1 Most providers treasure their ability to care for patients. The joy derived from the provider–patient relationship remains intact despite additional individuals (e.g., employers, insurers, benefit managers, billing and collection specialists, utilization reviewers, etc.) and regulations interposed by the current evolution of health care. Additionally, providers appear to be accommodating to longer-term alterations that materially affect overall patient– provider relationships. One feature of the changing relationship is increasing patient autonomy. Many factors likely have assisted this societal change, but the extraordinary impact of readily avail- able medical information on the Internet certainly plays a role. Concurrently, the paternalistic care model (marked by the inter- action goal being determined by the provider, the provider role being motivated by being a guardian, alignment of patient values with the providers, and patient acceptance of recommendations) is waning. Providers continue the search to improve the science of health care, while also seeking to improve the art of caring for patients. Indeed, during this decade there has been notable progress in both the science and art of caring for women. Included in that progress is the long overdue scientific recognition that men and women are different. There is now scientific recognition of both therapeutic dispar- ities attributable to gender as well as marked differences in gender inclusion in clinical trials. Additionally, there is a renewed appre- ciation that women frequently have different symptoms, risk factors, and drug reactions than do men. For example, recent changes, mak- ing drug protocols more gender-specific and including women in major drug trials have reduced the disparity in treatment; however, the disparities are not yet eliminated. Advances in the art of medicine include acknowledgment of difference in the way the two sexes approach problems. This sociolinguistic gender difference in problem solving affects the 1 THE FEMALE PATIENT CHAPTER Copyright 2001 The McGraw-Hill Companies. Click Here for Terms of Use. BENSON & PERNOLL’S 2 HANDBOOK OF OBSTETRICS AND GYNECOLOGY process of medical care. In general, men prefer to solve problems themselves. Male patients present problems that they expect the physician to resolve, whereas women seek opinions or suggestions from others and then solve the problem with this consensus. Female patients may want to discuss a problem but do not necessarily ex- pect their doctor to resolve it. Male physicians tend to think that problems presented must be solved. Women regard interview dis- cussions with their physicians as opportunities to clarify problems and to obtain information about the implications of problems and treatments in their lives. This expectation can frustrate men, in- cluding male physicians. For some time, providers have recognized certain complexities in communicating with female patients (v. male patients), includ- ing: lengthier and more detailed patient histories, more complaints expressed less succinctly in symptomatic interviews, and a greater variety of illnesses reported by female patients. Some of the other gender difference observations concerning the provider–patient re- lationships are summarized as follows: ● Providers spend more time with female patients. ● More diagnostic errors are made with women patients. The most common explanation for diagnostic errors observed with female patients is the clinician’s readiness to attribute women’s symptoms to “overanxiousness.” ● Interventions with women patients by physicians tend to be less aggressive. ● Generally, providers give more explanations to female patients. ● Providers impart more explanations rephrased from medical terms into lay terms when talking to women. ● When talking to women, providers give more responses to questions at the level of speech of the patient. ● In negotiation of treatment plans, male physicians may ex- plain the meaning of a female patient’s comments back to her and then attempt to guide her behavior through sugges- tions or instructions. ● Female patients may make overt attempts to share the control of the discussion by insisting on validating their symptoms with repetition, becoming more dramatic in their presentation of symptoms, switching to new symptoms, or reporting symp- toms of questionable severity. Other elements influencing the provider–patient relationship in- clude: provider gender, the nature of the interaction, the nature of the communication, understanding the patient’s perspective, com- munication training, and awareness of gender issues. PROVIDER GENDER AND OTHER CHARACTERISTICS Provider gender and other characteristics matter in shaping the provider–patient interaction. Indeed, recent studies comparing the communication of several groups of providers reveal issues useful to any provider wishing to enhance their patient communications. ● Female physicians (as well as family physicians) spend significantly more time discussing lifestyle during a first visit. ● Women physicians generally use more collaborative models of patient–physician relationship. That is, female physi- cians both facilitate and are more effective in developing provider–patient partnerships to enhance patient participa- tion in the medical exchange. ● Female physicians spend more time with their patients. The National Ambulatory Medical Care Survey reported that male providers spent 18.7 minutes per patient, whereas fe- male providers averaged 23.5 minutes. ● Female physicians spend more time communicating, specifi- cally more time: gathering information, offering explanations, negotiating treatment, and providing emotional support. How- ever, the additional