Asperger Syndrome and Patient Interactions (PART 2/2)

ICM taught me about what things were considered taboo and personal to most patients (ie Neurotypicals). I found this quite beneficial as I could also apply this to non-Medical social situations. Previously I openly talked about some of these things while upsetting or offending some NTs without realizing it, but now I know why, and I shall only discuss these topics in the appropriate social groups, whether online or in person.

Here is a basic list of topics from clinical conversations and the ICM booklets that I’ve discovered to be Taboo/ R-rated/Covertly discussed among most NTs:

- Sexual activity, Sexuality, Pornography

- Issues relating to Primary Sexual Characteristics (eg penis, vagina) along with breasts and bottom

- HIV/AIDS and other STIs (Sexually transmitted infections)

- Bowel movements

- Urination

- “Illicit” drug use

- Prescription drug abuse (especially Opioids and Benzodiazepines)

- Drug (including Alcohol) addiction

- Severe/Clinical Depression

- Bipolar Disorder, Schizophrenia and other psychiatric conditions that are (unfortunately) stereotyped by mainstream public and mainstream media to be “crazy” conditions

Engaging in clinical conversations also STRONGLY encouraged me to suppress my impulsivity in saying whatever comes into my head. I have quietly learnt (not from bad experience) that if I automatically say comments that may appear judgmental or not directly relevant to the medical condition, then it’s just going to hinder the conversation, not to mention having a very high chance of offending the patient.

Here’s a segment of me thoroughly censoring myself. I was conducting a sexual interview with a woman who had Bipolar II Disorder (fake name of Cassie). My internal thoughts are in brackets:

Me: (Ok start with the rote “politeness”)

Good morning Cassie, I’m Ken, I’m a third year Medical student from Melbourne Uni. I’ve been told by your GP to conduct a sexual interview on you before you proceed with the main consultation with her. This will involve me asking you about your potential relationships and sexual activity. I’d like to assure you that whatever you tell me will remain entirely confidential between you, me and the doctor. Are you alright with that?

Cassie: Yep that’s fine.

Me: (Ok good.)

Ok Cassie, firstly, are you in any form of intimate relationship?

Cassie: Yeah, I have a boyfriend.

Me: (Just as I expected.)

Ok. Are you sexually active with him?

Cassie: Yes I am.

Me: (I knew it, it appears that practically all of the patients that I’ve spoken to that have a partner or a spouse are sexually active with them! Very few of them seem to be able to cope with no sex life whatsoever.)

Ok, how often do you have sex with him?

Cassie: Um, usually 3 or 4 times a week.

Me: (OMG she’s really horny! I though most adults had sex once a month, or perhaps once a week at the most, but 3 or 4 times a week?! That sounds like heaps! That sounds very tiring and stressful to me! I bet she’s having all that sex when she’s hypomanic , I wonder if she’s even taking her Seroquel?!)

Alright, and how long do your sex sessions go for?

Cassie: With foreplay? Uh about 30 minutes.

Me: (Hmm I wonder what proportion of her sex involves foreplay. From the movies that I see that have sex in it, I estimate the ratio of foreplay:penetrative sex to be around 1:2 or 1:3. But this is probably irrelevant as she’s still doing penetrative sex anyway which has a risk of pregnancy and contracting STIs. I need to focus on any penetrative sex that she engages in.)

What kind of sexual activities do you and your boyfriend engage in?

Cassie: The usual foreplay, feeling each other, and penis-in-vagina.

Me: (hmm I’ll need to ask about contraception/protection now.)

And do you or your boyfriend use any protection when having sex?

Cassie: Well he uses condoms, and I’ve had the Implanon in me for around 3 months so it’s working out pretty well. It’s really cheap, I have a Health Care Card so it was around $5! We only have sex with each other and nobody else, so STIs aren’t an issue, but yeah I really don’t wanna be pregnant.

Me: (That sounds reasonable. Oh wow the Implanon’s that cheap with Concession Health Care Card, I wish I had a Concession Health Care card so I could get my prescription medications for that price! OMG shut up shut up, stop having irrelevant thoughts. What shall I say now? Oh yeah, talk about the Implanon.)

Alright, I can understand that you don’t want to be pregnant, and it’s good that you have very little or no chance of contracting an STI based on what you’ve said. Are you feeling any side effects from the Implanon?

Cassie: Actually no! It’s way better than being on the pill. When I was on the pill, my mood became even worse, and sometimes my face would go all red!

