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Archive for April 7th, 2009
While the patient is talking, one begins to get a feel about the patient. One may hear snippets about their partner, the family or the workplace and begin to understand their feelings about sex and contraception. Family intentions are very important and relevant to the discussion of different methods. Listening carefully may reveal the sort of conflicts mentioned earlier in this book.
A common practice in family planning clinics is for patients to see the nurse for history-taking and then go in to see the doctor. While fully acknowledging that many patients develop rapport with nurses better than with doctors, this split type of consultation can have disadvantages. Highly trained nurses can run their own consultations independently (the so-called delegation session) unless a medical problem arises or an IUD insertion is required.
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Miss B. originally attended with her partner for a new patient interview. They were an incongruous pair: he was grubby with a marked local accent, wearing torn jeans and with his hair in a pony-tail, while she was a slim, neat girl with a well-educated voice. He did all the talking and was concerned because she was always feeling ill. Some tests were arranged and the doctor was relieved when she reattended by herself. Miss B. ignored the test results and reassurance offered. Her boyfriend had told her to get a coil fitted. She said that after the enquiries at the last consultation (when he had assured the doctor that contraception was not a problem), he had thought about it and decided that as he did not want any children about the place, she had better get fixed up. Suggestions that she might have some opinions or feelings about it were met with a look of incomprehension and after battling for a while – ‘I must have a coil today’, she kept saying – the doctor gave her some leaflets to read and arranged to see her with her period the following week. At that consultation, she arrived in complete distress, her boyfriend having been picked up in possession of drugs. Decisions were postponed. Next time she was more composed and ‘they’ had decided she would go back on the Pill, which she had taken ‘for several years’. Further enquiry revealed that her boyfriend was on remand and likely to be sent to prison. Naively the doctor enquired why contraception was necessary, only to discover that Miss B. lived in a multi-occupied house and without her boyfriend’s presence would be expected to be available to the other men living there. The doctor, sure by now that there were deep underlying problems, probed and listened and encouraged until the girl, relaxed and open, was able to reveal that she had been dominated totally by her authoritarian solicitor father and sexually abused by him until she was 20. She had then met her present boyfriend through her black sheep brother who had rebelled against her father and was into drugs and various criminal activities. She had been thrown out of her home only to join another abusive environment, and had no idea
of how to take control over her own life or sexuality. She saw herself as available to be used and only considered contraception as a necessary part of this.
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Straightforward advice about the safety of combined oral contraception in the low-risk woman until the age of 45 or more can be sufficient, and the safety of the progestogen-only Pill up to the menopause is well known. Reassurance that the IUCD can often be retained longer than five to six years may put the patient’s mind at rest. Someone who has used the cap with no difficulty and is now in her 40s is unlikely to conceive with this method.
For those women whose partners have successfully used a sheath for many years, a failure is very unlikely, and a request for a change of method may be an indication of some other problem. For a man who is suffering some degree of impotence, the need to stop to put on a condom can be the last straw. If a woman is requesting contraception for the first time, or after using other methods for a long spell, or perhaps with a new partner, the sheath may be a little risky, especially if she is very definite about her need to avoid a pregnancy.
If the patient is allowed to express the feelings that have brought her to the consultation, reassurance and explanation may be sufficient. However, if her anxieties are not related directly to the method, the underlying difficulties should be explored further.
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Among the commonest interpreters available for immigrant couples are their children. These are the least suitable in my view. Either the clinician limits his enquiry severely, to spare the child distress, or, inured to the vulnerability of non-white children, he uses them indiscriminately. In the experience of Tower Hamlets general practitioners, stress-related illness has a high prevalence in Bengali children, and the role of go-between must increase their anxieties. Husbands who have preceded their wives to the UK often have sufficient English language skills to interpret. Such help for the woman is still quite different from having access to an impartial translator of her words, and there is a confusing overlap in the triangular consultation. The problem cannot be solved easily by bringing in an independent translator. Our own antenatal clinic was served by Bengali women who had been trained to act as interpreters for maternity services. Husbands of the pregnant women would usually ask them not to come in to the consulting room, for if they did the husbands saw that as a very obvious mark of their own inadequacies. Immigrants from a village culture are also understandably wary of the network of gossip.
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If patients have problems with mobility or mental handicap it may be necessary to see them on their own territory when familiar surroundings can provide a greater sense of security. Few general practitioners will have any difficulty in the home environment, but for other doctors the loss of the secure consulting room setting can increase their sense of unease.
If the doctor feels overwhelmed by the size of the problem it can be valuable to break it down into smaller parts, remembering that ‘the longest journey starts with a single step’. The areas of need can be divided into three parts; emotional needs, physical or practical needs (that is, ‘how to do it’) and contraceptive needs.
The first two areas of need may appear more difficult and may arouse more anxieties because, if the patient is able to achieve sexual intercourse, then the whole question of the advisabilty of pregnancy and the need for contraception will follow.
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