Bioethics Discussion Blog: Naked

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Sunday, August 21, 2005

Naked


There is an issue that most patients will experience and every family doctor or internist or surgeon will have contemplated as he or she has engaged in medical practice. Society has given the physician the right and duty to inspect and examine the human body by vision, hearing and touch. The issue will arise as to how the necessary examination can be performed skillfully and thoroughly and yet provide physical and emotional comfort for the patient. This procedure is what we try to teach medical students as they learn to perform physical examinations. Whereas, as mentors we can teach the techniques of inspection, palpation, percussion and auscultation and we can help the students understand general principles of professionalism and ethical behavior, more difficult for the student to learn is how to ensure a thorough and accurate exam while preserving the patient’s emotional comfort during the exam. In fact, there is also the issue of the student or physician’s emotional comfort during the exam. It all boils down to the matter of modesty by the patient and avoidance of any suggestion of voyeurism or prurient interest by the physician. Or even worse, sexual misconduct.

The problem in the American medical practice culture is that there are no strict and uniform rules regarding how to expose the patient’s body, whether or not to have a chaperone present with regard to genitalia, rectal or female breast examinations or other areas of the body and if present, who the chaperone should be.

This topic is discussed in the Perspective section of the current New England Journal of Medicine August 18, 2005 issue with the article “Naked” by Atui Gawande. M.D. Dr. Gawande is two years out of his surgical residency and has had the opportunity to talk with physicians who have practiced in other cultures around the world describing how the concern of modesty is handled in their country. He also discusses his own initial reaction about how he should examine a patient with strict attention to patient modesty such as avoiding the patient using a gown and simply or not so simply moving around the clothing. This action clearly became awkward and he resorted to gowned patients. Finally after noting the real professional problems of physician sexual misconduct but also false patient accusations due to misinterpretation, he concludes that explicit standards of what is a “normal” physical examination be set up or tightened so that both doctors and patients know and better doctor-patient relationships can be established.

I would be interested regarding what experiences you have had either as a patient or as a physician/nurse in the area of patient modesty and how the situation was managed. No names please. ..Maurice.

ADDENDUM (December 14, 2007): For more commentary on the same general topic, there are two addition thread sites, "Patient Modesty: A More Significant Issue?" and "Patient Modesty: Volume 2".

ADDITIONAL ADDENDUM: The photograph was taken by me on 8-21-2006 at J.P.Getty Villa Museum, Malibu, CA. is a Getty Bronze "Statue of a Victorious Youth" (Greek 325-300 B.C.)

ADDITIONAL ADDENDUM (May 10,2007): A link to the free pdf file of the NEJM article "Naked" was made available by one of the commentators. Use it to go directly to the article.

ADDITIONAL ADDENDUM (May 22 2008) WARNING:

THIS THREAD SEEMS TO BE OVERFILLED WITH COMMENTS AND YOUR FURTHER COMMENTS WILL NOT BE PUBLISHED. PLEASE GO TO "PATIENT MODESTY VOLUME 2" TO READ AND "PATIENT MODESTY VOLUME 3" TO BOTH READ AND WRITE NOW AND TO CONTINUE COMMENTS ON ISSUES WHICH HAVE APPEARED ON THIS THREAD. DO NOT TRY TO COMMENT ON THIS THREAD--IT WILL NOT BE PUBLISHED!!! HOWEVER, FOR THOSE WHO WANT TO READ ALL THE COMMENTS WHICH ARE MISSING ON THE FIRST PAGE, GO AHEAD AND CLICK "COMMENTS" ON THIS PAGE AND THEN CLICK ON "POST A COMMENT" ON THE NEXT PAGE AND FINALLY ON THE COMMENT WINDOW CLICK ON "NEWER" OR "NEWEST" OR "OLDER" AND SCROLL UP OR DOWN TO READ BUT DON'T WRITE!! ..Maurice.

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395 Comments:

At Monday, August 22, 2005 10:28:00 AM, Anonymous Anonymous said...

I recently had surery and was pretty upset when my first discussion about my general anesthesia was while I was lying in the pre-op room in a gown. Laying down and not being in my own clothing put me in a very compromising position. No one discussed the anesthesia with me before hand, so I had looked up a lot of information on the internet. Of course, I had a lot of questions. Unfortunately, I was practically naked trying to discuss whether or not to get pumped full of drugs. I really did not want to go under, but I was too flustered when I was talking with the anesthetist to push for a less risky alternative.

