Ineffective Path:
CLARK: Your chart says you’re Nicolas, but I’ve heard you referred to as Nicky, is that right?
CLARK: But my form says Nicolas.
NICKY: (uncomfortable) I’m trans. My name used to be Nicolas, now it’s Nicky. Can we just move on?
CLARK: Oh. Okay.
COACH: Learn more about how to chart and use names that are different from those found on insurance and ID forms. Please select which of the following resources you would like to review at the end of the conversation:
Do Ask, Do Tell: A Toolkit for Collecting Data on Sexual Orientation and Gender Identity in Clinical Settings
What is Deadnaming? Healthline
Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records, National LGBTQIA+ Health Education Center
Electronic Health Records and Transgender Patients: Practical Recommendations for the Collection of Gender Identity Data, J Gen Intern Med
NICKY: (visibly uncomfortable) Please refer to me as Nicky. I use she/her pronouns.
CLARK: I’ll need to add that information to my chart. I’m sorry if you were offended by what I said. You’re the first patient like this I’ve had.
NICKY: Like ’this’? What does that mean?
CLARK: I just meant that I’ve never had a trans patient before. You’re the first.
NICKY: (sarcastically) Do I get a prize?
CLARK: That’s not what I meant, I just,
NICKY: Whatever. Let’s just stick to why I’m here.
COACH: It’s a good idea to apologize if you made a mistake or your patient seems offended or hurt, but keep it direct and simple. Learn more about effective ways to apologize. Select which of the following resources you would like to review at the end of the conversation:
What if I make a mistake? University of Wisconsin, Milwaukee, LGBTQ+ Resource Center
What if someone makes a mistake and mispronouns someone else? Mypronouns.org
Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records, National LGBTQIA+ Health Education Center
Making an Effective Apology, Greater Good Science Center, University of California, Berkeley
CLARK: Have you been taking your medication as directed?
NICKY: Ehhh, I don’t know.
COACH: Asking a leading closed ended question implies there is only one acceptable answer, discouraging someone from sharing a more complex experience. Next time, try an open ended question to encourage Nicky to share more information.
CLARK: What’s the issue?
NICKY: Well, I haven’t really been taking them. I just didn’t feel like they were helping, so after a few weeks I just stopped.
CLARK: I can’t help you if you don’t help yourself.
NICKY: (confused) Uh, okay?
CLARK: (clarifying) I’m saying that things aren’t going to get better unless you actually take the medication.
NICKY: (frustrated sigh)
NICKY: It’s really hard for me to remember to take them, too. Other things get in the way.
COACH: Asking open ended questions shows that you are interested in hearing more about another individual’s perspective. Learn more about recommended ways to show sensitivity and build trust with patients. Select which of the following resources you would like to review at the end of the conversation:
Motivational Interviewing to Improve Chronic Illness Management in Marginalized Populations, National LGBTQIA+ Health Education Center
Tailored Motivational Interviewing to Improve Chronic Illness Management in Marginalized Populations, National LGBTQIA+ Health Education Center
Patient Centered Care for Transgender People: Recommended Practices for Health Care Settings, CDC
Questionable Questions About Transgender Identity, National Center for Transgender Equality
CLARK: If you want to take fewer pills, you could quit smoking, and not have to take smoking cessation medication.
NICKY: (slightly offended) Well, it’s not like I actually HAVE to take the smoking cessation pills anyway, right?
COACH: It can be tempting to try to problem solve for someone else, but it doesn’t show that we are listening or interested in their perspective and challenges. Learn more about how reflections can help build trust with patients and elicit motivations for change. Select which of the following resources you would like to review at the end of the conversation:
Encouraging Change Talk, Center for Motivation & Change
MI: Change Talk, Portico, Centre for Addiction and Mental Health
CLARK: I want to give you some information about smoking, but know it’s for your own good.
NICKY: Um, okay? Do I have a choice?
CLARK: Of course. But it’ll be good for you to know.
NICKY: Then, fine, I guess.
COACH: It can help to use transitional phrasing before sharing sensitive or challenging information, however remember that motivational interviewing is based on partnering with someone to improve their health instead of directing them. Learn more about how transitional phrasing and MI can help with patient care. Select which of the following resources you would like to review at the end of the conversation:
Questionable Questions About Transgender Identity, National Center for Transgender Equality
Trauma Informed Care for Trans and Gender Diverse Individuals, National LGBTQIA+ Health Education Center
Trauma Informed Care in Behavioral Health Services, SAMHSA
Trauma informed and affirmative mental health practices with LGBTQ+ clients, Psychological Services
CLARK: Do you know how bad smoking is for your health?
NICKY: (sarcastic) Wait, smoking is bad for your health? This is news to me.