dialogue with female physicians has not been associated with greater diagnostic or treatment accuracy. Much of the extra conversation is devoted to physicians’ talk- ing rather than information gathering. This suggests that fe- male physicians use the time to offer explanations to patients of both genders, to negotiate treatment, and to provide emo- tional support. ● Male physicians tend to explain the meaning of a female pa- tient’s comments back to her and then attempt to guide her behavior through suggestions or instructions. ● Female providers (v. male providers) are more likely to: have a dialogue concerning social and psychological issues, more often explore patient’s feelings and emotions, talk more pos- itively in the encounter, focus more generally on partnership building, and give information and emotional support. ● Women, family physicians, and recent graduates are signif- icantly more likely to have an empathetic communication style. ● Women and recent graduates are significantly less likely to have a directive, problem-oriented approach to care. ● Medical and surgical specialists are more supportive of pa- tients’ rights (than primary care providers). CHAPTER 1 THE FEMALE PATIENT 3 BENSON & PERNOLL’S 4 HANDBOOK OF OBSTETRICS AND GYNECOLOGY ● Female physicians are likely to view patient autonomy and initiative more negatively than their male colleagues, indi- cating again that women prefer consensual decision-making. THE NATURE OF THE INTERACTION The character of a therapeutic relationship may be described by who (patient or provider) controls variables within the interaction. These interactional variables include: determination of the inter- action goals, the provider’s understanding of his or her role (obli- gations), the role of patient values in the visit, and expression of patient autonomy. Given these variables, relationship types occur across a range from medical paternalism to patient consumerism. At one extreme is the paternalistic model. Characteristically, in paternalism the goal of the visit is determined by the provider. The provider’s role (motivation) is that of a guardian taking action in the patient’s best interest. Patient’s values are assumed to be aligned with those of the provider. Patient response to the provider’s recommen- dations is anticipated to be agreement. The other end of the relation- ship spectrum is the informative (consumerist model). In this model, goals are patient generated. The provider’s role (motivation) is that of an expert who conveys technical information. The patient selects the medical intervention deemed most appropriate from their various options. In a total consumerist model, patient values are not explored or linked to the information provided and patient autonomy is de- fined as independent control over medical decision making. Between these two extremes are patient–provider relationships of collaboration and partnership. It is within these relationships that the exploration of patient values is most authentic and the achievement of patient autonomy is most fully insured. In these models, the fol- lowing occur: mutual goal setting, a provider’s role as collaborator, mutual consideration of patient values, and ensurance of patient autonomy. Although in all human interactions, communication is cru- cial, for providers to succeed in collaborative/partnership models re- quires special attention to their communication. Indeed, communica- tion is the key to address perceived unmet needs in compassion of care in our technologically evolved medical model. Thus, a brief con- sideration of communication may be of assistance. UNDERSTANDING THE PATIENT’S PERSPECTIVE Communication is the key to any healthcare provider in their vital role of caring for patients. Communication is defined as the ex- change of thoughts, messages, or information. Ideally, communica- tion leads to those involved understanding each other’s position(s). Goals of successful communication include: discerning issues and concerns from the other’s point of view, identification of key issues and concerns, the determination of what would constitute an ac- ceptable solution, and successful ascertainment of possible options to achieve those results. To accomplish these goals requires effec- tive listening to the others involved in the communication. At a min- imum, listening requires patience, openness, and the desire to un- derstand. More effective listening requires being an empathic listener, that is, identification with, and understanding of another’s situation, feelings, and motives. Steps to empathic listening go be- yond mimicking content to understanding the message well enough to rephrase content, including the emotional context of the message. Communication is influenced not just by speech, but also by be- havior, body language, nonverbal signals, environment, and a host of other factors. Certainly, how the provider asks about symptoms (open-ended questions are most desirable), how the provider validates signs and/or symptoms, and the patient’s comfort in the atmosphere of that par- ticular provider, influences the quality and quantity of information transmitted. This is particularly true when there are difficult issues or problems (including psychological or physical abuse) involved. Thus, the very success of diagnosis, treatment, and prevention often rests on the provider’s cumulative communication skills. Im- proved clinician–patient interpersonal communication has a posi- tive impact on both therapeutic adherence and health outcomes. Similarly, less than desirable provider–patient communication has untoward outcomes for both patient and provider. Crucial issues in the provider–patient interaction frequently questioned (often through a legal or quality assurance process) include: gathering and validating information for a correct diagnosis, informed decisions, informed consent, and motivation to a therapeutic regimen with the best outcomes. When providing information, it is necessary for the provider to consider other issues concerning the material they are attempting to communicate. ● Do I cognitively understand the information well enough to communicate it? ● Have I communicated in a clear and unambiguous manner? Ambiguity (naturally occurring or experimentally produced) leads to reduction in attention engagement. ● Was there something in my behavior that influenced the manner in which the information was received? CHAPTER 1 THE FEMALE PATIENT 5 BENSON & PERNOLL’S 6 HANDBOOK OF OBSTETRICS AND GYNECOLOGY ● Is my communication acceptable to the patient (given their culture, circumstances, etc.)? ● Does my communication involve making a change that is unacceptable to the patient? Many times provider communication involves the desirability (or necessity) for a patient to change. These changes may be simple (e.g., one medication to another), complex (lifestyle or weight), or in conflict with established habits or addictions (smoking, drug use, alcohol, etc.). Providers may not understand, believe, or accept the logic (or thought processes) their patients employ in such situations. In these cases, providers need to recall a basic tenet of change, that is, no one can persuade another to change. The commitment to change must come from within the individual doing the changing. Additionally, the provider must consider the mental status of the patient. A number of mental conditions will materially affect the patient’s communication and nearly all of these are enhanced in in- tensity or frequency of occurrence during the internal surrounding birth. DEPRESSION Major depressive disorders are more prevalent in women. Although individual environmental experiences play a major role in the de- velopment of depression, these disorders are more heritable in women (as compared to men). Certainly, most providers are famil- iar with traditional depressive symptoms (sleep disruption, mood depression, and appetite disturbance). These traditional symptoms, however, are only a portion of the more global expression of de- pression. Other, and perhaps more subtle, signs of depression in- clude nonverbal hostility, social withdrawal, and/or submissive and affiliative behaviors. Although depressed women generally express more socially interactive behaviors than men, both may demonstrate global restriction of nonverbal expression. GUILT Guilt contains elements of shame, aggression, and vagueness in communication. The emotion of guilt most commonly arises when a woman perceives herself a failure in her responsibilities and most commonly arises in situations when a woman lacks control over the multiple demands made on her from different life responsibilities. Guilt may also occur in situations where a woman assertively puts herself and the responsibility for her own needs above others. Fre- quently, such conflicts and subsequent emotions arise about her mul- tiple responsibilities with children. Guilt is characterized by its emo- tional strength, repetition, and consistency. ANGER Gender role socialization can lead (or even teach) women to sup- press anger. This may lead to denial of a sense of self as well as to somatization. Women in this circumstance may profit from assertive communication education. The outcome of teaching women as- sertive communication is to provide effective tools to regain con- trol of their life experiences. Frequently, it is necessary to move from the belief that “others are responsible for meeting women’s needs,” to the belief that, “women are personally responsible for meeting their own needs.” PELVIC PAIN Pelvic pain patients generally express more hostility than patients with other conditions. Attitudinal and personality factors may alter both the expression of pain as well as the patient’s medical experi- ence, but providers should be prepared to deal proactively with the hostility. Generally, poor prognostic indicators include: more severe levels of pain, a greater number of impaired functions of daily life, and endometriosis; however, therapy is beneficially influenced by the provider’s success in communication. Indeed, providers’ subtle attitudinal and personality factors modify patients’ experience in these challenging conditions. PATIENT COMPLAINTS Publications concerning patient complaints, while difficult to sta- tistically quantify and compare, reveal trends that may assist the provider in avoiding behaviors or events triggering patient dissat- isfaction. Overall, nearly two thirds of complaints concern clinical care. The major dissatisfaction is with outcome. More than 20% of complaints pertain to rudeness or poor communication, and more than 10% relate to unethical or improper behavior. Women register 70% of complaints and nearly half of complaints are on behalf of another person. Over half of complaints arise from events occurring in doctors’ consulting rooms. PATIENT–DOCTOR COMMUNICATION SURROUNDING CRUCIAL CHAPTER 1 THE FEMALE PATIENT 7 BENSON & PERNOLL’S 8 HANDBOOK OF OBSTETRICS AND GYNECOLOGY LIFE EVENTS Clearly, communication about end-of-life care both improves the perception of quality of that care as well as beneficially influencing advanced directives. Equal benefits occur for thoughtful communi- cation with patients who have complications, untoward outcomes, or multiple disease states. As noted previously, all too frequently these patients have a variety of care providers, all well intentioned, but none assuming the important task of