Addressing Substance Abuse, Sexual Activity With Patients: Expert Insight

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The key to having conversations with your patients about sensitive topics is to make the atmosphere feel inviting.
The key to having conversations with your patients about sensitive topics is to make the atmosphere feel inviting.

Many physicians do not ask patients about sensitive topics, such as substance use/abuse or sexual activity during routine medical histories. One reason is that they feel uncomfortable or they do not feel adequately prepared to have these discussions (McBride, R. 2012). To shed light on this challenging topic, MPR interviewed Windel Stracener, MD, a family practice physician at the Wayne County Community Health Center, Richmond, IN.

Please tell us a little about your own background and work with patients.

I have been in family medicine for 22 years. For a while, I was a hospitalist but I am now practicing in a community health center. This gives me the opportunity to develop relationships with patients and their families, often several generations. These relationships can be very helpful in bringing up sensitive subjects because patients already trust you and know you have their best interests at heart and that the issues you raise are not being asked to belittle them but to offer solutions and help them avoid hospitalization or chronic diseases.

How do you discuss the subject of weight loss and lifestyle changes?

Patients must feel that you are empathetic and do not judge them. This is key not only to discussing weight, but to any subject that comes up. I always try to give honest, straightforward answers and make patients feel at ease.

When you are bringing up the issue of weight, it is important to do so in a broader health context. “I see from looking at your BMI that you've got some extra weight we need to deal with.” If relevant, you can explain how this affects the reason for today's visit. You can also explain the impact of extra weight on the heart, lungs, blood pressure, and renal system.

Patients should feel that you are a partner who helps them find a path in their health plan, which will make them more committed to the plan. You become a cheerleader to encourage success and urge them not to get discouraged when a plateau occurs.

It is also important to set realistic goals. I don't say, “You need to lose 110 pounds by the end of this year.” I say, “Your first goal is to lose 10 to 15 pounds. Great, you've lost 8 pounds, now let's see what we can do next.”

What is your approach to discussing sexual subjects?

Patients usually raise these subjects to me because they come in with a specific problem they want to discuss. With other patients, especially adolescents, I raise the topic of sexual health as part of a well exam, often using questionnaires. Our nurses will sometimes broach the subject, which helps identify the youngsters' questions, which they then bring up to me.

You mentioned adolescents. How do you address other topics with them?

We have healthy living questions and risk factors questions—for example, are you using drugs? Do you have friends? How do you get along at home? Do you participate in activities out of school? Are you sexually active? And if the answer is yes, we might ask, “Are you engaging in oral sex or intercourse?” Again, the atmosphere must be empathetic and inviting so that the patient will feel safe discussing these issues.

Problems may be brought to me by family members who are concerned about behavior at home, poor grades at school, or socialization. I live in an area where there is  a large heroin problem, which we deal with on a daily basis, so families sometimes want drug testing for their child.

Most patients will have a least one person in the family who is not happy with what is going on, and they won't be happy either because they are being accused. My job is not to be an accuser but to discuss drug use from a health perspective, offer to help, and find out if they are or are not using.

Because I work entire families, I can sometimes facilitate a balanced look, help all family members deal with the situation and help parents take a more positive and less judgmental approach toward their children.

Do you address sensitive issues with older adults as well?

Once a year, I try to do a mental evaluation of memory and cognition. If I see that those scores are sliding, I might say, “We did some testing today and, looking over it, I see that the scores are starting to slide. Have you noticed anything related to memory, such as not remembering appointments or having trouble paying bills?”

It will often emerge that the patient is already aware of these issues, which have been growing over time, and other family members are already stepping in to help with appointments, bills, or other tasks.

Children of older people see me because they are worried about their parent or grandparent. In that case, we may need to have a family appointment. If the elderly parent is living alone and becoming increasingly frail or cognitively impaired, I suggest services, such as home health aides, home nursing, or community help so the parent can remain at home, and I point out concerning signs to look for.

The hardest conversation to have is when I think the patient is no longer safe to remain at home. This is an ongoing discussion that will not necessarily be resolved in a single visit.

I explain that I think they need more help than they are receiving and initiate a conversation either about a rehabilitation facility, if the condition is reversible, or about other options. We discuss whether everyone's goals are reasonable and viable, and work with the children and patient, always trying to keep the best interest of the patient at heart and follow his or her wishes if it is safe and prudent.

If elderly patients trust you, they will understand that you are not trying to convince them to go to a facility for any reason other than their safety, and that every effort will be made to find a facility that is appropriate for their needs.

How do you discuss smoking with patients?

When I have patients who smoke, I ask at every visit whether they are thinking about quitting. Often, they roll their eyes at me and are not happy that I am bringing it up. But I remind them that when you come to the doctor, one of the things you expect is that the doctor will ask you important questions about your health. I say, “If I haven't asked you about smoking, I haven't done right by you today.” Usually, they say, “You're right.”

We talk about health risks, available tools for smoking cessation, and I remind them that we are available to help and discuss risks. Again, I take a nonjudgmental approach so they feel safe and accepted.

Do you discuss firearms with patients?

We ask questions about firearms routinely, as part of screening, although firearm ownership is a very sensitive subject. If patients have firearms in the house, I remind them that the firearms should be kept out of the reach of children and others who do not know how to use them, and encourage patients to take appropriate safety precautions.

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Reference

McBride R. Talking to Patients About Sensitive Topics: Communication and Screening Techniques for Increasing the Reliability of Patient Self-Report. Association of American Medical Colleges. Available at: https://www.mededportal.org/publication/9089/. Accessed: February 5, 2018.

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