Me: (Ok, now say something good about her Implanon, to show that you heard what she said. I can please her a bit.)

That’s good to hear that the Implanon isn’t giving you any negative side effects, and that it’s doing its intended action.

.

. [further questions regarding Cassie’s partner]

.

Me: (Ok I need to conclude now, I’ve collected all the information and it sounds like she’s horny and she has a very active sex life despite her Bipolar II Disorder. She’s unlikely to get pregnant or contract an STI, so that’s good. I need to thank her for revealing her info, to show that I appreciate her. Don't wanna piss her off.)

Well Cassie, that’s the end of the interview, thank you very much for your patience and cooperation.

Cassie: You’re welcome!

----------------------------

I’m appreciative and grateful for the theories and explanations that I’ve learnt, and have become slightly more aware of how the things I say impact on NTs, and I often try to use the “clinical communication rules” in non-Medical conversations with them, which has so far been more beneficial for me compared to the stage when I was “socially naïve/innocent” (prior to age 21). I still think that the majority of NTs are overly sensitive (emotionally) and very emotionally demanding, but unfortunately (for me, being that I’m in the minority group) that’s how their brains are wired, just like how AS wires my brain differently, so I can’t fully blame them.

In conclusion, ICM and clinical conversations with patients have been very useful to me as they’ve explained various complexities of communication and the thoughts and emotions that get created in patients who are primarily NT. My AS causes me to have a reduction in emotional complexity, and ICM teaches me how to appear sensitive and empathetic even though my condition causes me to not automatically be like that in regards to NTs. I’m still very inexperienced in Clinical communication despite having noticed a lot of social/psychological theories, so I’ll need to practice more and more when I enter Clinical rotations. As a matter of fact, I enjoyed the majority of clinical conversations that I’ve had with patients, because the conversation appears more structured, and the rules are more spelt out via textbooks and professional guidelines etc, and I get to collect information which is practical within a time limit.

I sincerely hope that the attraction and pleasure that I gain (despite the great stress) from such patient interactions don’t diminish in the future, and that as I gain more skills later on, such interactions in the hospital (and in life in general) will be even more manageable and less painful, like a positive loop.

Asperger Syndrome and Patient Interactions (PART 1/2)

I haven’t had too much experience in talking to patients as I’ve only completed my Preclinicals (first 2.5 years of Med course). During the entire Preclinicals, I’ve visited different hospitals and GP clinics around 30 times and there, I had the opportunity to interact with patients. I know that it’s very petty compared to the Clinical rotations that I’ll experience later on, but I felt that I learnt a noticeable amount of communication skills that would benefit me professionally and also socially in non-medical situations, so it can gradually reduce my innate social difficulties due to my Asperger Syndrome to an extent.

Along with such visits, we had many tute classes for a component in our Health Practices subject called ICM (Introduction to Clinical Medicine). ICM teaches you basics in how to conduct medical conversations with patients, how to say certain things, and what to say in reaction to certain comments by a patient. I need rules and details (step by step) on how to talk to patients and people in general, so I found the booklets quite useful because it was well written despite not being specifically intended for people with an ASD.

For starters, it gave extra enforcement of the concept that patients have FEELINGS, and how you say certain things will impact on their mood and subsequent interaction with you, for the remainder of the interview and in further visits. I always knew that practically everyone (including me) had feelings, but my AS caused me to have a reduced Theory of Mind which impairs my ability to intuitively understand the feelings of Neurotypicals (who comprise the vast majority of patients) based on their body language, facial expressions, and subtle social cues. The AS also causes me to innately communicate in a more objective/pragmatic/blunt manner as opposed to a style that’s primarily sentimental, hence causing me to appear “rude”, “weird” or “insensitive” to many NTs.

The ICM booklets were helpful in that they explained the types of feelings that get ignited in patients when you use certain communication styles, because what you say SHOWS something to them, and they often don’t take things literally or word-by-word like people with ASDs tend to do. For example, I learnt that after a patient tells me a load of information about their condition/illness, it really helps for me to paraphrase or repeat what they said, to confirm the info AND TO SHOW that I’m proactively listening to what they’re saying, and that I’m not ignoring them. They can also correct any mistakes that I make, while FEELING less offended.