communication. COMPLEMENTARY OR ALTERNATIVE THERAPIES Currently, patients may not fully disclose their use of complemen- tary or alternative therapy to their traditional medical provider(s). This is the case in even those who welcome an open discussion and in those with serious problems. For example, in breast cancer pa- tients, nearly three fourths of patients initially use (and by 6 months approximately two thirds) at least one complementary or alterna- tive therapy. Only slightly more than one half, however, disclose this use to their medical provider. By contrast, over 90% discuss details of their biomedical treatments with their alternative practi- tioner. In sum, if the health provider does not initiate or encourage discussion concerning complementary or alternative therapy, it may be an important area not communicated. MULTIDISCIPLINARY TEAMS Special attention to communication is mandatory in team care sit- uations. Multidisciplinary teams require theoretical, clinical, and professional consistency. Indeed, consumer ambiguities may be ex- pected if the entire team does not share common missions, objec- tives, and language. Consistency is easier to obtain in team care models planned for specific purposes than it is in situations where the team comes together for only that patient, or that particular prob- lem (e.g., crucial events in patient care). COMMUNICATION TRAINING Provider communication difficulties can be overcome by commu- nication training. Providers of both genders can be effectively trained to use more patient-centered skills. Once trained, these skills become evident in their practices. Moreover, female patients report greater involvement with male and female physicians who received communication training. Other provider opportunities in gender specific communication include: reducing gender bias by being aware that it exists and being aware of the implications posed by potential gender differences in both verbal and nonverbal behavior. THE UNIQUENESS OF THE PATIENT–PROVIDER INTERACTION Each female patient presents a unique set of circumstances, beliefs, and expectations. Her sexual and reproductive experiences and or- gan function are quite individual. She may be fearful of the gyne- cologic examination or may be uncomfortable confiding things that she considers private or embarrassing. Alternatively, she may be to- tally matter of fact about her body and its problems. Each patient at every visit is a whole person. She should not be regarded as an assemblage of parts, some of which are more interesting—pregnant or more apt to become cystic or cancerous—than others. To assist in establishing rapport early in the doctor–patient re- lationship, ascertain how the patient prefers to be addressed. Some women prefer the use of their first name, whereas others prefer to be addressed using the formal salutation of Miss, Ms., or Mrs. Make a notation of her preference, because she will recall the inquiry and expect her response to be remembered. In addition to possessing competence and skill, the provider must be able to instill confidence about the privacy of all discus- sions. Above all, the patient must sense that medical personnel truly care about her. A major step toward achieving this goal during the initial visit is to obtain the history in a quiet office with no sense of haste and with the patient fully clothed. Information not readily volunteered early may be disclosed when the patient becomes more comfortable as the interview progresses in a nonjudgmental fash- ion. Review pertinent episodes in her past medical history, family history, social history, and the review of systems, perhaps using a standardized questionnaire completed by the patient before seeing the care provider. Focusing on details of the patient’s concern early in the process may be helpful. For example, leaving the genitouri- nary system discussion until last may cause her to believe that you are avoiding her problem. Information about the number of preg- nancies, deliveries, abortions, contraception, sexually transmitted diseases, drug usage, sexual practices, and marital status is essen- tial. Current medications and any allergies should be prominent in CHAPTER 1 THE FEMALE PATIENT 9 BENSON & PERNOLL’S 10 HANDBOOK OF OBSTETRICS AND GYNECOLOGY the review of past history. Ascertain whether or not she has a fam- ily doctor, since the physician providing reproductive care may be the only one to examine the patient routinely and must, therefore, provide primary care. The patient’s answers to personal questions may not coincide with the caregiver’s personal moral standards, religious beliefs, sex- ual practices, or experience. He or she must not judge, however, but assist with the patient’s problems within her frame of reference. Nonetheless, do not neglect to give information about safe sexual practices, proper therapy, and potential consequences of her or her partner’s actions. Occasionally, one must stress that certain behav- iors may affect not only the patient herself but also her offspring (e.g., drug use, infection). The caregiver must be prepared to con- sider marital difficulties, sexual dysfunction, and sexually trans- mitted diseases including AIDS. THE PHYSICAL EXAMINATION The initial examination should be a general physical examination, including a breast examination and the gynecologic examination. If the patient is not performing breast self-examination regularly and properly, plans should be made for her to receive instruction in the correct method. Arrange the examining room to reassure the patient that her privacy is not being invaded via the doors or windows. For exam- ple, even the view of a beautiful garden can be distressing to the patient who fears that a gardener