** For the purposes of anonymity and confidentiality this interview has been fictionalised – no one real-life doctor corresponds to one character in the following piece. Rather, it is an amalgamation of views and statements from a number of healthcare professionals along with my own perceptions and ideas**
Hospitals are places that push our boundaries, our sense of privacy, and nudge us out of our comfort zones. Nakedness, crying, screaming, embarrassing fears of needles or blood, admitting to bad habits or addictions, strange fetishes, episodes of incontinence - the curtain dropped, exposing the parts of us we keep hidden from the rest of the world. An encounter with a doctor holds its own intimacy - one that is typically reserved for those closest to us. We expose ourselves to physicians and nurses, putting parts of us on display for their inspection.
The intimate doctor-patient relationship was never the norm before the 19th century, with even the touch of Laennec’s stethoscope on our chests considered to be a transgression of privacy. Yet over time, as we have gained more trust in doctors and science and medical knowledge has excelled, it has become the norm. We have accepted this intimacy with a physician as the new norm, one for our own good, one that silences our ‘what-if’ thoughts.
Where medical examinations are key elements of the hospital experience, I was curious about the factors that may affect patient engagement in these examinations and the doctor-patient dynamic.
The first factor I explored was the gender of the doctor - is the doctor-patient dynamic affected by whether the doctor is male or female? Answering, Jacob said that "often patients will find it easier with a female doctor, that is definitely true for women and, often they get specially requested, and fairly often even men find it more comfortable with a woman". Tamsin confirmed this by telling me that she frequently gets requested to do ECGs - a test that is quite invasive and intimate, especially for the chest and breast area: "Yes, I definitely think some patients do feel more comfortable in front of a female doctor especially when it involves exposing parts of their body". As far as female patients seeking out female doctors are concerned, there are good reasons for this. Firstly, no one understands the female body better than a fellow female, especially in relation to reproductive or sexual health. Secondly, safety, a point I need not elaborate on. And, we are increasingly learning that many illnesses present differently between men and woman, a heart attack being a prime example. However, many symptom lists we see on websites are based on only the male presentation. In this regard, trust in their judgement and knowledge, may constitute the third reason. In relation to men seeking female doctors, a 22 year old man I asked said: "I think the man-man relationship is just a bit different, from personal experience, you don't really discuss 'deep' or personal issues - its more light hearted and jokey. I think because of that, I just find it easier seeing a female doctor". It is important to note that this is a generalisation and by no means always the case: many people, myself included, many find it easier seeking help from a male doctor.
Jacob stated the second factor as the gender of the patient: “On the whole, women seem to be more comfortable having intimate procedures“. Offering an explanation, Tamsin said: “As a woman we have health problems and treatments relating to childbirth, and tests such as smear tests and mammograms. This means we are much more used to having to expose ourselves to healthcare professionals and so it comes more naturally.”
As a woman, this made me ponder consultations I have had with either my GP or doctors in hospitals. Like most people, I have had medical complications, albeit minor, that have caused me to answer personal questions, or have intimate physical examinations. While I may have been reticent the first time I had to expose a part of my body, the following times I recall being more relaxed and not as embarrassed. Perhaps that comes with maturity and awareness but also with the fact that, as Tamsin said, it is the nature of the game: a woman's anatomy and subsequent health problems that arise from it, force her to acclimatise to exposing herself. To understand this gender difference further, I asked the 22-year-old man how willing he was to attend a prostate exam: “It took my girlfriend telling me 4 or 5 times to go before I did. It’s just not something I feel comfortable doing because it’s rarely something I have to do." Here them, aligned with Jacob’s remarks, there is clearly something to be said about the effect a woman’s biological anatomy has on her comfortableness in the consultation room.
A further factor related to what the nature of the issue was: mental or physical. Firstly, the physical examination, where you're exposing your body and the secondly, talking about your mental health: discussing your life, personal beliefs, thoughts, problems, and behaviours. Both involve exposing yourself, just in different forms. Contrary to what might be popular belief, Tamsin said that it's often harder for a patient to talk about their feelings or behaviours than it is for them to expose a part of their body: “While a patient might be slightly uncomfortable or embarrassed exposing a part of their body, usually when they are having to talk about a mental issue – be it addiction, depression, uncomfortable thoughts or another unhealthy habit – it takes multiple tries to get the patients to open a bit. From my experience, the mental element is definitely what causes patients more angst discussing, and understandably so.” Expanding on this, Ben said: “In comparison to a patient's physical health, people definitely feel more uncomfortable discussing their mental state and we definitely have to push more.” Ben explained that for patients who suffer from illnesses that affect how they interact with reality, for example, psychosis or schizophrenia, this is made even harder: “These patients might not want to share their thoughts or information with us due to paranoia, for example. Overall it is definitely more challenging and can take a lot longer before they do.”
Classically, when a trip to the doctor involves exposing a part of our body, we tell ourselves "its nothing they haven't seen before". And, largely speaking, this is entirely true: every doctor has seen every part of the body and likely also every infection, virus, fungus or disease that has now invaded the part of your body under inspection. Your anatomy - be it normative or nonnormative - is likely exactly what they are expecting, nothing they haven't seen, or at the very least, read about before. However, our thoughts, beliefs, or behaviours are entirely specific to us. By the nature of each of our uniqueness, our personal mental workings are not available to be studied in medical textbooks. Undoubtedly, this makes it scarier to discuss them with a healthcare professional for fear that we may be judged or that what we say might simply be weird but nonetheless, it is important to remember that the uniqueness of our thoughts, is entirely ordinary and normal. And, while no two peoples thoughts might be the same, a lot of our brains work in the same way and form the same thought or behavioural patterns. Consequently, its likely that what you say might not be all that shocking or strange as you had imagined.
Having explored some of the different factors that effect the patient-doctor relationship in the consultation room, I felt it necessary to understand how doctor’s perceive this dynamic. Are they accustomed to seeing peoples genital regions or asking deeply personal questions? Tamsin answered saying: ”Nowadays, I’m so used to asking questions such as: when did you last poo? When did you last have sex? Have you had any discharge? What kind of sex was it? Did they come inside of you? I don't fumble on words such as penis, vagina, or sex in the way I used to when I had just started practicing. But that said, I always try to bear in mind that, despite how normal I am with the situation, the patient is probably very uncomfortable." Remembering a sexual health class she attended as a medical student, she continued: "On my first day, a doctor walked in and said: 'I want you to turn to the person next to you and after 3 you’re going to say the last time you had sex, what type of sex it was, who it was with, and whether you used protection'. We were all shocked. He proceeded to count down and then he said 'STOP - That’s how it feels for a patient when they walk in and you start asking them those questions'. That really resonated with me and has definitely influenced how I talk to patients."
And, lastly, in relation to the physical side of the examination, Jacob gave a resounding yes: "Yes, I am definitely very used to it now. Of course when I first started, it was bizarre. But after seeing any and every part of the body, even just 20 times, its nothing new, its very uneventful. Trust me, if you think your penis or fungus infected toe or back wart is the most embarrassing thing in the world - its not, least of all to me. I've seen it before, many a time."