Is There Anything Else You Would Like to Discuss?
“Okay Anne our next patient is a 14-year-old girl here for a sports physical. I know you’ve done a lot of these with Dr. Z, would you feel comfortable doing this one on your own then reporting back to me?”
Sweet! I do a mental fist pump into the air, as I calmly state, “Yeah, I can do that. I’m also comfortable kicking out the parents and talking about sex, drugs, and alcohol. Would it be okay to cover those topics as well?
“Sex, drugs and rock n’ roll. Go for it girl!”
I review the chart and walk into the patients’ room. Deep breath...
Okay, don’t forget to shake both the teenager’s and parents’ hands, talk mostly to the teen, instill confidence, and don’t forget to make them laugh.
I stop my hand from knocking on the door.
Shoot what’s her name? I look down at my notepad. Elise. Deep breath. You got this.
Elise is a 14-year old athletic female dressed in shorts and a sports jersey. She is shy, but makes eye contact and answers my questions. Both she and her mother are pleasant and appropriate. She is going out for the soccer team in the fall and basketball in the winter. She has a wonderful smile and almost laughs at my lame jokes. History, review of systems, and physical exam are complete, now the potentially awkward part of the exam. I’ve tried to create a comfortable and safe space with first part of the encounter, now it’s time to see how well that worked.
I inform Elise and her mother that we have reached the part of the exam where I would like to ask Elise questions on her own.
“Mom, Elise are you comfortable with that?”
The mother nods saying she was expecting that and gets up to leave. Elise appears ambivalent.
I wait a few moments after the door closes and turn my full attention to Elise. I explain that I’m going to ask some questions about her personal life. I assure her everything she tells me is just between us, and I will not be discussing any part of this with her mother. She nods her understanding and acceptance.
I ask about how safe she feels at home, does she drink alcohol, smoke tobacco, weed, do any recreational drugs. I internally wince as I stumble over some of the wordings of the questions. I don’t have the tact that comes with experience. Whether or not Elise feels the same, I’m grateful that she continues to stay engaged and answers my questions.
I look at my notepad: okay let’s talk about sex. Teenagers are learning about their world, their bodies, and getting hit with hormones—meaning this can be a tricky topic.
“Okay Elise, I want to ask you a few questions about intimacy.” She nods.
Okay good - not too awkward yet, “Are you interested in boys, girls, or both?”
Some hesitation. Maybe she expected me to ask if she was having sex first…
“I like boys,” she answers.
“Cool, are you dating anyone?”
Half smiling, she replies, “No.”
“Okay, is someone pursuing a relationship with you or are you interested in a guy?”
A little laugh as she shakes her head, “No.”
Yeah, I thought ‘someone pursuing a relationship’ might sound a little weird. C’est la vie.
I laugh, “Okay no worries. Have you ever had sex?”
“No.”
“Okay, do you have any questions about sex?” I say okay too much, I need a different word.
She smiles and shakes her head no.
Alright, I think we’ve reached our limit, let’s close it up.
“Alrighty then, if you ever have any questions please don’t hesitate to ask us. We are here to help you and answer your questions. Do you have anything you want to discuss before I invite your mom to come back in?”
Some hesitation again. She looks at the sink across the small exam room. I check my posture and make sure it is relaxed and open.
Elise breaks the silence, “How do you know if you like girls?”
I swear I heard my stomach hit the floor. Welp, they didn’t cover this in medical school. Can she see my carotid pulsing? Because I can sure feel it.
“That is a great question,” I say to buy some time. It’s my turn to look at the sink.
Fudge. We had numerous conversations about the LBGTQ community in medical school but not about this. Shoot. What do I say? Knock it off Anne you’ve given relationship advice before. You got this.
“I am attracted and married to a man, but the way it has been described to me is that it’s just like the movies.” She looks towards the door, worried for a moment that her mother can hear. I don’t feel that I’m speaking loud, but I lower my voice before continuing.
“You feel attracted, those butterflies in your stomach, perhaps even romantic feelings towards a person. Those feelings can be towards a boy or a girl. Does that make sense?”
She nods. Her stare is far away as she prepares to speak, “What if you have feelings, but you, like, don’t want them?”
My eyes soften. The struggle, the vulnerability, a hint of frustration – it’s real. It’s so real. This moment--probably the first time these thoughts, feelings, and genuine questions have been spoken out loud--cannot be taken back. It’s real. And she is courageously pursuing answers, advice. All I can do is follow her lead and do the same.
“My eyes soften. The struggle, the vulnerability, a hint of frustration – it’s real. ”
“That is another great question.” I look back to the sink, the fountain of all knowledge, apparently.
What do I say? Mercy girl, you’ve got me on the ropes.
Gathering my thoughts, I finally manage to say, “I don’t think this is unique to you. Everyone has feelings that come up that they may not want. They have to decide what to do with them: ‘Do I act on this feeling or not?’ Yours happens to be about attraction. ‘I think I’m attracted to this girl or this boy and now I have to decide what I’m going to do about it? Do I pursue a romantic relationship with them? Do I not?’”
“I think the most important thing for you to figure out is, what are you going to do about these feelings? Because they are going to continue to come up. Do you act on them or not? Does that make sense?”
She thoughtfully nods. I let the silence linger for a few beats, then one more just to be sure.
“As you begin to figure these feelings out we can help you. We have behavioral health specialists that you can talk to here at the clinic. You can talk to your school counselor as well. If you’re concerned that what you discuss will get back to your parents, you can always ask directly, ‘Is this conversation private, just between you and me?’ No one will be offended if you double check.”
She nods her understanding but is still mostly in her own world processing our conversation. I give her a few more moments and again ask, “Is there anything else you would like to talk about before your mom rejoins us?”
She half smiles and shakes her head. I get up to get her mom.
Once they’re both settled in, I inform them I’m going to go discuss everything with her doctor and that we’ll both be back shortly to talk about the assessment and plan. They nod and we all exchange smiles as I leave the room.
I exhale forcefully and pray I handled that well, for Elise’s sake. I return to my precepting doctor and discuss the encounter. I talk through the case just as it had happened in the room, following the format of the notes we write. My doctor is listening while reviewing the patient’s chart, when she hears, “then Elise asked, ‘how do you know if you like girls?’”
She stopped reviewing the chart and gave me her full attention.
I smile nervously. Yep I knew this was a big deal, my doctor’s serious and slightly worried face just confirmed that. She definitely did not mean to give that task to a medical student, nor could she have predicted this.
I walked through every detail of our conversation, adding in some of my panicked internal dialogue. I end by saying, “I think I handled it okay, although I definitely didn’t feel qualified to give that advice.”
The doctor nods encouragingly, her posture much more relaxed than when I had begun my report.
“Anne. You did well. The most important thing you did was normalize her feelings. You created an environment where she felt safe to be vulnerable with you. And you told her about the resources available to her. You demonstrated that the doctor’s office is a safe place to discuss her sexuality. You did a good job.”
Relief washed over me. I knew Elise’s moment of vulnerability about her sexuality was her cracking open her armor and giving me temporary permission to hold her precious, delicate, glass heart. I was praying I hadn’t fumbled, letting it shatter. I let out a slow deep breath. Good.
We returned to Elise’s room. My doctor confirmed my physical exam findings, asked a few questions I’d forgotten, then nodded to me, indicating I could end the visit. I enthusiastically informed Elise she was cleared to play soccer this fall.
Go get ‘em, girl.
Anne Keeling
Third-Year Medical Student (OMS III)
Pacific Northwest University of Health Sciences