CLARK: Well,
NICKY: I know it’s not great. And yet, here I am.
CLARK: If you’re not going to quit, there’s a few more things you should know.
NICKY: Sure, why not. I haven’t been lectured yet today.
CLARK: I have a responsibility to inform my patients of all medication interactions. Because you’re on estrogen, I wanted to clarify something.
CLARK: You really can’t combine smoking with taking estrogen, so one of them is going to have to stop.
NICKY: No, no way. If you’re saying you’re going to take me off my estrogen, sorry, but that is not going to happen. I’ve had doctors have taken me off it on the past and I cannot handle going through that again.
COACH: It can help to use transitional phrasing before sharing sensitive or challenging information. That would reassure someone that you intend to partner with them to improve their health and not work against what they want. Learn more about how transitional phrasing can help with patient care. Select which of the following resources you would like to review at the end of the conversation:
Questionable Questions About Transgender Identity, National Center for Transgender Equality
Trauma Informed Care for Trans and Gender Diverse Individuals, National LGBTQIA+ Health Education Center
Trauma Informed Care in Behavioral Health Services, SAMHSA
Trauma informed and affirmative mental health practices with LGBTQ+ clients, Psychological Services
CLARK: That’s not what I meant, I,
NICKY: What did you mean?
CLARK: I meant that I’m not going to take away your estrogen. But, there is an increased risk of blood clots for people who smoke and take estrogen.
CLARK: And so, I DO encourage people on estrogen to stay healthy by quitting smoking.
CLARK: For the sake of your health, you should consider doing that.
NICKY: (unsure) I mean,
NICKY: What’s the point? We all gotta die of something, right?
CLARK: So you’re feeling unmotivated?
NICKY: Ehh. Maybe that’s part of it.
CLARK: Well, let’s talk a little more about how you’ve been doing with work and your social life, that kind of thing, if that’s all right.
NICKY: (unenthusiastic) Sure, don’t know how much there is to tell, though.
CLARK: Have you made any friends in town?
NICKY: Well, I’ve become very close with the cashier at the liquor store and my pizza delivery person. Other than that, no.
CLARK: I see.
CLARK: I remember when I moved here, I just really put myself out there, and I made friends.
NICKY: Well, I’m glad that worked for you. But, the way I used to meet people was through my friends. So having to meet new people here is like starting from scratch.
CLARK: There might be a club or group for people who are trying to quit smoking.
NICKY: I think maybe I’ll wait till I find some more friends before I give up one of the only things helping me get by right now.
CLARK: Have you tried changing your mindset? Being in a new place can be exciting!
NICKY: Don’t you think I’ve tried just thinking about it differently? It didn’t work.
CLARK: Oh. Okay.
COACH: It can be tempting to try to problem solve for someone else, but a reflection of what they said can show that we are listening and interested in their perspective and challenges.
CLARK: I need to ask you a few questions about depression.
NICKY: Where’s that coming from? That’s not me. I go to work, I do my job. I (searching) I’m not depressed.
COACH: It can help to use transitional phrasing before asking sensitive questions. Asking for permission to continue could make the transition more effective. Learn more about how transitional phrasing can help with patient care. Select which of the following resources you would like to review at the end of the conversation:
Questionable Questions About Transgender Identity, National Center for Transgender Equality
Trauma Informed Care for Trans and Gender Diverse Individuals, National LGBTQIA+ Health Education Center
Trauma Informed Care in Behavioral Health Services, SAMHSA
Trauma informed and affirmative mental health practices with LGBTQ+ clients, Psychological Services
NICKY: Oh, is it I’m trans so I must be depressed, right? I’m just trying to live my life.
CLARK: I’m so, so sorry. I didn’t mean to imply anything, I would never think something like that.
NICKY: Okay, okay.
NICKY: Well, if that’s not what you meant, what did you mean?
COACH: It’s a good idea to apologize if you made a mistake or your patient seems offended or hurt, but keep it direct and simple. Learn more about effective ways to apologize. Select which of the following resources you would like to review at the end of the conversation:
What if I make a mistake? University of Wisconsin, Milwaukee, LGBTQ+ Resource Center
Providing Affirmative Care for Patients with Non binary Gender Identities, National LGBTQIA+ Health Education Center
Making an Effective Apology, Greater Good Science Center, University of California, Berkeley
CLARK: There was no bias behind my asking you to answer the questions.
NICKY: (throwing her hands up) Well, that’s good to know I guess.
CLARK: So, about answering them.
NICKY: I just want to get out of here.
COACH: Nicky declined to answer additional questions about how she is feeling.
CLARK: How would you feel about talking with a counselor?
NICKY: I don’t think so. Don’t think it would help.
CLARK: Okay. If you ever change your mind, let me know.
NICKY: (dismissively) Sure.