By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting
On Call Magazine, November 13, 2008

Sexual dysfunction, depression, and abuse are only a few of the many touchy” topics patients find hard to bring up to their healthcare providers. But these very problems could actually be at the root of what is happening to them medically.

Machelle Seibel, MD, has had a lot of experience talking with patients about difficult topics. Seibel is director of the Complicated Menopause Program at the University of Massachusetts Medical School in Worcester, Massachusetts. People of both genders and all ages, he says, face life challenges that affect their well-being. “I’ve never met anyone going through a transition in life who didn’t think it was complicated,” he says.

Sometimes, what’s troubling patients when they come into a health provider’s office is not what they made the appointment for. For example, Seibel says a patient may come to see him because she says she wants to talk about medication or needs help knowing how to deal with hot flashes. But the conversation that needs to take place may actually be quite different. For instance, she may be worried that her recent forgetfulness and mood swings are symptoms of a more serious psychiatric disorder. Another patient may actually bring up the topic of a declining libido while, in her mind, she is really associating her sexual problems with an unraveling relationship.

When I recently talked with Seibel he shared some tips about what healthcare professionals need to do to help patients who have touchy subjects to explore.

Listen for clues about possible problems.

Active listening is always an important communication skill. Seibel says one indication that there are unspoken concerns is a patient’s response to a topic that is “out of range.” A reaction that’s out of proportion to what could normally be expected should alert the provider to pay close attention to what the patient is saying and not saying. Another clue, Seibel says, is when a patient “won’t talk or won’t stop talking, about a topic.”

Establish rapport.

Clinicians need at least tacit permission from patients before exploring difficult topics. Seibel starts with gentle questions about overall well-being. He then follows-up based on the patient’s response. For instance, when a woman says that she fears memory loss means that she is losing her mind, Seibel might ask, “Can you tell me about family members with a history of mental disease?” He may follow-up with more specific questions such as, “What type of situations make you more tearful?” or, “What type of situations cause you to act in ways that are out of character?” Seibel asks these in open-ended ways so that responses provide more information other than just “yes” or “no.”

Take a complete history.

Seibel schedules extra time to discuss health histories with new patients. Some medical practices ask patients to complete and return health histories prior to first appointments. In Seibel’s opinion, while this process may be efficient, it is not necessarily effective in uncovering “touchy” topics. He learns much more when talking with patients directly and noticing eye movements, hand gestures, and overall body posture.

Raise topics yourself.

Sometimes patients won’t initiate discussions of topics they consider embarrassing or perhaps trivial. Clinicians may need to mention them first. For instance, when Seibel does a physical exam and notices that a woman’s bladder has dropped, he might ask about problems with urine loss. This scenario is very common as about 30% of women have stress incontinence (or other type of urinary loss) but wait about three to five years to say anything. Seibel knows that incontinence is a highly treatable condition and therefore will mention it.

Understand problems in context of family and social history.

Although patients may come to appointments alone, their concerns may be as much about others as themselves. Many patients worry if they are destined for the same medical fate as their parents. For instance, a 59-year-old woman might be very concerned that she is getting osteoporosis since her mother fractured a hip at age 60. Likewise, people may be concerned about their loved ones’ mental or physical health. This can be a “chicken and egg situation,” says Seibel, as when a woman makes an appointment for problems with sexual functioning but spends most of the time discussing her husband’s job stress or prostate cancer.

Know your boundaries.

Patients are likely to pick up “vibes” when providers are uncomfortable discussing certain topics. This might happen when providers are in the midst of their own marital or financial problems or have strong views about sexual practices. In such instances, Seibel recommends that providers refer patients elsewhere. You can do so with statements such as, “We may have touched on something important, but I’m not the one to talk about it with you. I have a colleague who can help.” And then make the referral. Another time for referral is when the patient’s symptoms are outside your area of expertise. For example, you might refer patients to acute psychiatric care when they raise serious psychosocial concerns.

Manage issues of time.

Even though Seibel invites patients to share concerns at the beginning of appointments, very often they wait until the very end to say what is really on their minds. If there truly is no time, you might say something like, “You just raised a very important point. Unfortunately, I don’t have time to talk about it now. Let’s make another appointment for you to come back and discuss it.”

Occasionally, patients may be very tearful or upset and need time to regain their composure. There is no way around this. They need extra time. As needed and if appropriate, you might acknowledge that you have another patient to see but will come back in a few minutes to check on how he or she is doing.

Over the years, Seibel has found that it is “more embarrassing to bare your soul than your bottom.” People obviously are willing to show off their bodies (as when wearing skimpy bathing suits or being examined) but far more reluctant to reveal any weakness or feeling of failure. To Seibel, being neutral, empathetic, and willing to listen transcends all differences when it comes to talking about touchy topics.

Ways to learn more:

Dr. Machelle Seibel is Professor of Obstetrics and Gynecology and Director of the Complicated Menopause Program at the University of Massachusetts Medical School. You can learn more about his work by going to his Web site.

Helen Osborne, MEd, OTR/L, is president of Health Literacy Consulting. She received two “Gold” 2008 Plain Language awards from NIH for her work on the NCI booklets “Radiation and You” and “Chemotherapy and You.” Her column appeared regularly in On Call. You can contact her by e-mail at Helen@healthliteracy.com.