Summary: encouraging self - awareness and respect for sexual diversity in the clinical setting.

Medical students must be prepared to discuss intricate details of sexuality with a diverse range of patients. Issues of sexual activity and function significantly impact patients' physical, mental, and emotional health. A special challenge is that students need to both learn a set of interviewing skill and develop sensitivity to the vast array of personal attitudes and beliefs about sexuality present in the United States. Thus students must consider their own attitudes towards sexual issues and reflect on how they might respond in unexpected clinical scenarios.

In previous years, students were encouraged to watch sexual explicit excerpts from educational videos. Some American medical schools have used sexually explicit videos to prepare students for sexual history-taking since the 1970's. At UCSF, this exercise was switched from an optional "movie night" to a required session with small group discussion in 2001. This change provoked fierce criticism from both students and faculty members. Some felt the material was offensive and/or alienating. Many questioned how watching sexual activity prepared students to talk clinically about sexuality. Thus, we decided to create material that would help students reflect on their values and attitudes towards sexuality as it might arise in a clinical setting.

ASSESSING THE NEEDS

The first obstacle was the lack of consensus on what type of clinical situations require a clinician to be aware of their personal values and attitudes. Although there is a great deal of literature on patient-clinician interaction, none we could find surveyed the range of challenges that arise when taking sexual histories. Therefore we interviewed 23 community clinicians, purposively sampled to include varied religiosity, sexual orientation, ethnicity, and type of practice.

These participants informed us about when sexuality was discussed in their practices, what challenges they have perceived, and how effective care has been provided to patients whose values and attitudes were perceived to be different from their own. A thematic analysis was performed on this data.

CREATING THE RESOURCE

The next step was to create a video tape for small group teaching. We wrote four vignettes of patient-clinician interaction, based on actual situations described in the interview data. In each vignette, two challenges arise. The scripts were designed to allow a pause for small group discussion after each dilemma emerged. After the pause, the clinical encounter resumed with the clinician demonstrating one possible response to the challenge.

For example, in one vignette about evaluating decreased libido, a physician becomes embarrassed when a patient demonstrates a sexual position. The tape stops for discussion after the patient asks the doctor whether he is embarrassed. When the encounter resumes, the clinician apologizes for his discomfort and emphasizes his wish to continue to learn the details of the patient's problem.

As the story unfolds, the patient casually asks the doctor about a sexual topic the physician knows nothing about. After a pause for discussion, the doctor admits his lack of knowledge, and asks the patient to explain the topic to him, so he can continue to gather an appropriate history. At the end of the tape, the clinician provides medical information while respecting the patient's knowledge. The patient and clinician collaborate to form a plan appropriate for her concerns.

The vignettes were designed to cover diverse patients and clinicians. For example, in one vignette, a clinician faces a conservative mother who does not wish her adolescent son to be interviewed by himself. In another, a medical student neglects to take a sexual history with an elderly patient.

USING THE VIDEOTAPE 

The videotape of the vignettes was used in small groups of six students and one faculty member. We created a facilitator guide created to suggest major discussion points for each vignette. It also includes advice for respecting the diverse backgrounds of students and faculty. Finally, it emphasizes that discussion must recognize that each situation could be handled in many appropriate ways, often based on the individual background of the clinician.

The videos were used last fall with second year medical students. We look forward to evaluating this tool in the current academic year. Currently, we are grateful to have a teaching modality that anecdotally is described as thought-provoking but, unlike sexually explicit educational material, does not generate student complaints to our deans.

Laura Hill-Sakurai, MD

Assistant Professor

Christina Lee

Medical Student

William Shore, MD

Professor

University of California, San Francisco School of Medicine (UCSF) San Francisco, CA