Effective Path:
CLARK: Hi, I’m Clark. I use he/him pronouns. How would you like me to refer to you today?
CLARK: And how would you describe your gender identity?
NICKY: I’m a trans woman.
CLARK: Okay, thanks for sharing that.
NICKY: (visibly uncomfortable) I don’t know what it says on your chart there, but please, refer to me as Nicky.
CLARK: I’m sorry that information wasn’t already in your chart. I’ll make sure to update it.
NICKY: (pause) Thanks. Not everyone does that, so I appreciate it.
CLARK: And how would you describe your gender identity?
NICKY: I’m a trans woman.
CLARK: Okay, thank you for sharing that.
CLARK: So, how has your experience with the medication been?
NICKY: Okay.
CLARK: Just okay? Have you experienced any side effects?
NICKY: I don’t think so?
CLARK: Okay, that’s good to hear.
NICKY: I mean, I haven’t really felt like I needed to take them, so.
CLARK: How often do you take them?
NICKY: Well, I took ’em for a few weeks. Then I just stopped.
CLARK: What’s made it difficult to stick to taking the medication?
NICKY: Y’know, I have a hard enough time dealing with all the other stuff I have to do. I know I “should”, but other stuff gets in the way.
CLARK: You’re feeling like there’s not much point to taking the meds, but you know they’ll be good for your health.
NICKY: (agreeing)Yes, I mean, I know I’m “supposed” to take them, just, I didn’t really notice a difference between when I was taking them and when I wasn’t, and I guess it just felt a little pointless, yeah.
CLARK: Before we go on, I just wanna say, the reason I’m here is to partner with you to find out what’s best for your health, and to help you get there.
NICKY: Thank you. That’s very nice to hear. Most doctors it’s just like, I feel like they don’t actually care about ME, I’m just a chart or something.
CLARK: I’m sorry you haven’t had better experiences with doctors in the past.
NICKY: (feeling better) Well, I’m here now.
CLARK: (smiles) That’s good.
COACH: Nice job using transitional phrasing. It can help to remind someone that when we ask questions about their behavior, we are interested in helping them improve their health and not trying to judge them. 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: What do you already know about how smoking can affect your health?
NICKY: Uh, lung cancer? Throat cancer? The lady on TV who talks through a hole in her neck?
CLARK: Yeah, the research shows us that it can lead to lung disease, and increase the risk of some cancers.
NICKY: I know all the bad stuff that can happen, but y’know, it’s hard. I know I should be doing all these things, but I just can’t make myself. I don’t even want to get out of bed some days, and then just having all these pills reminding me of. I don’t want to think about it.
CLARK: How would you feel about me sharing some other things smoking might affect?
NICKY: (sigh) I’m sure I’ve heard them before, but (relenting) why not.
CLARK: I have a responsibility to inform my patients of all medication interactions. Because you’re on estrogen, I wanted to clarify something.
CLARK: I know being on estrogen is important to you, and I’m not asking you to stop taking it. You should also know that smoking while on estrogen can increase the risk of blood clots, which can lead to heart attack and stroke.
NICKY: I never heard that before. That’s pretty, it’s jarring.
CLARK: (nods)
COACH: Nice job using transitional phrasing. It can help to remind someone that when we share challenging information, we are interested in helping them improve their health and not trying to 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: And so, I DO encourage people on estrogen to stay healthy by quitting smoking.
CLARK: With that in mind, what are your thoughts?
NICKY: I thought it was just, y’know, the bad teeth and cancer stuff. But hearing about how smoking affects my estrogen, that changes things. Still, though,
NICKY: It just seems kind of pointless. It feels like, if it’s not smoking, it’ll be something else. I mean, of course, I don’t want to have a stroke someday. But today, I want to keep smoking.
CLARK: Can you talk more about that feeling?
NICKY: I mean, it was stressful enough having to move here, and now everybody I know is four hours away. I can call them, but it’s not like I can go out anywhere, unless I wanna go alone.
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: What’ve you been doing for fun?
NICKY: Well, my friends back home and I, we used to get together every weekend to watch our favorite show, Court of Justice. It’s about lawyers who play basketball, anyway I miss doing that a lot. I’ve been watching the show on my own but it’s just not the same.
CLARK: Mmm, how so?
NICKY: Well, first we tried to videochat but it’s like I said, it’s not the same, and it got kinda tedious. People are moving on cause everything’s the same for them, you know? When the only thing missing is you, their life continues. But everything is new for me. They all still have their lives, so it’s easy to forget about the friend who moved away, I guess.
CLARK: What about family?
NICKY: Haven’t talked to my ex in a long time. My kids call every now and then, but y’know, they’re all grown up and busy, now. They have their own lives to live, I don’t want to bother them with my problems.
CLARK: It’s been difficult to find friends here, and you miss your friends back home.
NICKY: Yeah. Back home I mean, I was totally fine spending a weekend all alone. But now that I have no choice. I wish I had seen my friends more when I had the chance.
CLARK: That’s understandable. Thanks for sharing with me.
CLARK: I noticed you said a few things about feeling down. I want to make sure I can provide the best care for you. Would it be all right if I asked you a few questions about that?
NICKY: Uh, I guess?
NICKY: Oh, is it I’m trans so I must be depressed, right? I’m just trying to live my life.
CLARK: Sorry I offended you, I should’ve explained my reasoning behind that. I ask all my patients, if I have concerns about their wellbeing. Some of the things you mentioned, about sleeping a lot and being unable to destress, sounded like symptoms of depression.
NICKY: Okay, I understand now. It just didn’t come off that way at first.
CLARK: So, about the questions.
NICKY: (opening up) Yeah, sure.
CLARK: Okay, great.
COACH: Clark asked Nicky the questions on the PHQ 9. Nicky received a score of 16, which indicates moderate to severe depression.
CLARK: How would you feel about talking with a counselor?
NICKY: That might be okay. I guess it depends on who they are.
CLARK: I’ll make the phone call myself and try my best to make sure whoever you speak with is trans sensitive.
NICKY: Oh, okay. Yeah, that sounds like it could be good.