Another thing I learnt is that when patients are feeling anxious or upset because of their pain or illness, it helps to acknowledge their anxiety/depression by saying a sentence like “I’m sorry to hear that you’ve been having [X condition] for [Y amount of time], it would certainly affect [Z aspects of patient’s life], so I can imagine that this would be very frustrating/upsetting for you.” By saying such a sentence, it SHOWS to the patient that their illness isn’t trivial and that they’re being taken seriously. However, my problem is that my AS causes me to have difficulty with reading body language and facial expressions as previously mentioned, so it’s hard for me to figure out when people are a bit anxious/depressed, so I have to compensate by using more verbal info such as asking “How are you feeling today?” (near the very start of interview), “How’s Uni/work going for you?” or “How’s your family?”, and seeking for certain cue words in the patient’s answer to indicate their mood such as “pisses”, “sucks”, “hard time”, “bitch”, “tired”, “shit”. ICM also taught me that if I see a patient crying, that I should offer them a box of tissues.

ICM taught me that it can be helpful to say certain things in a more indirect manner to avoid offending or upsetting the patient, to avoid appearing aggressive and to SHOW that the patient plays a role in directing their own healthcare and that it’s not being forced on them. For example, if I spoke to a person who’s a chronic smoker, I learnt that I shouldn’t say “You should quit smoking coz it’s bad for you.” , but you suggest it by giving other alternatives or asking questions such as “Have you considered quitting smoking?” , “How do you feel about stopping smoking?”, “Have you tried Nicotine Patches or Zyban?”.

But it also states that at certain times, it’s better to be direct for certain sensitive questions (which I’m very grateful for coz I’m naturally blunt), because if you were to ask it another way, it can appear judgmental and offend the patient even more. For example, the ICM booklet states that when asking people about “illicit” drug use, it’s best to ask directly like “Do you use Cannabis/Marijuana?” instead of “You don’t happen to use Cannabis, do you?” because by asking it in the indirect manner, it actually ignites the patient into feeling like they’re being stereotyped or judged negatively. I also appreciate that ICM taught me how to ask questions in a specific order and explains why. For example in the area of “illicit” drug use, you start off by asking the usage of the most popular drug, progressively to the less popular ones. If the patient asks why you ask in such an order, you then have the medical excuse of stating that you’re asking in terms of epidemiological relevance, and that you’re not being judgmental. There are many “illicit” drugs in existence (in fact the list of “illicit” drugs is astronomical in Australia due to the ridiculously insane Analogues Act), so you only ask the top 5 or so, ie Cannabis --> Methamphetamine --> Ecstasy (MDMA) --> Cocaine --> Heroin (if I recall this order correctly).

So for some situations, it’s best to be indirect, but in others direct is better, and this is quite confusing for me as my AS causes me to have a naturally more rigid mindset. Hopefully as time goes on, I’ll gain more decent Clinical experience and learn to be more rapidly flexible in figuring out how which questions are asked more appropriately and in the least offensive manner.

Then there’s the case where I learnt that you have to be direct, but delicate with the words that you use, as verbal differences are converted into social subtleties that are intuitively noticed by NTs, igniting further emotions.

For example, when I begin to conduct a breast examination on a woman, I’m extremely tempted to say:

“I want to see and touch your breasts to see if you have Breast Cancer.”

coz it’s the direct/blunt Aspie method. If I was to say this to a woman with an ASD, she most likely wouldn’t be offended at all. HOWEVER in the minds of many NT women, the segment “I want to see and touch your breasts” is automatically correlated with sexual harassment despite this being a medical examination, and the segment “to see if you have Breast Cancer” is also alarming due to mention of the potential pathology, igniting fear/anxiety. Therefore I was taught instead to say:

“I want to inspect and palpate your breasts to make sure that they are healthy.”

The words “inspect” and “palpate” (both are synonyms of “see” and “touch” respectively) are used because these words are used less frequently in informal conversations and therefore have a more professional/clinical tone to it, hence having less correlations with sexual harassment. The segment “to make sure that they are healthy” is used instead because it avoids mentioning any pathologies, but it still directly retains the intention of the examination, ie just said differently. “Healthy” is considered by many to be a positive word and hence the breast examination APPEARS to have more positive connotations with it by NT women, and so they’re more willing to proceed.

I’ve learnt that not only do the majority of NTs care about substance, but the vast majority of them also care about APPEARANCES and what you SHOW to them by the way you talk (social subtleties), sometimes even more so than substance!!!

It appears that if you cater to the patients’ emotions to an extent, the entire conversation is more likely to be cordial. Although very tiring and difficult for me, I treat the talking in an “emotionally sensitive/empathetic” manner as a price to pay for a smoother medical conversation and for a politer relationship.