We were knee-deep in therapy, about halfway through our session together. Amy* had been my patient for about two years, and we met every week for 50 minutes. A young, Asian-American female college student, she struggled with many of the usual young college student challenges that arise en route to adulthood: relationships, exams, career decisions. In the midst of our usual conversation, she turned to me and mentioned something that hadn't come up in all of our previous hours together. She was bisexual. She had not mentioned it before, but I also hadn't asked. Not in so many words. Certainly not in a way that invited such self-disclosure from her.
I have spent a great deal of time reflecting on the session we had that day. Her sexuality was clearly something that was important to her. I wondered what assumptions I had previously made about her preferences, either implicitly to myself, or even out loud without my conscious awareness. I recognized that it had taken her two years to feel safe enough to share this part of her life with me, her psychiatrist. Two years for us to develop a trusting enough relationship for her to feel secure in stating something so central to her identity.
Perhaps it just takes time for us to eventually feel like we are ready to share the most intimate parts of ourselves. We don't know how we will be received. We don't know what response we will get when we share our sexual preferences, our gender identity, our childhood abuse, our domestic violence story, or our secret alcohol addiction. We don't know whether we will be judged, or somehow seen in a different light. We don't know whether we will be treated differently, now that we have shared something that is deeply personal, central to who we are, and a key part of how we live out our days.
In our current climate, my patients feel there are fewer and fewer spaces to fully embody who they are. But where else could it be more critical for our patients to feel safe? The physician's office should be a zone of radical acceptance, non-judgment, and trust. The patient must feel comfortable sharing their full narrative, without self-censorship or concern for what the doctor will think.
If we as doctors don't have the full story, we cannot properly treat our patients. Our work-ups will be unfocused, costly, and unrevealing. Our patients will continue to present with mystery symptoms that don't make sense. Our work will feel disconnected and unsatisfying because we won't know the truth of our patients' lives.
Abdominal pain means something different in a woman who recently had unprotected sex. A migraine headache carries a unique significance on the anniversary of a husband's loss. Seizures may all of a sudden reveal a hidden cocaine problem.
Yet we cannot expect that our patients will simply tell us everything. It doesn't work that way. Patients have likely experienced stigma, shame, and judgment prior to walking into the doctor's office, even in other health care settings. They are embarrassed and afraid of their symptoms and what they might reveal. They are worried about what their doctors might secretly think. They are highly attuned to even the most subtle suggestion of disapproval or criticism.
So how do we as physicians actively create the conditions for patients to tell the stories that need to be told? The burden rests on our shoulders to invite the conversation, not on the patient to somehow find the courage to say the words. The physician's office or exam room should be a confidential and protected space for such stories to unfold.
We can start by actively letting our patients know that we want to hear everything that they feel comfortable sharing with us. We can reassure them that our job is to walk alongside them on their journeys through illness and health, in a manner free of criticism and shaming. We can make a conscious effort to become aware of our own biases, and do our own personal work towards eliminating biases that interfere with our patient relationships. We can ask questions that might feel difficult or uncomfortable to ask. We can listen to every part of our patients, with every part of ourselves.
How do we translate this into practice? As with so many things, it is perhaps the small gestures that matter most. We sit down. We make eye contact. We allow our patients to tell their stories without interruption. We make sure to have some time alone with our patients, free of family members or spouses. We try to find an interpreter service if needed. And we can end with the question that I didn't ask Amy: "Is there anything else that feels important for me to know, that I haven't yet asked you?"
Making an intentional effort and commitment to be a safe space for our patients might take a little time, but perhaps not as much time as we envision. In fact, the time and money lost when we don't have all of the information in front of us is a far greater cost, to us and the patients we are here to serve. The potential reward of being privy to the most sacred details of our patients' lives is immeasurable. It is how we will save their lives, and ours.
Monisha Vasa, MD is a board-certified General and Addiction Psychiatrist. She is in private practice in Newport Beach, California, and also teaches medical humanities and topics related to physician well-being at the UC Irvine School of Medicine. She is currently a scholar of Narrative Medicine at Columbia University, and enjoys playing with words on her blog. Dr. Vasa is a mother of two children, has a house full of animals, and enjoys long-distance running and mindfulness practices when she needs a break from all of the above. Dr. Vasa is a 2018–19 Doximity Author. All names and identifying information have been modified to protect patient privacy.