Make no assumptions! Even when patients are younger than you.

It was a quiet afternoon at Dr G’s paediatric endocrine clinic. After running through the referral letter of D with Dr G, we invited D into the clinic. As with all Dr G’s clinics, I was introduced as the student doctor and I was asked to take a complete history from D. D is a 16 year old young Chinese boy who looks tanned, lean and well built. Otherwise, he seems well thrived for his age. He has a neat and tidy appearance.


“Hi D, How can I help you today?”, I opened the interview with an open question.


“I had gynaecomastia.”, replied the young boy.


“So when was the first time you noticed the breast tissue?”, I asked.


“It’s not breast tissue. It’s gynaecomastia.”, the boy quipped.


“Yes, gynaecomastia. When did you first notice the gynaecomastia?”, I quickly corrected myself.


“Last year in December.”, he replied.

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That was a rough start, I told myself. Reminding myself to be more sensitive to the teenager’s concerns, I suddenly became more aware of how I would feel if I were to have gynaecomastia as well. I would be rather frightened. Especially at the age of 16, when youths are most concerned about their looks. Particularly at a time when they explore boy girl relationships or further explore their new found sexuality. Their peers could sometimes also be less than forgiving when it comes to teasing or making fun of one and another. Many a times, I became too immersed in the process of asking questions often forgetting to put myself in the patient’s shoes.


This is not uncommon in medicine. Making assumptions. I suppose one of the main reasons why we are pushed to make assumptions is because we are called upon to make judgements on a frequent basis. Often times, despite our best efforts, we are not able to gather the complete clinical picture not because we are not competent. Rather, because not every disease presents in a similar way, we cannot always reliably gather all the relevant clinical signs and symptoms. Therefore, we are often asked to live with uncertainty. Despite so, our patients need certainty and we are required to provide advice on the next steps in management. Inadvertently, assumptions fill up these gaps of uncertainty. Being cognisant of that, we should not however form the habit of making assumptions on a regular basis.

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“How about your private parts? Did you notice any abnormalities since young or when you are born?”, I continued. This was a question to screen for any congenital genital abnormalities at the point of birth.


“Not that I know of. However, I did have a similar experience when I was 12 years old. It went away after a while though.” He replied.


“Now you have it again, are you extremely concerned about these changes?”‘ I asked, trying to probe as much as possible since he seemed unwilling to elaborate his answers.


“I was concerned and checked out some stuff over the internet. I think I might require an operation to remove the tissue. I also had a male friend who went for an operation to remove breast tissue...” His voice trailed off towards the end.

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Although I managed to build some rapport with D over time, I felt it was slower than expected. Many times, I felt that he did not feel comfortable discussing the details of his condition with me, even when I was introduced by Dr G to be a training doctor. On too many occasions, as a medical student, we tend to think that it is difficult to build rapport because our patients think us as an untrained medical professional. However, I realised that mentality had slowly began to hinder me from finding out why I failed to build that rapport. After much reflection, I felt that there were many missed opportunities for me to build rapport with D. For one, I could have complemented D for knowing what “gynaecomastia” is and for looking up the facts on the internet. Secondly, I could have felt more at ease connecting with him given that I am also a guy and that I had once experienced similar physiological changes.


I suppose the greatest point of discomfort with me not being able to build the rapport is this fear that I would not be able to secure the diagnosis as a result of a dysfunctional doctor-patient relationship. After the interview and the physical examination, we concluded that D’s gynaecomastia was most likely caused by an exogenous source (essential oils). However, it was a great lesson to me in particular. I learnt more about the nature of medicine, the assumptions that we made on a regular basis and how to build good rapport with the patients we look after.

This is a  Public reflection which is publicly available for anyone to read.

Created on 19 October 2017 by Li Lianjie Anthony