As medical professionals, we often assume that by completing an assessment, defining the problem list and outlining our treatment goals, we will succeed in achieving the best outcome for our patients.
However, a thorough assessment is just a starting point; there are so many potential pathways that can be chosen. It can be surprising which basic acts can make all the difference in developing the therapeutic relationship needed to get the outcomes that we desire. Our patients need to trust that we always act in a way that shows that we have really listened to them and connected with their story.
Gwen (not her real name) was referred to pelvic floor physiotherapy with a diagnosis of vaginismus. Vaginismus is spasm of the pelvic floor muscles, making penetration very difficult or impossible. At 38, Gwen was single, had never been sexually active and was terrified of a speculum exam. Her GP had tried 3x to do a PAP smear and finally referred Gwen to a gynecologist hoping for a better outcome. The gynecologist worked in a teaching facility and ran a very busy practice. After the first visit the gynecologist referred her to pelvic floor physiotherapy. No speculum exam was performed.
Gwen was instructed to return in 3-4 months and the gynecologist would reassess her ability to have a PAP smear at that time.
Gwen was seeing a psychiatrist for treatment of Obsessive Compulsive Disorder (OCD) and had a long history of anxiety. She was also a successful business woman in a busy practice.
“No one at work knows anything about this,” she said one day.” I just think that I should have a PAP smear to make sure everything is healthy down there, and obviously if I want to have a relationship, I have to be able to have sex.”
She agreed that she was ready for pelvic floor physiotherapy which included manual stretches, superficial connective tissue work (the connective tissue is the container of the muscle) and performed a diligent home exercise program using dilators to stretch her vaginal muscles and the vaginal opening. Teaching strategies to encourage normalizing pelvic floor muscle tone was carefully structured around her anxiety. Improvements were made as her dilators demonstrated the improvement of both ease and size of dilator used; however, Gwen remained constantly anxious about her situation and frustrated that progress was not faster. Throughout the course of treatment, she displayed a distinctive breathing pattern- shallow, rapid, apical and mouth breathing. When she spoke she frequently had to gulp her words. Rarely did she make eye contact.
On a recent visit she voiced her frustration about her upcoming gynecologist visit. She was worried that the gynecologist would follow her typical pattern of speaking to her for about 2 minutes, dismissing the need for an internal exam, and asking her to come back in 4 months. Her routine gynecological visit entailed being seen by a nurse, then a medical resident and eventually the gynecologist. Any attempted internal exams were done with a resident with sometimes the nurse observing. This made Gwen anxious. We discussed how she might ask the nurse to speak to the physician on her behalf stating that she requested a private exam.
Gwen believed that if you ask that the students not be present, the physician would be upset. “They will be angry with you for making the student leave the room,” she stated.
We problem solved a variety of solutions, and eventually I offered to write a letter on her behalf asking that she have an exam that respected her privacy. She quickly agreed to this.
As I was preparing the letter I realized how making this request was slightly anxiety provoking for me as well. I did not wish to offend the physician, but wanted her to understand Gwen’s concerns. The letter was written, Gwen brought it with her to the next gynecology visit and returned for follow up 2 weeks later. The session with the physician went very well. Gwen was pleased and relieved. She gave the note to the nurse and the gynecologist herself came in without the student and sat with Gwen. She explained why she did not need a speculum exam at this time and would not likely need one for another 1-2 years. She told her she was healthy and everything was alright in her pelvis.
“Your letter really helped. I am so relieved. It was the first time she just sat and talked with me.” Gwen had been heard; I listened, her gynecologist listened, and Gwen was empowered.
As she was talking I realized that she had a normal and quiet breathing pattern for the first time in 15 visits. Later when I did an internal exam I found relaxed muscle tone and Gwen didn’t even flinch. Tension driven by anxiety and fear can resolve quickly if the underlying fears are addressed.
As I reflect on this, what we do is so much more than just understand what is happening in our patient’s tissues. Once we really listen, recognize their struggle, and help them to project their voice into the world, trust is earned. Trust in medical professionals, but more importantly, trust in themselves.
Written by: Beth Kroetsch