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            Mrs. Smith brought her child; Alexandra, to see Dr. Sumal
for her first gynecological visit at 14 years of age and as of late began to menstruate.
Dr. Sumal administered a routine physical however did not administer a vaginal
exam. Rather she just addressed Alexandra about her body and what
transformations she ought to anticipate now that as she will start to develop.

Dr.
Sumal did not see Alexandra for a year until she made an appointment out of her
own stress over a persistent groin irritation. Dr. Sumal conducted an
examination of her and observed the irritation to be caused by a STD. She explained
to Alexandra what the STD was and emphasised that she talk to her partner so
they also may get tested. Alexandra, stunned and humiliated, gave a short and
blunt explanation about the subject and was not ready to agree with Dr. Sumal
that she would discuss and urge her partner to get checked. Alexandra seemed to
ignore everything and was persistent that Dr. Sumal not disclose any of this to
her mom.

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Beside
that Alexandra was in good overall heath and Dr. Sumal prescribed her a STD
treatment that required her to visit Dr. Sumal again in 3 weeks. Dr. Sumal
addressed Alexandra and discussed long term effects of specific STDS and how
safe sex could help in avoiding them. Once more, Alexandra pleaded to not have
any of this disclosed to her mom. Dr. Sumal assured her she would not but
rather that this diagnosis would be reported on her private medical record.
Alexandra returned in three weeks and was clear of the STD.

Following
a couple of months Alexandra was back, again with side effects of a STD. Dr.
Sumal was worried that Alexandra was back with a STD and additionally the casual
sexual relationships she was having; as she wasn’t 16 years old yet.

I
believe this is one of the harder aspects a doctor must deal with not only
because you feel morally obligated to warn Alexandra’s parents but also as a
doctor must be mindful of patient confidentiality. I believe the key here was
to make Alexandra more open to talking about sexual health. This could have
been done right from the beginning appointment. What my personal doctor has
done and what I believe is the best course of action is to first speak to both
Mrs. Smith and Alexandra then explain to Alexandra’s mother that Dr. Sumal
speaks to teens privately while emphasizing patient confidentiality thus
allowing Alexandra to take her guard down and feel more comfortable to talk and
listen. The best way I believe to start these discussions of sexuality is to
ask Alexandra what she believes to know about puberty so Dr. Sumal can gauge
her knowledge while at the same time showing respect and willingness to have
open discussion on the topic.

 During the second visit Dr. Sumal spoke to
Alexandra about long term effects of specific STDS and how safe sex could help
in avoiding them. Instead of having a one-sided conversation I feel that Dr.
Sumal would have been better off ask Alexandra after the STD test what she knew
about the STD she had gotten and see if Alexandra was misinformed and ask for
permission to explain what it is, again demonstrating respect resulting in more
open dialogue.

During
the third visit Dr. Sumal should not have assumed that Alexandra is having “casual
sexual relationships” because she had new symptoms. Rather it may have been
from her partner not being treated causing an infection again. The best way to
get feedback on the STD is to present it to the patient in a nonjudgmental way.
Asking question of “what kind of changes can you make” gives a sense of
autonomy to Alexandra leading to less resistance.

Lastly
after asking and receiving permission, Dr. Sumal could have expressed her worries
with Alexandra to give clear and concise advice. If that did not work then ask
Alexandra herself what may be a list of options for her to implement and if
that does not work then Dr. Sumal should provide more than 3 options so that
Alexandra will be more likely to pick an option rather than argue why 1 or 2
may not work.

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