Consultation skills - Consulting with male patients

Make the most of what may be a rare opportunity with male patients, advises Dr Tillmann Jacobi.

How can it be so different to deal with men in a consultation than with women?

Although it may seem stereo-typical, it is known that many men are doing comparatively badly regarding their health behaviour: too many drink alcohol excessively, smoke, eat a poor diet, use illegal drugs, have unsafe sex, are more likely to take risks (for example, they may drive dangerously) and tend to ignore signs and symptoms of stress, or at least don't talk as much about them.

Men are now more at risk than women of problems with mental illness. Men die younger than women and they are genetically more at risk of developing a number of cancers, for example, bowel cancer. The prevalence of testicular and prostate cancers has also risen in recent years.

Barriers for men
On average, men see their GP less frequently than women do. In the 16-44 age group women are twice as likely to use a GP service as men.

Men also make less use of dental check-up programmes, family planning clinics and sexual health help lines, weight management facilities, cancer support groups or carers' networks, as well as the resources in community pharmacies.

This means that men tend to attend late, even for serious problems, which can lead to much worse outcomes. A striking example of potentially preventable deaths is malignant melanoma: it affects more women than men in the UK, however, more men than women die from it, typically because of late presentations.

There are a number of fairly straightforward barriers to more or to better consultations between GPs and men.

  • Restricted availability of appointments due to working patterns.
  • A persisting 'macho' attitude among men, influenced by the expectations of society and experiences through peer groups and the media.
  • A lack of awareness and knowledge among men that GPs provide more holistic medicine and prevention than just treating acute injuries or giving out prescriptions.
  • In some regions, a possible objective lack of local services that are specifically designed for men.

Quality of interaction
A lower frequency of attendances may also affect the quality of the interaction and the chance to discuss other topics during consultations.

Consulting is not just a skill practised by the GP, but also by the patient, so more practice can make it better. Trust usually develops over a period of time, and with trust grows the ability or readiness to discuss more sensitive and complicated personal issues.

Interestingly, some studies have shown that GPs often fail to pick up cues from men, especially when those cues involve concerns about their emotional well-being.1

In other words, men seem to find it more difficult than women to put across in a consultation what really troubles them. This means that GPs should try to adapt consciously and shape the style of their consultations to the needs of the men they meet.

Lifestyle
Men are anything but a homogenous group. Social class, ethnicity, sexuality, disability, age and other demographic factors impact on their use of services.

For example, men from ethnic minorities are less likely to seek help, especially for mental health problems.

Also, gay men often seem reluctant to use traditional primary care services because too many report experiences of homophobia - an outdated and rather alarming situation.

It is thought that up to 10 per cent of men in Britain are homosexual or bisexual, although it is difficult to verify statistics reliably. We know that, from a medical and psychological point of view, this group of patients often needs specific advice, help and understanding.

With sexuality in general, many GPs are often not particularly pro-active in discussing it, unless the patient gives a clear prompt. Even then, we are still learning to take some common symptoms, such as erectile dysfunction, more seriously with regards to possible multi-system disease, rather than just blaming stress and lifestyle.

Improving the consultation
GPs should encourage the use of information resources for men, including online facilities.2,3

Another option might be to simply throw in the stereotypical health behaviours of men, as described above. Try 'We often find that men typically drink alcohol excessively... etc. What do you think?'

It might be somewhat provoking and not fully in line with the modern, patient-centred consultation approach, but it does get straight to the essential risk points. It also indicates to the patient that you are aware of some of the typical problems and that you are quite apparently unafraid and keen to deal with them.

Any consultation with a man is, potentially, an important opportunity to explore additional aspects of their health behaviour and state of health or well-being.

Being pro-active can be particularly effective if the man in front of you comes for something very simple, but hasn't attended for anything else for some time.

Learning points

1. Adapt your consultation style for a male patient.

2. Don't be afraid to deal with issues that may traditionally seem more male centred.

3. Men consult less frequently, so be pro-active when you have the opportunity of a consultation.

4. Men are likely to present later with a problem.

References

1. Shiels C, Gabbay M, Dowrick C, Hulbert C. Depression in men attending a rural general practice: factors associated with prevalence of depressive symptoms and diagnosis. Br J Psychiatry 2004; 185: 239-44

2. Do-it-yourself health-'MOT' for men www.malehealth.co.uk/userpage1.cfm?item_id=589

3. Health questionnaire for men www.malehealth.co.uk/userpage1.cfm?item_id=498

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