Parts

On my first day as a medical resident in clinic, one of the patients on my roster was listed as having a chief complaint of "genital rash." No big deal, I thought to myself. I am a young, progressive, body-positive doctor. Everyone has genitals! I am unfazed by genitals! Let there be a genital jubilee in my clinic! I'll make s'mores!

But when I walked into the room and saw the patient-a 24-year old guy with not-small shoulders and a great big smile-a policeman, for the love of God-my hands got clammy. I was torn between the urge to flirt and the urge to bolt. But I am a doctor now, so I faked as matronly a smile as I could, and said, "What brings you in today?"

Countertransference is something we discuss mostly as an issue in psychotherapeutic care, but in reality, it happens on every ward of every hospital. In simple terms, it is the projection of the care provider's needs or feelings onto a patient. When a doctor countertransfers, he or she imagines the patient to play a role in his or her life that is oustide of the role of a patient, often to the detriment of the objective doctor-patient relationship.

Some examples might help illustrate what countertransference is: If a doctor ignores her patient's complaints because he reminds her of her whiny little brother, that's countertransference. If a doctor aggressively pursues curative treatment in a dying patient because the doctor himself is afraid of death, that's countertransference. And if a doctor avoids discussing sexual issues with a smoking hot 24-year old patient because she knows that if they had met outside the clinic, she would be gathering very different data points, and Jesus, why won't he stop smiling at her-that's countertransference.

It's a good thing I'm aware of the issue.

The policeman smiled. He had some bumps, he said. They weren't itchy or painful or oozing or anything-they were just there. He and his girlfriend were monogamous, so he wasn't worried about a sexually transmitted infection. But still, could I just look?

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Hunky young men need medical care, too, and for better or worse, I occasionally have to provide it to them. It's inevitable that I will find some patients attractive. Acknowledging this allows me to take note of the times when I need to be exceptionally careful in my workup: Whereas I often allow some elements of the history-taking, physical exam, and diagnostic strategy to be nearly reflexive, I make especially certain with hot patients that I can explain every choice I make. It's both for their safety and my own.

Although the policeman was without much risk and entirely without symptoms, he wanted to be checked out for sexually transmitted infections. This meant having a look at his junk. I did so, chaperoned per office policy by Dr. B., a [female] attending physician. The patient seemed nervous and uncomfortable during the exam. I probably did, too. But everything looked normal, and a urinalysis was so clean that we didn't even bother ordering any lab tests. I had him put his pants on and, because he was due for a full physical, asked him to make an appointment to return in a few weeks.

He did, with news: his girlfriend had been cheating on him. This changed things: he was now at greater risk. Even if he had no signs or symptoms of disease, I would need to test him for asymptomatic infections like Chlamydia and HIV. Which meant another look at his junk. I did another, more invasive genital exam, again chaperoned by Dr. B.

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In speaking with Dr. B. after examining the patient, I dubbed him "Penis Man." Given the 1:1 ratio between his office visits and my encounters with his business, I joked, he might be coming to clinic not so much to address health concerns as to have his genitals carefully examined by me. The attending gave me a funny look. "You might be on to something there," she said. "He sure does smile an awful lot."

That smile could certainly have represented discomfort. I mean, I distinctly recall laughing hysterically through my first gynecological exam at the age of 16, and it wasn't because I was happy to be there. The smile could have represented something else, however. I had been very conscious of my countertransference, possibly to the point of ignoring its reciprocal: transference, the projection of a patient's needs and feelings onto a care provider.

It made sense for my patient to prioritize my station as a woman over my station as his doctor. After all, I had to work not to make a similar judgment toward him. I had devoted a lot of attention to making sure that my potential for countertransference didn't impact his care. But he wasn't being so careful, possibly because his career didn't depend on it.

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The most obvious-and certainly, the most creepy-consequence of transference here is that there might have been a genital jubilee in my office less for the purpose of medical evaluation than for the purpose of patient enjoyment. But transference has another potential consequence: suboptimal patient care. What if this patient values the impression he makes on me more than he values the appropriateness of the health care he receives? In this case, he might modify his story to sound like he's better-behaved than he is. Although I can't say that happened with this patient, it's easy to see how it could.

I wasn't sure whether the policeman's smile reflected nervousness, lascivious glee, or simple interest in me. I was also uncertain whether he felt he could be completely honest with me about his history. My solution? I thought that if I removed any mystery surrounding the dynamic between us, I'd remove both the thrill of the exam and the desire to impress-if either existed to begin with. So before the second pants-dropping, I looked Penis Man right in the eye. "This exam might seem like an uncomfortable thing," I said. "But the simple facts are, your 'parts' are body parts, too, and as your doctor, I am as concerned about the medical health of those parts as I am about the medical health of all your other parts."

Did it work? I don't know. He did smile a little less during his third visit, during which I gave him the [negative] results of his lab tests. I'd like to think that his newfound focus was a result of his reorientation to both of our roles in his health care, but it might also have had something to do with the cotton swab I jammed an inch into his urethra.

I suppose only time will tell.