 
At Monday, August 22, 2005 11:04:00 AM, Blogger Maurice Bernstein, M.D. said...

A patient is already vulnerable to a life preserving anesthesiologist when the patient is wearing street clothes. The patient, as anonymous has noted, is even more so when clothed only in a gown and lying down on a table. Discussions about anesthesia should be done ahead of the time of surgery, unless emergency conditions exist, so that the patient is not under pressure or embarrassed and able to make a better informed consent.

Some anesthesiologists are really not thoughtful of their patient's emotions since I guess their patient is generally unconscious. I was to undergo major surgery and had already consulted my medical and surgical physicians and agreed with their consensus that there was no alternative to surgery. On the morning of surgery, just prior to being taken to the OR, a anesthesiologist came into my room, while I was lying down and gowned, and asked me if I "really wanted to undergo the surgery" and if I had considered the non-surgical alternatives. It seemed to me that the anesthesiologist had not even communicated with the surgeon! I was perplexed and upset. Everything turned out OK with the surgery and anesthesia itself but I have always remembered the incident. ..Maurice.

 
At Sunday, September 11, 2005 2:46:00 PM, Anonymous Anonymous said...

I grew up in a country (USSR) where the gowns were never offered to the patients, so showing my body to a phisician have never bothered me, regardless of whether the physician is a male or a female. I guess it is because my mother told me that it is OK to undress in front of doctors when I was still a child. I do prefer female genecologists, though, but as far as the physician opening my gown - it doesn't bother me at all. Growing up without gowns, I am just grateful I am given one. But I guess we are all different.

 
At Monday, September 12, 2005 7:55:00 AM, Anonymous Anonymous said...

I came to your site from a link at another blog-shrinkette. I found this story interesting. Having grown up with total trust and faith in our medical community (although the last two years have been a huge struggle in some regards), undressing and putting on a gown for a doctor, nurse, or any specialist has never been uncomfortable for me. It has always just been routine from the time I was a child, although probably somewhat awkward as a teen...probably not an uncommon feeling for most teens. All medical professionals here (I am from Canada) have always left the room for the quick change into the gown that I can remember.
I remember when having my son, which was a long period with toxemia of hospital rest, followed by an emergency c-section, how all the nurses were adoring the beautiful job the DR had done with my cut, and laughing about how it was a good thing I had no issues with being viewed so much!

 
At Wednesday, December 14, 2005 5:36:00 AM, Blogger gwc said...

You are brave to talk about this. The assumption by medical people that patients and family accept their intrusions gladly is selfservingly false. After 37 years of accepting that the Dr is always right I ran off 5 male student doctors who were gaucking at my wife's nude body while the female nurses were dressing her. They didn't have the couth to turn their backs for even a moment. The medical need to know was on the monitors not on her hips and breast. In the next three days I had to run off two male nurses who tried to check my wife's ecg leads even though her chart and the room door plainly stated female personal only. A male ecocardiologist made no attempt to drape my wife durin a 45 minute test. By this time my wife became dissociative of the entire experience and remains so one year later. I had to force the operating room staff to use proper draping prociedures. The only feed back I got was grunts and groans about the extra work. One female nurse privately said that she wished her husband loved her this much. I said that he does but that there are strong sociatial norms that people are afraid to break.

 
At Friday, December 30, 2005 2:22:00 PM, Anonymous Anonymous said...

I appreciate the fact that an MD would have such concern for his patients. I had come to feel medical staff have little concern for the emotional stress the situation puts people in. I do not feel the medical profession does so with bad intent so much as indifference. As a patient I have heard "its no big deal I see this all the time"...or "I am a professional so it isn't a big deal", but I would bet if the roles were reversed it would be a big deal. Ask a nurse to do her rounds in only the open back gown we are given and see if it matters. It isn't so much the fact that it can't be avoided as much as it isn't. We all know there are going to be occassions where the patients privacy must be compromised, it is the numerous times when it does not have to be and is. Recently I had a throat exam and was required to wear only the open back gown...another time I had to have an ultra sound on my testicles, a female nurse did the procedure, I could hear a male nurse performing an ultra sound on a pregnant woman on the other side of the curtain, when I asked why he didn't do my procedure she replied it wasn't his turn, we just take the charts as they come up without looking at who or what. Since I am a 50 year old male it wasn't suppose to matter, but it did. I have put off going back for screening that I know should have becasue I just don't want to go through that again. If everything that could be done for the patient such as providing scrubs or exam shorts when possible, or offering the option of same sex staff when possible was done, we would not have a problem, its the don't not the can't that I find to be the problem.

