To ED or Not to ED

To be honest, berapa ramai antara medical student (= MS as in Multiple Sclerosis and Mitral Stenosis) yang berani delve into kain orang? What I mean is berapa ramai yang berani tanya…

“Pakcik ada main dengan perempuan lain selain dari isteri pakcik?” atau lebih sopan “Pakcik ada ‘makan luar’ tak?”

…dalam social history (SHx) diorang.

Iya secara jujurnya soalan itu sangat janggal. Aku sangat rajin bertanya soalan itu adalah sewaktu di IPR dulu, for the sake of getting a complete history. Setiap clerking aku tanya dengan tanpa segan silunya, dan without any sound guilty of prying. Dan Alhamdullillah tanpa lempangan sedas dua ke pipi yang sekadar ada sedikit fascial muscle dan kulit sensitive, mereka menjawab secara jujur (or was I that naïve to believe so).

Kali pertama tanya soalan itu sebenarnya sewaktu clerking session masa MSC Mini Clinic dulu-dulu. Dua kali klinik dianjurkan, dua kali juga aku kena jaga station history taking. As if aku ni adalah people person. Masa ni baru nak berjinak-jinak nak recall balik history taking berbekalkan nota Clinical Method Prof Yasmin. Tapi surprisingly, most of the students I clerk really confided in me and they really tell if they are indeed sexually active. It was such an honor to be someone they share about such things. Masa tu kite semua student lagi, tapi diorang boleh percaya nak tell-all hal peribadi dia kat kita. Oh, betapa sangat convincing-nya muka un-judging dan indifference aku dulu.

And terkadang aku pulak rasa segan bila terserempak dengan students yang aku clerk masa mini clinic dulu, because I used to know their story that maybe neither their closest friend nor their parents know about. Kenapa aku yang patut malu, aku pun tak tahu.

Ada suatu peristiwa lucu berkenaan isu ini.

Aku bertanya kepada seorang pelajar lelaki tentang samada dia sexually active. Dia bertanya semula, apa yang aku maksudkan dengan sexually active. Aku menjawab dalam interpretasi Bahasa Melayu,

“Maksud saya, adakah awak aktif secara seksual,” with an indifference tone and not a slight expression of prying.

Dia menjawab “Ya,” dalam nada hesitancy.

Aku bertanya semula “Berapa kerap awak melakukannya?”

“Maksud awak?” dia bertanya semula, cuba melengah-lengahkan untuk menjawab walaupun aku pasti dia paham soalan itu.

“Maksud saya, let say dalam seminggu, berapa kalikah awak melakukannya?”

“Oh, dalam…” pause sebentar “…tiga empat kali macam tu ar, ikut mood.”

Sambil menulis di dalam borang clerking, kemudian aku bertanya semula. “Ada guna protection tak?”

“Hah?” dia tanya tiba-tiba with a sincere confuse look

“Maksud saya, ada guna kondom atau apa-apa cara pencegahan?”

“Oh, yang awak tanya tadi tu maksudnya ‘buat’ dengan girlfriend ke?”

“Yup, tak kisah lah, dengan girlfriend ke, dengan sape ke,”

“Oh tak, saya tak pernah buat dengan sape-sape?” dia tersengih malu sorang-sorang

“???” <--(making my expressionless face)

Soalannya: Jadi apakah pemahaman dia kepada soalan yang aku tanya tadi? Hahaha…(lu pikirlah sendiri).

Kembali kepada isu awal tadi. Aku sedar semakin lama, aku bergerak terkebelakang dalam konsep SHx ini. As I am advancing in remembering important symptoms for Review of System (ROS), aku dropkan soalan tentang sexual history or promiscuity. Memandangkan dalam ROS genitourinary ada bertanyakan kisah dysuria, erectile dysfunction etc., so sexual history became less prominent in my history taking. Only if I find the patient are in a condition or state of trusting to willingly give out such information, will I delve about it.

Hari ini, dapat patient with Juvenile onset of DM, or DM Type 1. As we know, DM complications involving macro- and microvascular pathology, so one of the question to ask about is ED as macrovascular complication. To make it worst, in 17 year-old male.

Waktu tu baru habis buat lower limb examination of tone, sensory, power and Babinski sign (menggunakan pen), which surprisingly is positive in him for unknown reason, I re-confirmed it 3 times and it still positive. Memandangkan waktu tu takde tendon hammer untuk test ankle and knee jerk (oh pathetic-nya), so my partner-in-crime, saudari Farah AJ pergi mencarinya. While I got the privacy, I asked him about that with introduction sentence. I should not ask this such question in front of my female friend, for the sake of preserving patient’s ego.

