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Thursday, February 9, 2012

Politics, religion and sex--avoiding 'third rail' topics in the exam room

An ancient maxim of dinner party etiquette, which I believe has been proffered from more than one source, is "Never discuss politics, religion or sex in polite company." In some ways, for me as a physician, entering the exam room with a patient seems to require some similar degree of discretion. But the consequences of straying outside the bounds of polite discussion in the doctor's exam room are quite different from any awkwardness that might ensue after a social misadventure.

Dr. Henry Lee, the well-known Connecticut State forensic medicine expert, likes to relate a tale of his own introduction to dinner party etiquette, which I will try to relay somewhat faithfully. His English was poor when he arrived in the U.S. and, invited to a party in which guests were seated in the traditional "boy-girl-boy-girl" arrangement, he knew he would be pressed to make conversation with the women on each side of him. A friend reassured him, "You'll have no problem if you can just get the woman talking about herself and then all you have to do is listen politely. Simply ask 'Are you married?' and then ask 'Do you have any children?' This should get things going just fine."
Armed with this stratagem, Dr. Lee was seated and turned to an attractive young woman on his left and asked if she was married. She replied "No." So of course, he went on to the next question, "Do you have any children?" He was surprised when she reacted with a look of indignation and quickly turned her attention to the guest on her other side.

Puzzled at her reaction, he surmised that he must have gotten the sequence out of order. Trying out the other way around, he turned to an older woman on his right and asked confidently if she had any children. "Three!" she replied happily. Delighted with his progress, he then inquired if she was married. Dr. Lee says he spent the dinner conversing with his soup and salad.

I have also had exam room encounters come to grief because of sex, politics and religion, but nothing has caused me more regret than politics. I will explain.

Sex is not taboo. In fact, it is something I am expected to inquire about as part of the medical history. A sexual history is essential if one is concerned about infectious diseases, reproductive health, domestic abuse, and even what drugs are prescribed and which are proscribed. I was taught even back in the dark ages of medical education in the 70s that one should take a careful "non-judgmental" stance in taking a history. Students are taught to ask first, "Are you active sexually?" If the answer is yes, we ask "Do you have sex with men, women, or both?" Then the question is asked in a way that allows the patient to discuss past behavior that he or she might be ashamed of: "In the past, did you …?"

Nonetheless, if at all possible, I avoid asking about sexual activity as part of a history unless it is essential to the diagnosis. Why? Because I have only so much time to see the patient, and time spent on sex is time lost to discussing bowel habits, which is essential if you are a gastroenterologist. A few years ago it was found that women with irritable bowel syndrome (IBS) have an increased incidence of childhood abuse, emotional or otherwise. We were encouraged to add that element to our discussion about emotional factors in IBS.

I found that a colleague at the other practice in our hospital added that question to his interviews, at least for a time, because I had the pleasure of having to review the charts of several of his former patients who took offense to that line of questioning. Even if sexual abuse was an easy topic to discuss, I would not want to go there. If I did I would have become a Freudian psychiatrist. It's tedious enough as it is, listening to detailed descriptions of stool from people who think they are suffering from a rare and unusual type of excretory syndrome, not to add to it tales of childhood trauma. In sum, discussions of sex are appropriate in the exam room, but I avoid them because they take too much valuable time.

On the opposite end of the scale, religion is no problem because it is rarely a necessary aspect of the medical history unless it has some bearing on dietary habits. I like to know if my patient is a Hindu and follows a vegetarian diet. If my patient is a worried older Jewish woman, I like to blame her symptoms on having eaten trafe, i.e. non-Kosher food, just to get a laugh and break the ice. But as far as I know, the Presbyterian diet is not too different from the Episcopalian, and beyond that I really have no interest.

I never bring up my patient's religion unless it is germane to our discussion, as in "Are you certain your communion wafer is gluten-free?" Occasionally a patient will ask me if I happen to be Jewish. When I say "Yes, although not very observant," they will sometimes even betray that they subscribe to an old prejudice that is as amusing as it is false: "Jews make the best doctors, you know." I reply that good doctors come in all shapes, sizes and colors. So much for religion.

