My patient looked amazing. Dazzling even. Her hair was perfectly coiffed, her make-up expertly applied, her clothes stylish, and her earrings dangled to her shoulders. She was calm and confident. She looked fit, healthy, and terrific. I was stunned.
Stunned because I hadn’t seen her in over a year, and the last time I saw her she was miserable. She had been coming to me regularly, seemingly every few weeks. Every visit was a new crisis, a new fire to be put out: vaginal bleeding, intractable pain, anger issues, and suicidal thoughts. It seemed endless, and each time I tried to address each problem with expertise and compassion. And then, she disappeared.
Fast forward a year and here she was, looking like a new person.
When I asked her why she was doing so much better, she calmly said, “I think it’s because I gave up smoking crack.”
I laughed, and then I realized she was dead serious. She had been smoking crack? How had I missed that? I’d taken a social history the first time I saw her; was I too rushed to notice? How did I miss her most relevant condition?
I see about 24 patients a day at my community clinic. The bulk of my patients are women, but I see men and adolescents as well. I am well aware that some doctors do not prefer female patients, believing that they talk too much and take up too much time. Since we all have to care for as many patients as we can in a day, many doctors dread any patient who will slow them down, and for some doctors that means women.
As a woman and as a doctor, I want to be sensitive to the special needs of my female patients, but I had fallen short in this case. In reviewing this patient’s file and considering the needs of my other female patients, I realized that women are different, and that the key to caring for women patients is to focus on those very things that make them different and to design their care differently. But by different, I am not advocating more care, just better care—care that is sensitive to what women need, care that is sensitive to the way women give and receive information, and care that doesn’t compromise our schedules or efficiency.
From that moment on, I changed the way I treated my female patients. I didn’t spend more time with them; I spent better time with them, and found that I was able to provide better care. Here are six simple things we can all do right now to provide better care for our female patients:
First, ask, and then ask again. When I think about the times that I have failed my female patients, it’s because I should have asked more than once about issues like domestic violence, alcohol, and drug use. I have been burned many times on this. I routinely ask at the first visit, but patients can deny these troubles to a stranger. It is imperative to revisit these questions months or years later when she knows and trusts you. In the big picture, who cares if your patient is vigilantly following the American Heart Association’s guidelines for cholesterol screening if she is trying to hide her bruises or is drinking herself to sleep every night? By taking the time to ask and ask again, you will save time later. And don’t base inquiries on race or socioeconomic factors; alcoholism, drug use, obesity, and other addictions and afflictions cut across class and race.
Second, listen, and I mean really listen. I am often reminded of how equally diagnostic and therapeutic listening can be. It is the integral component of healing. At times when I’ve felt stuck, spinning my wheels, and unable to reach a patient or make the true diagnosis, I close my laptop, pull my chair closer, and give her 100 % of my attention. For some particularly challenging patients, that’s the only way to access the true narrative. It surprises me that intensive, undistracted listening can indeed fit into these ridiculous 15-minute appointments to which we are subjected.
In truth, listening helps us more than them. Not only does it improve the quality of the information we obtain, I have learned more from my patients about health and humanity than from any professor. One of my patients, a healthy 70-year-old woman, recently asked me to share her astute advice with my other patients suffering with menopause. She espoused the wonders of olive oil for a dry vulva. And also: “It is essential that in order to get through ‘the change’, a woman ought to have an orgasm every single day. An orgasm a day keeps the doctor away.” I did not learn this in med school.
Third, understand that women represent a diverse population. We will better understand a woman if we can attune ourselves to her specific needs and circumstances and the specific demands placed on her. To this point, I have cared for three female patients who are overweight because that is exactly how their husband or boyfriend likes them to be.
Fourth, let’s be humble. I have often heard women’s symptoms dismissed as too vague, too expansive, or too bizarre, when in fact they simply lack a clear explanation. Medicine has a dirty history of blaming women for their problems—thus the word “hysteria.” Fibromyalgia is a strong example of a condition that affects women more than men, and we have more to discover about it than we currently understand. Because there is no test for fibromyalgia, many doctors may still be prone to say it’s all in the head. I have deep sympathy for my patients with this profoundly painful condition. They hurt like hell, and their pain is real. We have yet to understand the cause or the cure, but in the meantime, we can humbly assure these patients their pain is not fictitious while we stand by their side to help them.
Fifth, we ought not be afraid of lady parts. It still amazes me that first year medical students are often taught a physical exam that does not include a breast or pelvic exam. In fact, those exams aren’t taught until second year, when pathology is traditionally covered. It is absurd to suggest that a woman’s medical or surgical anatomy spans from the head to the clavicles, the xyphoid to the pelvic rim, and then south of the inguinal canal.
In practice, why do so many doctors skip the breasts and the pelvis? Because they are not “women’s health experts”? That’s akin to doing a physical exam without listening to the heart because you’re not a cardiologist. I had a patient who went to the hospital twice for chest pain. After one emergency room visit and a hospitalization, she was assured she wasn’t dying and discharged with her chest pain still unrelenting, with those four common words at the end of her discharge summary: “Follow up with PCP.” Somehow, her world-class $6,000 cardiopulmonary work-up excluded a simple breast exam, which later revealed that on her chest were—yes!—breasts that were causing her pain.
And moving south, we cannot pretend to evaluate abdominal pain without examining the female pelvis. We mustn’t get lazy with the speculum. It’s not heavy. It’s not going to hurt us. And it may give us the answer we’re looking for. Women are unique physically. So examine her properly, lady parts and all.
Finally, be proactive. Help her prevent damage through health screenings, monitoring her weight, etc. Educate her to lose weight, reduce fatty food intake, and to get moving. We can’t be afraid to talk about her weight when it is her biggest issue, but then we need to empower her to change it. Medicine shouldn’t function solely as a deli counter, where one waits for customers to request their orders. We need to function like a classroom, with an attendance list. Know your patient panel. Take roll call, and reach out to your most vulnerable patients who have been tardy, absent, or needing the most care.
As important, we need to call her out when she is ignoring her own health. Recognize that women often put the needs of others before their own, so it is critical for us to be proactive and to remind her (and empower her) to take care of herself—not just her kids, spouse, parents, etc. She will not be able to take care of others unless she takes care of herself first.
Every day I am confronted with the same truth: female patients are different, and they need to be treated differently. That’s a reality. The speed with which we have to see patients is also a reality. When it comes to serving the needs of our female patients, we have to understand that women don’t need more care; they need better care—better listening, better questioning, better exams, and better doctors—doctors who listen, encourage, empower and learn from their mistakes.