 
At Monday, January 30, 2006 9:16:00 AM, Anonymous Anonymous said...

My wife just had a pericardical cyst removed thought VATS ( Video -Assisted Thoracic Surgery ). When we first talk to surgent he said all the incisions would be very small and on her right side and that she would be position where she would lay on her left side. After she came out of surgery there was on under her breast. I asked her about it and she didn't know why it was there. But she does remember be brought to the operating room where they started taking off her gown before she was put to sleep. She said she was a little upset because everyone in the room was men. It makes me angry to think that they didn't try to keep her cover as best as possible when getting ready for surgery asleep or awake and making sure she would be draped before being everyone walked into surgery. I also asked the surgean about the incision under beast and if the breast was draped and he looked at me very angry and said he doesn't remember. Should I asked him what is the proceedure on keeping the patient as covered durning preping them for sugery and the draping procedures for a female having VATS. And why was a female not present in the operating room. Did a male put in her folly? All these question keep going though my mind making me event more upset.

 
At Tuesday, February 14, 2006 9:39:00 AM, Anonymous Anonymous said...

As a person with a disability I have expierenced a phenonome know as forced stripping. From eary childhood and well into my twenties medical staff would routinely call over colleagues to "take a look" with no regard to my state of dress.
During some examinations I was offered a drape, sometimes the entire exam or test ws conducted with me totally nude. It really appears to depend on the practicanor and the nature of the problem. In my twenties I was the subjected to a Uroligst give a history of my medical condition to his students. I was lying on the bed naked while he pointed out my defficies. At this point in my life I'm habitualised to the point where if a gown is not offered I don't bother asking.

 
At Friday, February 24, 2006 4:44:00 PM, Anonymous Anonymous said...

While the doctor/patient relationship is unequal, it doesn't mean that patients should be treated with any less respect than the doctor's performing procedures.

Currently, working on a research project regarding this subject, I have come to realize that once someone has a bad experience the reactions are from annoyed to Post Traumatic Stress Disorder. Once a patient has an agenda that differs from that of the doctor, there is a conflict of interest. Doctors and other medical employees are
as engrained by their training as we are to religious, political, racial preferences, etc. They just don't get it.
The consequences from bad behavior are limitless. Once you add the deviants (and there are about 7000 in the US at this time), there is no patient accountability or responsibility to take care of those which have been either victimized from "the system" or victims of previous sexual abuse.

The courts support bodily privacy and trumps it over antidiscrimmination/employment lawsuits. When you sign a consent form in a hospital, you are giving away your privacy rights.

Humiliation studies are ongoing and they have found that extreme humiliation causes permanent damage to the psyche. When this happens for no apparent reason, it can damage a patient forever.
If a patient enters a hospital with a request for same gender care due to previous abuse, PTSD, it should be mandated, or lack of adherence should be considered medical malpractice.

 
At Saturday, February 25, 2006 3:29:00 PM, Blogger kimberly said...

My husband has had four operations and has one more to go. I am very concerned about the staff protecting his modisty when he is in the operating room. I was abused as a kid and have a trust issue. I want to tell his doctor my concerns but feel it would just make things worse. That and I'm not the patient. I keep telling myself to be gratefull he is alive and that the other stuff dosen't matter. (but it does) I have done resurch on the internet and medical books but they don't tell you much. My fear is that the staff acts different when the patient has had verced or is under. I have no idea how to get past the way I feel about strangers seeing my husband. Any ideas?

 
At Sunday, February 26, 2006 9:22:00 PM, Blogger Maurice Bernstein, M.D. said...