But politics in the exam room, that's a pitfall and a booby trap that makes me wary as soon as I sense the subject is about to come up. I try to avoid politics whenever I can, because it is the biggest time-waster of all when it comes to getting through my day. It would only take three minutes per patient to set me back 30 minutes by the end of the morning, and that would be in addition to the extra 5 minutes taken up by additional unexpected complaints and reports about my patients' jobs, families, social lives and other circumstances which are the glue that holds our relationships together in a way that simply prescribing medications cannot. Keeping on time is already a challenge I have described in my last post, and politics is yet another impediment.

Even so, politics comes up. Mostly it is because my patients want to know my political opinion. They especially want to know what I think about medical care and how our elected (and don't forget, appointed!) officials are handling it.

Many of my patients want to discuss "Obama-care" and my attitude toward how it will affect me, although I think their concern is how it will affect our relationship. Some of my patients want to discuss "socialized medicine," or how care is delivered in Canada. Some just want to know who I plan to vote for, or who I think will win the Republican primary. Maybe they want to get to know me better, or maybe I am the first person they have encountered since they read the morning paper and they want to air their strong feelings about who said what. Whatever the reason, if I allowed myself to be drawn into political discussions, my schedule would be an even greater disaster than it often is.

Surprisingly, many of my patients assume my politics are conservative because I am a doctor. Because so many doctors are Republicans they assume I am too. Many patients assume that I am fiercely opposed to socialized medicine, since surely I don't want to be told how to practice or what I can earn. Some people even presume that I must be angry at the government laying claim to such a large share of my income.

When they bring it up, I never hesitate to tell them that I think the financing of medical care in this country is a disgrace and we should have a single-payer system. Some people react with shock. A doctor in favor of socialized medicine? I confess, when I get that reaction I take a certain amount of malicious amusement in following up by a provocative statement such as medical care in Canada has a great deal to recommend it and we might be better off here if we adopted such a system. I am especially amused at the story of the Tea Partier who held up a sign at a rally two years ago, "Government hands off Medicare!" For all its faults, I tell my patients, Medicare is the most generous insurance plan out there. Why not extend it to everyone? Of course, we would have to control utilization. Upon hearing that, some of my patients seem almost apoplectic.

It doesn't much matter whether my political opinions agree or disagree with those of my patient; either way it's a sticky wicket. Some will be particularly eager to have a discussion especially if they find the least suggestion I share their beliefs. Who better to lend a sympathetic ear to your opinions on the absurdity of the term "death tax" than your doctor? After all, doesn't he have an intimate acquaintance with life and death? Who better to unburden your political prejudices to than the person who is paid and obligated to listen to your most intimate fears and anxieties about life? Surely your doctor would lend you a sympathetic ear, right?

Thus I have learned over the years that it is best to keep politics from intruding into my medical encounter, but recently I encountered a patient's political views in a way I could not avoid. I was glancing through the letters-to-the-editor page of our local small town gazette when I came across a letter submitted by one of my patients who I have attended to for many years. He is a very pleasant, intelligent and appreciative gentleman in all respects and we have had many conversations about his career, family, hobbies and retirement pursuits. The letter was prompted by some issue about the town budget, if I recall correctly. I was dismayed to find it proceeded to a reactionary and bigoted diatribe against immigrants, poor people, liberals, our President and his party, so laden with half-truths, vitriol and outright nonsense that even a Rush Limbaugh could not have concocted it!

I could hardly believe it was written by my very same patient. I wondered immediately how that might affect the care I provide him in the future. Will I be less sympathetic? Will I unconsciously skew my use of health care resources on his behalf? Will my advice regarding end-of-life issues be influenced by his views on the "right to life"? Should I recuse myself from his care? But that would constitute a form of retaliation to someone who has entrusted me with his life, and what sort of person would I be if I only plied my skills with those I agree with? In fact, wasn't it part of my Hippocratic Oath not to be swayed by such considerations? I have a few times cared for criminals and felt as though I was doing my duty, and they presumably have committed far more egregious offenses than were committed by my patient.

In the end I decided to file it away and never mention I had seen the letter. But my relationship will never be quite the same, in the same way that one might be put off to find that someone we respect has committed some act that betrays that respect. Sometimes patients find that their doctors have feet of clay, but it is a rude shock for me to learn that my patient is not all the man I thought he was. I guess this is just something else I have to accept: I have to maintain my role as a healer regardless of whether I have contempt for a patient's substance abuse, legal problems, sexual misconduct, or abhorrent political attitudes. Somehow the last one feels uniquely difficult today.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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