15 June 2018

Tears and smears (not that there’s anything wrong with that)

Communication General Practice

As I put the fifth used plastic speculum of the day into the yellow hazardous waste bin, I begin to muse. Tears and smears – the lot of the female GP! 

As opposed to Tears for Fears, I’m not one of the everybodys “who want to rule the world”. But as I go on to complete the paperwork and launch into my spiel about the changes to the cervical screening program for the umpteenth time, I’m torn between the mundanity of this repetition and feeling like I’m helping empower a whole generation of women, one patient at a time.

So I restart my well-rehearsed explanation: “No, we can’t call it a Pap smear anymore because … it isn’t.” The explanation of how the routine Pap smear has evolved into the tongue-twisting “cervical screening test” is now part and parcel of the standard well-woman’s preventive health consultation.

All fairly straightforward, except when the woman in front you doesn’t speak English as her first language. What is the word for cervix in Turkish or Arabic? And let’s face it, even Marcel Marceau might have had trouble miming HPV PCR testing. And these new communication challenges come on top of the well-recognised complications that can be uncovered during these very personal consultations. Discussions about periods, fertility, sex and relationships are commonplace, often opening the flood gates for all the emotional stresses and pressures these patients are experiencing. 

Routine questions can lead to often-emotional discussions about relationship difficulties, the effects of high pressure work environment, long-held fertility fears and future concerns – even disclosure about childhood abuse.  

None of this will fit neatly into a three-problem list – examination, investigation and management, all tied up with a bow – within a standard consultation.

It is a fact female doctors spend more time on average with their patients compared with male doctors, and that female doctors see a greater proportion of female patients than their male counterparts. What’s more, each consultation with a female doctor tends to cover more problems than are covered in a standard consultation with a male doctor, according to BEACH data.

A discussion on an online forum recently centred on why it was that young female doctors, in particular, seemed to elicit a torrent of tears in their patients early and often in consultations. Even in my experience as a female but not-so-young doctor, tears are a frequent component of my day-to-day clinical work (the patient’s, not mine, usually). And not just in my female patients, men too seem to reach for the tissues more often with me than with my male colleagues. 

This phenomenon that has ramifications for time management, financial remuneration and the doctor’s own mental health.

But why should the expression of empathy, a characteristic so appreciated by patients, cause such a penalty for the practising doctor particularly in terms of income earned? Surely the job of general practitioners, whatever their sex, is not just to type-up histories while saying the odd “hmmm” and then sign the appropriate scripts and referral letters.

A person’s medical needs are often as much emotional as physical, and the expression of these often does not fit conveniently into a six-minute time slot. Empathy demonstrated by a person the patient trusts, namely their GP, should be considered integral to high quality primary care.

I consider it an honour and a privilege to have my patients entrust their fears, hopes and disappointments to me. And more importantly, for them to know that they are being heard.

As I finish labelling my fifth Thinprep bottle for the day, I think maybe the female doctor’s role as an expert in “tears and smears” may not be the derogatory put-down it was thought to be in the past.

There’s nothing wrong with smears if they saves lives and provide an opportunity to practise preventive health, and educate and empower. And, for that matter, nothing wrong with tears, either. 

Give me life stories and real people every time.

Dr Dawn Oi is a GP in metropolitan Melbourne who hones her skills by writing referral letters all day