You can be assured that the surgeons and nurses are not your abuser but I can imagine how your experience as a child can affect your current concerns. Despite being an internist, I have been numerous times in operating rooms and I have never seen any undue or unprofessional scrutiny or handling of genitalia. The genitalia are actually covered while the patient is brought to the table and layed out on the operating table. Then the patient's body is fully draped with only a hole at the operative site.

If I were you, I would talk frankly about your concerns and fears with the patient's surgeon. It will help you by ventilating your upset but also your surgeon, "captain of the ship", will be able to assure you of total professional behavior by the surgery team.

Best wishes to you and, of course, your husband. ..Maurice.

 
At Monday, March 13, 2006 6:24:00 PM, Anonymous Anonymous said...

I am a sometime medical patient, a 57 year old man who is amazed at the complete lack of respect given by female medical personnel for male nudity. It is assumed, correctly, that I don't care if I am completely exposed, totally nude in bright light, in a large room to many female medical personnel in a medical situation. (St. Barnabas Burn Unit, Livingston, NJ) Yes, I really don't care. Getting the medical job done is important.

Yet, I wonder whether these same female medical personnel would accept their own total nudity, under the same conditions described, in full view of many male medical personnel. Males are rightly assumed to have no, or very little, modesty. While females, all females, must have their modesty protected at all costs. There is a definitely a double standard. Yet females whine and bitch incessantly when males are given preference in other aspects of life.

 
At Wednesday, March 15, 2006 10:16:00 AM, Anonymous Anonymous said...

Ok one more time. I'm not sure you understand what I'm asking. I don't think that most people know that after you ar transfered to the operating table and put under. You'r gown is almost completly removed and you lie there naked while the pe-op skin scrub is done. I do understand that this is a must for infection reasons. Here is my question. How do medical people get used to seeing this and how do you know they are professional in thought? We are after all human. Kim

 
At Wednesday, March 15, 2006 12:04:00 PM, Anonymous Anonymous said...

Besides It's not about me. The important person is the patient. Will the doctor really care about how I feel? What if I offend the doctor. I don't feel they will understand. I just have to pray they are all good people and he will be ok. I hope medical professionals read this. You never know what the person you are treating has been through. I usually get treated as if I'm crazy. When I'm really just scared. It is very hard keeping it all to yourself.
Kim

 
At Wednesday, March 15, 2006 6:01:00 PM, Blogger Maurice Bernstein, M.D. said...

Kimberly, you must attend an operation to see what is going on. Patients are not laid out naked, fully uncovered, for what you describe as "pre-op skin scrub". The patient under anesthesia is very susceptible to bad effects from either chilling or over-heating and the anesthesiologist will see that the patient's core temperature is normal. Only the area involved with the surgery is exposed for antiseptic scrubbing. I restate that you must talk this all out with your husband's surgeon. Maybe he/she will allow you to take a peek into the operating room while the preparation for surgery is going on. ..Maurice.

 
At Thursday, March 16, 2006 1:15:00 PM, Anonymous Anonymous said...

I have a scoliosis which slightly curves my spine. When I was 18 I agreed to allowed my consultant to use me as a teaching aid. And I do mean use. I was brought to a lecture hall at the hospital. There were about 20 medical students (male and feamale) I was nude except for a hospital gown. The consultent delivered his lecture and gave my medical history as if I was thing, not a person. I had to walk up and down so they could observe my gait. Then I had to remove the gown completly so the students take a good look. I had to endure this for almost an hour. I just did what the asked like a robot. But inside I felt trapped and humiliated. This all happend 20 years ago and I hope that attitudes have improved over the years. I would be interested to know if any doctors out there have heard of similar stories from there older colleagues.

 
At Thursday, March 16, 2006 8:33:00 PM, Blogger Maurice Bernstein, M.D. said...

No patient is under any obligation to be a teaching subject for medical students. All patients must give their informed consent to participate. Patients can refuse. Perhaps 20 years ago, the standard was a bit looser but certainly under current HIPAA federal regulations regarding patient privacy there is more attention by those in the medical teaching profession about these matters. I am involved in facilitating first and second year medical students in taking histories and performing physical exams on both private and county hospital patients. All patients are informed by myself and the student about what is requested and if the patient refuses, we thank them for listening and then leave. Nudity of patients is not necessary for medical teaching. If substantial degrees of nudity is required for teaching physical landmarks, paid "standardized patient" models are used. ..Maurice.

