Practice What Your Patient is Thinking

Dropping in to “drop-in” sexual health clinics is not easy

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2270 (Published 01 June 2017) Cite this as: BMJ 2017;357:j2270
  1. Alan Short, former manager in British Telecommunications and subsequent international consultant, now retired
  1. alanashort{at}aol.com

Alan Short describes his experience of attending a sexual health drop-in centre as an older patient

It all started last spring. I noticed some small bumps underneath my foreskin while showering. I thought, if it starts to itch it’s probably a fungal infection. I’ll show it to my GP the next time I need to visit him for another reason.

That was two months later, and my GP suggested I went to the local sexual health drop-in centre. They see penises every day and would be able to diagnose quickly. A referral to the local urology department could take 18 weeks.

Visiting a sexual health clinic is not easy

I found reasons not to visit the clinic. I am 72 and in my youth these clinics were known as the “pox doctors,” and there was stigma attached to attending them. Eventually, after 11 weeks, I “dropped in.”

I arrived shortly after 9 am on a Saturday. The clinic was full and I was the only person who appeared to be over 30. I was sent to the men’s section where there were six others waiting. The second was seen at about 11 and those in front of me said we wouldn’t be seen as people were “thrown out” at 11 30 when the session ended. The receptionist suggested I came back another day and to my surprise destroyed my form, leaving no record of my request for the clinic’s services.

At the next clinic I attended I was told they were fully booked. I was worried and pleaded with the receptionist who I think took note of my age and made a call. I saw a doctor who was clearly concerned and immediately sent me to his consultant who said he thought I had penile cancer and referred me to the local urology consultant. He saw me five days later and confirmed the diagnosis. Two weeks later the tumour was removed by local anaesthetic, and at a separate operation four lymph nodes. The treatment was excellent. Surgery procedures were fully explained, the staff were caring, and pain control was fine.

Although things happened very quickly this didn’t stop me worrying about the nature of the operations, their impact on my relationship with my wife of 55 years, and my psychological state. I looked up the diagnosis on the internet and found that if I had had a diagnosis earlier I might possibly have been treated by ointment application rather than surgery. If only counselling had been suggested, but there was no time to arrange it.

The hidden downsides of specialist centres

Penile cancer is rare, and in England it is treated at only nine specialist centres. The journey from home took nearly three hours, and surgical schedules meant that I had to arrive the night before. My wife came to help my morale and visit me and we incurred six nights’ hotel expenses and, with travel included, spent £800. The financial implications of treatment were not mentioned.

I was told by telephone that the lymph nodes were clear, and because of the distance involved I agreed my follow-up should be done “remotely” by a phone call with the specialist nurse. Postoperatively I had pain and swelling in the groin, which turned out to be due to lymphoedema. The health professionals I saw and talked to did not mention this as a possible complication and it wasn’t in the written information I was given. I learnt about it from another patient I met by chance and who had also had penile cancer and he told me about a local lymphoedema service, where I am getting helpful treatment and support.

What you need to know

  • Older patients may be reluctant to visit a sexual health clinic or even their doctor despite worrying symptoms. They need encouragement to do so

  • Patients treated outside their local area may incur high travelling and accommodation costs and should be warned about this at the outset

  • All possible complications of treatment should be discussed with patients and details of local services where they can get appropriate help

Education into practice

  • Attending a sexual health clinic can be difficult. Do you check how comfortable patients feel about being referred to a particular clinic? Might you alter your language or offer alternative referral?

  • Genital diagnoses or symptoms might be encountered or referred to in several specialties. To what extent might the choice of specialty referral affect the patient’s experience or speed of diagnosis? How do you reflect on the choice or patterns of your referrals?

  • To what extent do you discuss the practicalities of management, such as travel and costs of referral to centres far from home?

  • Distance might be one reason to opt for remote or telephone follow-up. Are there ways that you might alter your style of follow-up to do this?

  • On the basis of what you have read in this article, are there ways in which you reflect on your own practice differently, or plan to change it?

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following: none.

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