“Maaf ye kalau saya tanya soalan ni, tapi saya kena tanya. Awak ada masalah erection tak?”

This question not merely asked for the purpose of menjaga tepi kain orang. Tetapi dalam DM complication screening question, I should ask about that. Since this patient already have retinopathy, lower limbs neuropathy, hearing trouble, and taking cholesterol-lowering drug, it is only right to ask the extent of complication as it will effects patient’s future plan of being married and having a child.

“Maksudnya?” dia tanya balik. Standard lah dapat respons ‘soalan berjawab soalan’ seperti ni bila nak tanya hal-hal sulit macam ni.

“Awak pernah rasa tak yang…(try re-arranging the correct way to ask)…kemaluan awak ada masalah untuk mengeras?”

Shit!!! This is such bad selection of words. I should ask “Barang awak ada susah nak ‘naik’ tak?” for simplicity, tapi sebab tak nak sounds like insensitive bastard; I made the question as palatable as possible, though it eventually made me sounds like a vocabularily crippled.

“Oh, takde masalah.”

Then I explained to him the reason of me asking the question. Nasib baik dia paham, dia kata dia ada terbaca juga tentang tu, tapi again he emphasizing that he is okay. Fuh! Punyalah susah nak tanya soalan berkaitan diabetes ni, ko ingat senang?

Sebelum clerking patient ni sebenarnya plan nak baca sikit pasal DM clerking tapi disebabkan time tu MS UM tengah berkeliaran, maka tanpa full preparation, terus pergi ke patient tersebut sebab takut MS UM sambar dulu. Tu yang soalan berterabur besides normal clerking questions.

In HTAR medical department, your history taking will be polished and readjusted an fine tuned real good, that for each disease and symptoms you get, there will be some specific question you should ask further and specific examination. Lagi-lagi kalau diabetes. Kena tanya diet dari sarapan ke supper, portion of diet, compliance, physical activity, current blood sugar reading, etceteras. In this patient, I take my time to explain to him the importance of compliance to medication since dia ada HPT and Hypercholesterolemia sekali. I think instead of scolding the patient (as the MO did), it is better to make them understand about their disease and how it is related to the manifestation of symptoms, rather than threatening patient with such hurtful words such as “Kalau awak tak ambil insulin awak, next time awak masuk hospital, masa tu awak dah koma, entah bila awak nak sedar,” dan “Awak nak ke next time awak masuk awak kena buat dialysis,”. Oh maybe MO ni penat sebab tak cukup tidur, let just give her the benefit of doubt.

Again, masalah kesukaran pertanyaan Sexual History ini jarang pula berlaku apabila nak clerk female patient especially kat O&G department. Maybe sebab female dalam soal kesihatan memang takde inhibition dan tak akan hold back any information. Sebab they want to get better to take care of their family. So they'll answer to anything as long as she can get back to her family. And they pretty comfortable discussing it with someone they could trust, even MS.

Berbeza dengan lelaki, as proven by statistic, they are less likely to go for medical check-up or hospital sebab tak nak appear weak. Only bila penyakit tu dah sampai tahap ‘close the door behind, and go straight to the light’, barulah diorang nak admit. Bila dah admit, dah one way street, tak boleh nak buat U-turn balik. Meaning, maruah dan kelelakian itu haruslah dijaga walaupun terpaksa menipu symptoms berkaitan sexual health mereka hatta nyawa terancam sekalipun. Maka jadilah fenomena lelaki kahwin sampai 4 still tak dapat anak dan lepas tu siap ceraikan isteri untuk cari isteri lain yang boleh bagi dia anak walaupun dalam realitinya yang barren itu adalah dia jugalah. Sanggup kahwin cerai dan kahwin multiple untuk dapat anak, namun pergi dapat nasihat urologist dan fertility expert jangan sekali. Perkara begini tak berlaku kat negara maju seperti negara-negara eropah dan US.

Thus, kerana menyedari fenomena begini. Aku selalu skip bertanyakan sexual history pada patient lelaki kerana, even if they have problem, they won’t admit it. So equation-nya samalah kalau kita buat assumption yang pakcik tu sihat-sihat belaka. Dan kerana dia nampak cam alim, kita assume dia tidaklah ber-promiscuity dengan orang lain. Walaupun rupanya dia itulah kaki seberang Golok.

Kejanggalan begini aku percaya dialami oleh semua MS di seluruh dunia. To ask or not to ask.

Primum non-nocere. If they think it is good for them; then it is good indeed. First do no harm.