 
At Sunday, March 19, 2006 1:28:00 PM, Anonymous Anonymous said...

OK I'm starting to believe you. I went yesterday to talk to my doctor and she said I should talk to his surgen. She also said if I couldn't she would be glad to call for me. She said surgery is all busness. It's about saving lives and making people well. Part of me knows that. I am so close to being as strong as I've ever been but so close to as week as I've ever been. I just need to hang on, so I can continue to help care for my husband. Say a prayer for him on March 31,2006. It's going to be a big operation bowel resection, gallbladder removed, and a plastic surgen will redo his ab muscles to close without mesh. I wish his doctor would let me be in there. I have done so much of his care here at home I feel like his nurse. I't will be hard to turn him over and wait. Not only do I love him with all my heart. I have become a control freek about his care. His meds (TPN) are at the exact time every day. I'm very picky about making sure every thing is very clean. He had staph from a military hospital. I know that happens everywhere but it happens at this hospital alot. It would be nice to have them respect me enough to let me see at least the start of the operation. I will not count on it though. I'm fighting to get them to let me into the pre-op area. I think they just want people out of there way. We will see. I don't give up very easy. However I'm always nice you don't get anywhere being a grouch.
I also wanted to tell you I'm going to nursing school. I hope to bring this topic to light at least to the people I will work with. When I was 25 I had a hystroectomy. I woke up during the operation. It was horable. But through all of it there was one nurse I will never forget. He picked up on my fear and never uncovered me to take out my foley. He also gave my husband a wash cloth and said I think she would rather you do this. Thats the kind of nurse I wan't to be.
I will call his surgen on Monday. I can't cry when I talk to her she is very serious. She won't respect me if I loose it. When my husband had one of his operations I was very scared (his wound came open and his intestines came out) She touched my shoulder when she walked away. So I know she has compassion. I hope she will hear me and I don't sound like a nut.
Thanks Maurice.
Kimberly

 
At Thursday, March 23, 2006 9:53:00 PM, Blogger Maurice Bernstein, M.D. said...

Kimberly, I would be very interested to know how your discussion with the surgeon went and whether you would have the chance to watch that part of the surgery about which you are most concerned. ..Maurice.

 
At Wednesday, March 29, 2006 3:41:00 PM, Anonymous Anonymous said...

I called. I am not even allowed in the pre-op area. The hospital has strict rules. They are using the HIPPA law. I called HIPPA and they said they are using the law for there convince not for it's intention. So if I can't even get that far how would I get any further? I am again miss understood. We leave tomarrow and the surgery is friday morning. I feel helpless. Out of all the nurses we have encountered there have only been two that I have felt were trying to see too much when there was no reasion to be doing that. Maybe they are few and far between. I can only hope. I will write again after the surgery. Thanks for takling to me.
Kim

 
At Saturday, April 01, 2006 8:41:00 PM, Blogger Jim said...

The subject of patient modesty is one that I have given a lot of thought to recently.

I’m a longtime athlete and was an Army volunteer at a young age. I was conditioned early in life to strip to undershorts for physical examinations. I was taught that gowns were for female patients with male doctors. I was almost 24 before I ever had a doctor or nurse offer me a gown. Trying to wear it just didn’t work for me. It was a joke.

Ever since then, if a doctor or nurse has offered me a gown, I have politely declined it, telling the provider that I’d prefer to just keep my briefs on instead — and even those have to come off toward the end of the exam. Their responses: “Fine,” “No problem,” “Whatever you’re comfortable with,” etc.

I respect the preferences of other patients. And I feel that gowns and drapes should always be available for patients who feel the need of them — but never compulsory. We all have our different levels of modesty. One size doesn’t fit all.

Also, I suspect that the over-emphasis in some medical offices these days on gowning and draping actually makes some patients more ill at ease, not less. One fellow who is studying to be a pediatrician and has worked as a PA (physician’s assistant) has shared with me some helpful insight from his supervising MD: Having the patient strip down right at the start — just get it over with before the exam begins — tends to help the patient calm down early and get over his nervousness about the exam.