may suddenly appear during the examination. The patient should be undressed completely and draped for ex- amination. Sensitivity to the patient mandates that she not be placed in the dorsal lithotomy position to await the caregiver’s arrival. This position may soon become uncomfortable and may leave her feel- ing vulnerable. When performing the pelvic examination, have a female nurse or attendant present, if possible, for assistance and to provide a measure of comfort and reassurance to the patient. Explain the pro- cedure before performing any maneuver, and give advance warn- ing of any procedure that may be uncomfortable or even painful. Use instruments deftly. Warn the patient that you will be doing a vaginal or rectal examination before insertion of fingers or instru- ments. Warming the hands and instruments is a small act that indi- cates interest in the patient’s comfort. The teenage patient responds to open, honest dialogue. Parent(s), if present, should be asked to wait in the reception room unless the [...]... differentiate in the embryo at about 6 weeks The upper ducts elongate and the lower ducts fuse The tract then canalizes to form patent oviducts, the uterine cavity, the cervical canal, and the upper two thirds of the vaginal canal The lower one third of the vagina is formed from invagination of the cloaca This duct development requires 4–5 months ORIGIN OF THE FEMALE EXTERNAL GENITALIA The external genitalia... duct is vestigial in the female, but it becomes the epididymis and vas deferens in the male The metanephros (true kidney) begins about the fourth week, as the mesonephric tubules develop and degenerate The mesonephric diverticulum (ureteric bud) begins to grow out from the mesonephric CHAPTER 1 THE FEMALE PATIENT 19 duct slightly cephalad to the cloaca to become the ureter and the metanephros or permanent... development of the female urogenital system is well under way by the fourth week after implantation, following the sequence shown in Figures 1-1, 1-2, 1-3, and 1-4 The external female genitalia evolve after about the seventh week ORIGIN OF THE OVARIES During the fifth to sixth week, primitive sex cells migrate from the yolk sac into the dorsal mesodermal genital ridge, destined to become the ovary The sex...CHAPTER 1 THE FEMALE PATIENT 11 patient (not the parent) insists otherwise It may be difficult to obtain an accurate history from the teenager because there may be a high degree of misinformation or misunderstanding of the function of sexual organs and the terminology Open-ended questions, however, should provide the examiner with a fairly accurate estimate of the patient s knowledge and... with the genital tubercle becoming the mons pubis and clitoris The hymen represents the merge of the upper vaginal (mullerian) portion and the lower vaginal urogenital sinus Because of the intricate interdevelopment and the small size of the parts, the sex of the fetus rarely can be determined with confidence by ultrasonic scanning or even direct visualization until after the 22nd week ORIGIN OF THE. .. affront, that what they would choose for themselves may be unacceptable to the patient because of her lifestyle or financial and social situation Thus, the patient must be respected as an individual The expression of that respect must continue through the development of a partnership with the patient to improve her health and well-being NORMAL DEVELOPMENT OF THE UROGENITAL SYSTEM The female generative... that merge with the allantois The eventual bladder architecture is apparent by the tenth week, when the caudal extension, the urethra, finally opens into the urogenital sinus derived from the cloaca The adrenal (suprarenal) glands begin to form about the fifth week from mesenchymal cells, similar to those that produced the nonterminal portion of the ovary, together with nearby cells from the neural folds... permanent kidney During the fifth through sixth weeks, the ureter divides within the developing mesonephric mass to form calices Collecting and secretory tubules then appear within the renal mesenchyme to connect the true vascularized glomeruli in the renal cortex There is slight kidney excretion by the tenth week During the second through third months, the bladder develops from the widened lower wolffian... knowledgeable about the many problems that arise in the geriatric patient When the health care provider recommends a particular course of therapy, she or he must be prepared to offer alternatives, to accept a second opinion, and, above all, to allow the patient the opportunity to participate in decision making There may be instances when financial concerns dictate the best course of action under the circumstances... are italicized The mesonephros (middle kidney) forms caudal to the pronephros along the mesonephric duct, which finally extends to the cloaca Along the duct, mesonephric tubules, each with an arteriole and a venule, form primordial glomeruli The mesonephros, developed by the seventh week, extracts waste products from celomic fluid and blood By the ninth week, the tubules degenerate The mesonephric . severity. Other elements influencing the provider patient relationship in- clude: provider gender, the nature of the interaction, the nature of the communication, understanding the patient s perspective,. reported by female patients. Some of the other gender difference observations concerning the provider patient re- lationships are summarized as follows: ● Providers spend more time with female patients. ● More. problems themselves. Male patients present problems that they expect the physician to resolve, whereas women seek opinions or suggestions from others and then solve the problem with this consensus. Female patients