Meet Adrienne, tbd clinician

Adrienne is a clinician on the tbd care team. She has extensive experience working with many different kinds of patient populations, and one of the things that really drew us to Adrienne was her public health and policy background. Her special combination of sensitive caregiving and way of making complex topics seem easy to understand and relatable, and her ability to contextualize individual patient care in the larger picture of public health issues and trends, made her a great fit for our team. In our conversation, we talk about barriers to care, the health system in the US, and how we can encourage women to ask for the care they need.

[Daphne] Hi Adrienne! So, tell us a little bit about how you got into nursing.

[Adrienne]: So originally my background was in public health. That’s what I studied in school. With public health, you're thinking more about kind of big picture population health, [things like] what you're seeing right now with covid-19, and I knew that, while I did love public health and the bigger picture research type stuff, I really wanted to interact with folks one-on-one and help of on a more personal level.

So, I went into nursing because it gave me the opportunity to really interact with folks and build relationships. It's been super rewarding.

My nursing approach to health is really focused on the whole person, not just about the conditions or medical concerns, but just thinking about things like, where does the person come from? What are they experiencing? Do they have a stable job? Do they have access to good food and are their home lives stable? Have they had access to education? I look at all the ways that people might need and want help, other than just medicine or treatment.

[Daphne] How do you think about adapting patient care to personal circumstances?

[Adrienne] It’s different for everybody. I primarily have worked in community health, so that means working with a lot of folks who are coming from all different backgrounds, including ones where they don't have a lot of money, they might not have insurance. And so, these folks have often experienced firsthand these big population level problems and policy level problems. For instance, if they don't have the access to a good grocery store because they live in a food desert, of course, they're not going to be eating healthy. And so if I tell them, hey, you have diabetes, you need to eat more fresh fruits and vegetables, but they can't afford the fruits and vegetables, that is something I absolutely take into consideration. I try to give them resources, but I also try to give them advice that is contextually specific to their situation.

[Daphne] What do you think is the biggest barrier is to care?

[Adrienne] It’s really access, and access to preventative care as well. Many people simply do not have clinics or doctors nearby, and only go to see doctors once they are ill. So much of the American healthcare system is about treating existing illnesses versus giving people the tools and education they need to understand their bodies and maintain their health. All this is often coupled with socioeconomic disadvantages or gender-based disadvantages [Ed. Note: there is shortage of 9,000 gynecological clinics and resources in the US.], and the lack of health literacy.

"So much of the American healthcare system is about treating existing illnesses versus giving people the tools and education they need to understand their bodies and maintain their health."

[Daphne] How is healthcare changing with telemedicine? 

[Adrienne]: I think telemedicine is opening up a lot of opportunities for healthcare because it saves you time-- having to come into the clinic, which, you know, maybe it's a 15-minute visit, but for that person, it can take three hours out of their day and they have to take off work. But everybody knows how to Facetime. Telemedicine allows people to seek care on their own schedule because the barriers and access are minimized.

It’s not always perfect, there are definitely folks who aren’t super comfortable with technology, and telemedicine is a new thing for them to learn, but in general it’s really working for our patients.

[Daphne] Let’s talk about sexual health testing, which has been challenged during covid with the shutdown of multiple clinics. Pre-covid, what were some of the most common barriers facing women getting screened for STIs?

[Adrienne] I see a lot of women who feel like they have to justify their need or desire for an STI test. Patients are very open to getting tested if I offer it, but much fewer of them ask for it-- I notice that sometimes some women have this idea that if they ask for the test, that they like that they'll that I might judge them or disapprove. It’s awful to see how many of them think assume their care provider will be disapproving or disgusted or what have you. There’s a ton of stigma around testing and sometimes women are scared that I will judge them for their decisions.

I think effective care starts with sensitivity and compassion. I try to tell them this is what I emphasize with everybody, and help them understand what's recommended, but it's definitely a little bit scary for everyone. That whole process is very intimidating. So, I try to just offer people information and education if I can.

[Daphne] What role do you think clinicians have in helping to educate the public? How much education do you think that women are getting with their healthcare providers? You know, you have sex ed that ends in middle school or high school and then after that, what is the role of the gynecologist in educating women about sexual health?

[Adrienne] I think that that a lot of women actually don't necessarily go to a gynecologist, because they rely mostly on their PCP [note: primary care physician]. PCPs often don’t have in-depth knowledge about gynecology so might not have the info to weigh in on specific questions or concerns, and they probably won’t proactively offer education about it either.

So not everybody is getting their kind of general education from a gynecologist. A lot of people I think are just getting it from their general practitioner, which might be totally fine. But, again, I think that it's typically a 15 to 30 minute visit. It can be really hard to really dive into detail in that amount of time. Plus, what is often recommended in hospitals and clinics is to follow guidelines from the CDC and they don’t provide for a ton of proactive education. It’s just not something that medical professionals are measured on in terms of metrics. Although it definitely helps patients, it's not something that is kind of measured on a larger level. I think if education was proactively offered, it would definitely raise patient awareness and knowledge and help equip them with the information to monitor their health more effectively.

