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When patients won't speak up


Shame and stigma can keep people from relating important symptoms. Here's how to break through to them.

The patient was a 55-year-old who hadn't seen a doctor in years. Although he seemed perfectly sober, his doctor, internist Bill Clark, detected a faint odor of alcohol on his breath. "But when I asked him if he drank alcohol, he told me only a glass or two of wine. He said he couldn't recall a time when he'd had more than six drinks," recalls Clark, an internist in Bath, ME, and president of the American Academy on Physician and Patient, an organization that conducts research and training on doctor-patient communications.

When the man's tests came back, however, there were liver abnormalities and a blood alcohol of 0.1 percent. "That's a reading I'd expect to see if I were dealing with alcoholism" Clark says. Clark intervened, and this patient was eventually able to quit drinking.

Every doctor has seen it: not only the alcoholic, but the teenager with genital itching, the middle-aged man with sexual problems, the woman with urinary incontinence, the aging patient who keeps losing the car in the parking lot. All these patients have conditions that carry a certain amount of social stigma, and, as a result, they may be too embarrassed to tell their problems to their doctor.

Over one-third of the cases of urinary and fecal incontinence in the country are never brought to the attention of healthcare providers, says internist Jan Busby-Whitehead, chief of geriatric medicine and director of the Program on Aging at the University of North Carolina at Chapel Hill School of Medicine. "We are trained almost from birth not to talk about such things," says Busby-Whitehead, who also sits on the board of the National Association For Continence ( http://www.nafc.org). Yet, she adds, these disorders cause a great deal of misery and affect the quality of life. "Physicians need to deal with them."

To the list of stigmatized conditions, Mary E. Frank, president of the American Academy of Family Physicians, adds diabetes, obesity, alcoholism, domestic violence, and even hair loss in women.

Mental and emotional disorders and deficiencies carry perhaps the worst stigma, says Marla Rowe Gorosh, a family physician at the Henry Ford Medical Center in Troy, MI. "I've seen patients who want to cover up ADHD, who won't tell me that someone in the family is learning disabled, who gloss over confusion, who'll never mention a suicide attempt, who think that obsessive compulsive disorder is shameful," she says. Adds Frank, "Patients sometimes won't tell you that they're taking antidepressants or other psychotropic prescriptions."

The stigma of mental illness can be particularly intense among certain populations, like Asian-Americans, says Joshua Fogel, an assistant professor at Brooklyn College of the City University of New York. But, no matter the nationality, studies show that mental disorders affect a significant number of Americans-some estimates put the number at nearly 50 million-yet only about one-third of sufferers will seek treatment.

Getting patients to talk

When patients are too ashamed or too embarrassed to tell you about their symptoms, that can obviously have a detrimental effect on their healthcare. To help you learn techniques for eliciting important information from your patients, we talked to your colleagues as well as to experts in the field.

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