During her time at Stonewall Medical Centre in Brisbane, GPTQ’s Associate Director of Medical Education, Dr Rebecca Lock has cared for patients from all walks of life, including those working in the sex industry, those living on the streets and those recently incarcerated. She has also been privileged to spend time helping patients from LGBTIQ+ communities in areas such as transgender medicine, HIV testing and treatment, and mental health support.
Here Rebecca offers an insight into her clinical work at Stonewall, along with a range of tips for registrars when working with vulnerable patient groups.
Stonewall aims to be a ‘place of relief’
Rebecca began working at Stonewall in 2018 during the practice’s 23rd year of operation. The clinic was started (and is still run) by practice principal, Wendell Rosevear.
“In the early 90s, both Wendell and his friend and colleague David Orth, watched a lot of their friends die from HIV. They wanted to help, so opened a practice in a house given to them by The Sisters of Mercy at South Brisbane. It initially focused on palliative care,” Rebecca explains.
“But over time, the demand for a place where people could get medical treatment without judgement for being gay or HIV-positive really grew. They then split into two practices, with Stonewall being one of them.”
Rebecca says the clinic’s population base is extremely varied.
“We have a lot of people from the LGBTIQ+ communities, including transgender patients and patients seeking gender affirming treatment. We see many patients living with HIV, and also a large proportion of mental health patients who’ve felt stigmatised at other clinics. We have homeless patients, those struggling with IV drug use and other substance misuse issues, and those working in the sex industry. We also see recently-released prisoners, some of whom still have their ankle bracelets on. It can be really challenging.”
While Stonewall warmly welcomes patients who live in the area or walk-ins, the main aim is to create a space for people who feel like they don’t quite fit into mainstream general practice.
“We want to provide an environment where people don’t feel judged or stigmatised, or like they can’t reveal what’s actually going on for them,” Rebecca says.
How the team turned Stonewall into a haven for the vulnerable
According to Rebecca, creating the right environment at the GP clinic was based on two key things – relationships and practicalities.
“Most of our patients come to us by word of mouth. Part of that is having good relationships with not just community groups, but the local mental health unit and the police. As an example, sex workers in the area know they can get a certificate from us for ongoing work in a brothel without any hassles. They feel safe enough to ask,” she says.
When it comes to the practical parts, Rebecca says the clinic has carefully considered the design of their waiting areas, as well as practice protocols.
“The artwork and our practice pamphlets are very affirming. We have posters talking about gender diversity, about being HIV-positive, or about being a sex worker. This helps patients feel like they’re not the only ones, and that it’s a normal part of our practice.”
“It’s also important to ensure our staff are very well-versed when it comes to paperwork, and managing people who may not have a ‘Mr’ or ‘Mrs’ in front of their name, or have a different name to their Medicare card.”
You already have vulnerable patients – you just might not know it
While it’s obvious many of the patients Rebecca sees have experienced trauma (whether that’s at the hands of medical professionals or the wider community), many vulnerable patients are also hidden, some of which you’re likely to see at your practice.
“Your vulnerable patient might be somebody experiencing domestic violence at home, or somebody who’s been questioning their gender since teenage hood, and hasn’t felt comfortable talking about it. Your vulnerable patient might be somebody who’s been sexually assaulted. It’s important for you to recognise that what is a normal day consulting for you, may be an extraordinary day for the patient coming to see you.”
Dr Rebecca shares her tips for working with vulnerable patients:
- Consider your personal boundaries and biases
In her time at the clinic, Rebecca has been confronted with horrible stories of prejudice and discrimination, one of the most powerful being a patient who told his regular GP he was gay and living with HIV a few years ago. His GP then refuse to continue to treat him, labelling him as dirty.
While the unfairness of this incident stuck with her, there have also been times where she’s had to confront her belief systems and reassess her boundaries.
“When I first came across a patient who was a convicted paedophile and still being actively monitored, I found myself thinking ‘I don’t know if I can treat this person,’” she says.
But the key was noticing she was having judgemental feelings, and making a conscious effort to ensure it didn’t impact her care.
“It’s about checking in with yourself and saying ‘Am I making assumptions here or holding biases?’ This goes hand in hand with recognising every patient is a human with a unique story and set of circumstances. You really can’t understand what’s driven the decisions they’ve made, but you can bet there’s a complex story behind it. It’s important to try and figure out the context,” she explains.
- Know this – your vulnerable patients will test you to gauge your trust level
Rebecca says: “Patients are more likely to open up if you can show yourself to be nonjudgmental, even if it’s about something entirely different to the medical issue they have. These patients are always testing you to see if it’s ok to tell you the next level of what’s going on for them.”
