervix. For patients with pain or increased anxiety, their cooperation must be continually reinforced by slow, gentle placement of the instrument, maintaining downward pressure against the relaxed perineal body and away from the urethral and anterior vaginal areas. Some women may wish to watch, by the use of a mirror, as the genitalia are inspected and may gain confidence from visualizing the cervix and vagina. The Papanicolaou (Pap) smear may be uncomfortable for some women, and they should be alerted when the test is being done. The bimanual examination should also be explained to the patient. When the uterus is anteflexed, the woman may want to appreciate the size and location of her uterus by feeling it with the guidance of the examiner. The rectovaginal and rectal examinations, if performed while the patient relaxes her anal sphincter, provide additional information and can be another source of reassurance for the normal patient or a means of diagnosis for the patient with disease. If an ultrasound is indicated as part of the gynecologic or obstetric examination, additional participation by the patient in the evaluation can be obtained by explanations of the visualized anatomy.
Implications of Technology
The scientific knowledge base for obstetric and gynecologic care has grown in parallel with general medical advances. In some cases this proliferation of information and technology has profoundly altered the relationship between health care providers and their patients. For example, the change from an intuitive management of labor and delivery to active monitoring and subsequent interpretation of data has provided a more rational basis for decision making. This change of management style has also created a potential for conflict or confusion in the relationship between patient and physician. In seeking to obtain additional information, the physician can be perceived to be intervening unnecessarily. More than ever before, issues of consumerism and participation in decision making require an understanding of the expectations of each individual woman. Whether a woman perceives herself as a “client” or as a “patient,” and the degree to which this perception coincides with the views of her physician, may alter her acceptance of recommendations for care. The fact that several options are available in the management of many obstetric or gynecologic situations may further complicate the relationship. However, this situation provides an opportunity to allow the patient to participate actively in choosing the best therapy for her particular circumstance.
COMMUNICATION
If the first foundation of a strong therapeutic relationship is knowledge, the second is communication. The ability to establish trust, to obtain and deliver complete and accurate information, and to ensure compliance with recommendations depends in large measure on the health care provider's communication skills. In some individuals these skills are innate, but for most the ability to become an effective communicator in a variety of settings requires an active process of learning and a willingness to be evaluated by peers. The information communicated in each encounter, whether by written material, in face-to-face discussion, or by telephone contact, extends beyond the factual content provided to include a demonstration of the provider's willingness to be available to answer questions and to encourage patient involvement in decision making.
One common barrier from the patient's perspective is that medical information is communicated via a foreign language to the layperson. This foreign language is often spoken in a hurried fashion and the listener is not given the opportunity to ask questions for clarification. The patient may also find it difficult to voice her concerns within the traditional doctor-patient relationship. She may be embarrassed to reveal intimate details of her personal life to a provider who does not take the time to show interest in her story. By not allowing the patient to express her fears, concerns, or questions, the provider can miss valuable clues to diagnosis and formulation of a treatment plan.
Solutions to these communication barriers can be found by educating patients and providers. The physician should provide a comfortable environment, encourage the patient to ask questions, listen carefully both to her story and the way she tells it, and explore with her the goals and expectations she has about the treatment. Videotaped interviews are a very effective means of educating providers about these skills. The patient should be asked to repeat instructions, and written material should be provided whenever possible. For her part the patient can be asked to take notes and keep a diary for review at subsequent visits.
Enhanced communication has been shown to dramatically increase compliance. A striking example of lack of compliance occurs with prescription of hormone replacement therapy (HRT). Overall compliance with HRT is approximately 30%. Patients either do not fill or renew their prescriptions because of fear of cancer or due to inadequate or inaccurate information regarding risks and side effects. Long-term continuance rates are highest among patients with the greatest understanding.
For the health care practitioner, the counterbalance of a litigious society that may hold the physician responsible for treatment outcome places a high premium on documentation and scientific justification for each intervention or nonintervention and can place the physician in an adversarial position with respect to the patient's desires. The obligation to inform the patient, to obtain surgical consent, or to advise about choices regarding pregnancy outcome, is becoming in some instances a matter of law rather than established medical practice. These legislative initiatives, while offensive to many, are signals that the public feels it requires protection from manipulation at the hands of those who have the power of knowledge and training not available to the layperson. Regardless of the validity of this perception, it can only be countered by efforts to establish and maintain the trust of each individual with whom the physician has a medical relationship. This trust is rooted in the physician's medical knowledge and is maintained by conscientious structured lifetime learning, the frank assessment and acknowledgment of areas of ignorance, and the willingness to discuss with the patient what is known and what is uncertain.
ETHICS
If the bricks of the foundation of the relationship between physician and patient are knowledge and communication, the mortar that forms the basis for trust is the integrity and ethical behavior of all participants in the relationship. Ethical dilemmas in obstetrics and gynecology are receiving increasing recognition, particularly as they deal with the provocative issues surrounding the beginnings of life, the nature of parenting, and the control of individual patients over their own destiny. Ethical dilemmas only arise when there are conflicting obligations, rights, or claims. Since the delivery of health care involves multiple participants, a consensus of values must often be sought when the patient is cared for by a team, even when significant pluralism of views might be represented. To minimize potential ethical conflicts, to anticipate potential areas of difficulty, and to achieve consistency in behavior, individuals may avail themselves of a number of resources for ethical decision making. In addition to the growing literature in the field, many hospitals and practice settings have formal consultation services for resolution of ethical dilemmas. Before seeking an external framework, however, the practitioner should be aware of his or her own values and understand the basis of these values. The values of the medical profession and of the institutions in which the physician practices, as formulated by codes and standards, but also as expressed indirectly through past actions, are usually then helpful in providing a decision-making framework. Finally, a familiarity with ethical theories may permit decision making that achieves an acceptable consensus in the face of conflicting values. Discussions based on consideration of the ethical principles of patient autonomy (respect for persons), beneficence (doing good), nonmaleficence (refraining from doing harm), and justice (consideration of resources and fairness of opportunity) will prevent capricious and arbitrary decisions.
The principle of autonomy, or respect for each individual person, may form the underlying basis for resolving many ethical questions and will determine appropriate attitudes toward confidentiality, privacy, right to information, and the ultimate primacy of the patient in making treatment decisions. Since caring for women necessarily involves information regarding sensitive and intimate relationships and activities, as well as access to a woman's thoughts, feelings, and emotions, full disclosure of such information by the patient places a burden of trust on the health care provider to protect the rights and privacy of each patient. The relationship established at an initial gynecologic visit between a young adolescent and the physician may potentially extend throughout her adult life and include such major life events as education about reproductive health, assistance in family planning and childbearing, and preservation of physical fitness and well-being through the postmenopausal years. To successfully establish such an enduring clinical relationship requires a sensitivity to the changing goals and needs of the individual patient. Offering care to some patients or providing some types of services may not be comfortable for all practitioners. For example, establishing a rapport with an adolescent seeking birth control or providing health care for a lesbian woman may require a nonjudgmental approach when one is interviewing the patient and a balanced consideration of lifestyle options. The recognition of these special needs has led to a compartmentalization of health care in some regions, so that specialty practices or clinics directed toward adolescent health care, family planning, fertility, oncology, and menopausal care are frequently available. These resources can best be utilized by referral, with guidance provided by a primary provider, so that appropriate use of such resources can be an integral part of the general health care of each woman.
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