"...if education was proactively offered, it would definitely raise patient awareness and knowledge and help equip them with the information to monitor their health more effectively."

[Daphne] You mentioned metrics. In the realm of women's health, what are the metrics that providers are measured on?

[Adrienne] A lot of what we are told is to adhere to general guidelines, whether it's put forth by the CDC or the US Preventative Task Force. And usually it’s more like recommendations. For instance, for things like how much STI testing needs to be done at different age groups and for different demographics, and pap smear guidelines and how frequently they need to be administered or immunizations, is another good example. Things that are concrete. Things like education are not so easily measured. Sometimes the guidelines will account for this by prompting “have you had a discussion about X or Y?” But nowhere have I seen comprehensive guidelines. For example—we really should be advising folks on the consequences of infertility as it relates to STIs. But there are no measures for ensuring this knowledge gets to the patient.

The healthcare industry is very similar to every other industry and that like you're looking for measurable outcomes. And so to a large extent, I think people look at doctors as there to treat conditions rather than playing that educational kind of role.

[Daphne] What are some of the things you’ve had to educate women about STIs? Anything you think is a big gap in our collective understanding?

[Adrienne] Oh yeah, I think one of the biggest things that I always hear is, “I don't have any rashes or I don't feel any pain so I'm totally fine. I can't have an STI.” or “my partner and I have only been with one or two other people. So there's no way that I can have an STI.” It’s these ideas of like, the kind of people who would have an STI. It’s always “that won’t happen to me.”

So I try to usually explain how common STIs are and how many of them are easily treated if caught early, and that the majority of infections are asymptomatic for women and that you can contract an STI from a single sexual encounter, and so on an so forth.  But giving that information out in a non-overwhelming way is super important, otherwise it scares people from going to the doctor even more.

Another thing I often find myself having to explain is the connection between STIs and infertility. I often find most clinicians and doctors might focus more on “oh, you could spread this to other people” or they focus on short term symptoms like pain. The long-term consequences are not often discussed. I wish that we did talk more about that because I don't think most patients understand.

[Daphne:] Do you think like women would change their behavior if they knew?

[Adrienne:] I think so. You can see it happen with the HPV vaccine, Gardasil. The discussion has become okay, well, you should protect against cervical cancer. Beyond this, I don't know that as a society we're really good at instilling healthy sexual behavior, healthy sex practices within young women to help them protect their fertility.

So much of what we are taught early on is to focus on not getting pregnant. We're just so focused on not getting pregnant while protecting your ability to get pregnant later isn’t given any thought.

[Daphne] Why do you think that women don’t know about this?

[Adrienne] The sex education in the country is not up to par. Not all states are invested in providing accurate, factual, helpful sex education [ed note: only 15 states in the US require that sex ed be medically accurate]. A lot of people's understanding and education kind of comes from that. It’s where women first internalize the message to don't get pregnant, and then when you are trying to get pregnant, no one tells you that it might be hard to get pregnant or that the sex you had years ago could affect to your ability to get pregnant now.

[Daphne] How many women in the US have a really robust screening habit?

[Adrienne] I don't have the figures offhand but I would say not many, and I think it is related to some of those misconceptions of “I’m not the kind of person who would get an STI.” For the majority of women I see, they are actually only getting screened while at their annual exam, which isn’t frequently enough for most.

[Daphne] There’s been a lot of data that says, if you don't live within near a provider, you're much less likely to go seek care. What we're hoping with TBD health is that, by making screenings available at-home, it becomes a lot easier for women to develop and maintain a habit because now it's, we're coming to you instead.

 [Adrienne] Yeah. I mean, I think a lot about those patients who want to be screened, but couldn't make it, or were scared to, or whatever it might be.  And these days, with covid-19, people are just too afraid to go to the clinic and then there are also a lot of places that have either shut down or reduced their availability.

The fear of going to a clinic and contracting COVID is such a double bind to be put in as a patient, especially for things that are asymptomatic. If you don't feel like you have something, then risking a visit almost seems like doubly worse.

It's like, why would I go if I don't even think I have anything? And the problem with STI is of course being that a lot of them are asymptomatic.

[Daphne] Ok, final question! If you could share one piece of information with every woman that comes into your clinic related to sexual health, what would it be?

[Adrienne] I think one thing that I would tell a patient, is that you don't have to justify wanting to get tested. You don't need to justify why you want to do that. You don't need to justify like, whatever, you know, how many partners you have or what kinds of sexual activity you're having. We're not here to judge you. We're just here to answer your questions and talk to you about risks and benefits and everything that you need to know to just keep yourself as healthy as possible. You don't have to justify anything.

"We're not here to judge you. We're just here to answer your questions and talk to you about risks and benefits and everything that you need to know to just keep yourself as healthy as possible."