She can remember two occasions that highlighted this. The first was a patient living with HIV who only visited Rebecca for their HIV medications, saying their regular GP didn’t know their status as they were scared they’d be judged. The second was a nurse who worked as a sex worker for a few months each year for extra income, and felt she couldn’t reveal this information to her normal GP.
In both instances, Rebecca’s reaction was naturally one of deep concern.
“As a GP, that’s really important information you need to know, so you can look after their health properly, especially when it comes to medication interactions. It’s really worrying they can’t trust their regular doctor enough to reveal that information.”
- Ask before you tell
Rebecca says one of the best ways to build trust with vulnerable patients is to ask before giving out information.
“You can say ‘Tell me a bit about what you know about this, and I’ll fill in the gaps.’ Showing genuine curiosity, rather than simply following a formula when taking a history also contributes to trust building,” she says.
“At the same time, it’s also about having a poker face when you find out something that might be a little bit outside your comfort zone. You might say ‘Oh, wow. That’s difficult. Can you tell me more about that?’”
- Be mindful of names and pronouns
When it comes to dealing with transgender and gender diverse patients, Rebecca says the best policy is to be upfront, asking them how they like to be addressed. Does the patient prefer he/him, she/her, or they/their? What about their preferred name?
“I’m really conscious that many patients can’t change their name on their Medicare card, so pathology forms and scripts will come up with their assigned birth name. I make a point of putting a line through it and writing their preferred name on top. The pharmacist or pathology company can still see the name that’s on the Medicare card, but I’ve acknowledged that’s not their preferred name,” Rebecca explains.
This extends to referral letters, with Rebecca recommending you pay particular mind to any auto-generated sentences that may need adjusting.
In addition, if Rebecca needs to call in an authority script and use the patient’s assigned birth name in their presence, she warns them ahead of time.
“It can be really triggering for transgender people to hear their ‘dead name’. Address that by simply saying ‘I do need to use the name that’s on your Medicare card when I’m on the phone requesting the scripts. I’m just letting you know that’s what I’m doing here,” she advises.
“If you do make a mistake with a patient’s preferred name or pronouns, simply acknowledge it and move on. Don’t make a big deal about it, or try and explain or justify”.
- When it comes to taking a sexual history, practise, practise, practise
Taking a sexual history can be a little uncomfortable for both you and patient, but Rebecca recommends you practise asking the questions until they feel natural to you.
“Just be really matter of fact – do you have any regular partners? Are they male or female? Do you have any other partners? Are they male or female? You can use the same questioning tone as if you were asking ‘Would you like a cup of tea? Would you like milk with it?’”
- Use universal precautions at all times
Vulnerable patients, particularly those who are living with HIV, can be very sensitive when it comes to physical exams.
“If you examine somebody 10 times and you never use gloves, and then you find out they’re HIV-positive and you start using them, that sends a message. That’s why I feel it’s better to use universal precautions at all times,” Rebecca explains.
- Equip yourself with the right evidence
When it comes to treating people living with HIV, Rebecca says it’s essential to stay up to date with the evidence.
“If you have a patient living with HIV and they have an undetectable HIV viral load because they’re well controlled on medication, the disease is untransmissable. That’s something a lot of junior doctors don’t quite believe. Use the guidelines appropriately because when you don’t, that’s unfair to your patients.”
- Reset after each patient
Rebecca says ‘it’s an exceptional thing’ for any patient – particularly a vulnerable one – to open up and tell their story.
“If you’re having a bad day, or are tired or hungry, take the time to check in with yourself and reset after every patient. Those vulnerable people are out there, and until you’re able to prove you’re worthy of their trust, they won’t share their experiences with you, and that means the care you’re giving is suboptimal.”
- Understand it’s unlikely you’ll be able to ‘fix’ everything for them.
In her experience, Rebecca says registrars are so keen to do a good job that they feel frustrated when they can’t solve their vulnerable patient’s concerns in one or two consultations.
“In these populations, that’s not really possible. For people who’ve experienced trauma, or who are in difficult circumstances, it’s just about chipping away a little bit over time and creating those long term relationships. Sometimes it’s about holding stuff, not necessarily fixing stuff,” she says.
“Your job is really about providing information to guide them to make their own decisions. I find it alleviating to know I’ve done my job in terms of giving them the options, but I don’t have to make the decision for them. If I do, that’s my judgment getting in the way.”
Rebecca commenced her general practice at Pomona Doctors Surgery on the Sunshine Coast in 2004. After thirteen years at the same surgery in Cooroy, Rebecca moved to Stonewall Medical Centre in 2018.