My experiences corroborate these observations. I had one experience with the STRIP AS YOU GO method — a procedure that strikes me as really absurd. My doctor is going to see all of me anyway. So I’d rather just strip down to near-nudity and get it over with before the exam starts. Then he can go efficiently and uninterruptedly from one part of the exam to the next. From experience, I also know that having nothing between my skin and his hands and instruments gives him a quicker, more accurate overall assessment — and a better chance to spot conditions that need correcting.

 
At Sunday, April 02, 2006 10:14:00 PM, Blogger Maurice Bernstein, M.D. said...

Jim, I can see that you don't understand the actual process of the physical examination when you call some serial undressing "strip as you go" as "absurd". Doctors are dealing with human beings who may have significant emotional changes with physiologic consequences related to the issue of modesty in addition to the effect on patient participation in the exam. In addition, the body can produce vasoconstriction and shivering when exposed to a certain degree of cold. All of these responses can interfere with attempts to do a proper, accurate and complete physical exam. For example shivering can be heard on listening to the heart and interfere with correct intepretation of the sounds. On abdominal exam shivering can be associated with tension of the abdominal muscles making the exam more difficult. Emotional upset may affect heart rate, blood pressure and respiration as examples.

Therefore, we teach the medical students to make sure the patient is warm and comfortable and not chilled and to bare the skin of the patient in sections at a time based on what the student is going to examine. Even male patients should be covered sufficiently to prevent shivering. Not uncovering the patient at all is poor practice since examination through clothing yields poor and ambiguous results.

I hope this helps those who didn't understand the principles of doing a proper physical exam. ..Maurice.

 
At Wednesday, April 05, 2006 7:35:00 PM, Blogger Jim said...

Dr. Maurice, thank you for taking the time to reply to my earlier posting and offer your feedback.

I fully concur with you on your last point: “Not uncovering the patient at all is poor practice since examination through clothing yields poor and ambiguous results.” I had a doctor — just one visit — who stethoscoped my back, chest, and abdominal areas without ever asking me to remove my t-shirt. How, I wondered, could this guy get accurate, intelligible respiratory, heart, and bowel sounds this way? To me, that’s cutting corners. He wasn’t very thorough with the rest of the exam, either. You guessed it — I never went back to him.

You also stated that “the body can produce vasoconstriction and shivering when exposed to a certain degree of cold. All of these responses can interfere with attempts to do a proper, accurate and complete physical exam.” I’ve always been highly sensitive to cold temperatures. Yet, so far, I’ve never encountered an exam room too cold for me. If the room were too cold, either I’d get the staff to remedy the situation, or I’d call off the visit and reschedule. In a cold room, I’d need my shoes and socks, long pants, and a long-sleeved shirt — a lot more than the typical gown or drape can provide — to keep from shivering. And, as we have already agreed, that’s no way to do an exam.

“Doctors are dealing with human beings who may have significant emotional changes with physiologic consequences related to the issue of modesty. . . . Emotional upset may affect heart rate, blood pressure and respiration . . . .” Definitely true. Like many other patients, I have what’s known as white-coat hypertension — plus an accelerated pulse (in the 80s) — when I go into a doctor’s office. In my case, though, it’s not because of modesty issues. I’ve been on the exam table in just my shorts many times; but once the exam gets rolling, the nervousness fades fast, and my blood pressure and pulse rate drop. I know, because I’ve asked the doctor to re-check the numbers at the end of the exam. This somewhat parallels the experience of performing musicians in recitals — keyed up to start off, more relaxed after the opening. BTW, one doctor’s nurse showed me some years ago how to take my own BP readings at home. Once I got over my initial apprehension, I got consistently good readings.

“I can see that you don't understand the actual process of the physical examination when you call some serial undressing “strip as you go” as ‘absurd.’”Actually, I do understand the process quite a bit — at least from the patient’s point of view. I have gone through exams 1) fully clothed (just once — see above); 2) stripped to shorts (many times); 3) gowned (just once — trying to use a flimsy paper gown that didn’t work out and wouldn’t have offered any protection from cold); 4) doing “strip as you go” (just once). Now that I have the comparison, it looks as though you and I will have to “agree to disagree” on this point.

In my one experience with “strip as you go,” the doctor was a young intern. He had me fully clothed at the start of the exam to check my eyes, ears, nose, tongue, throat, thyroid, neck glands, reflexes. Then he had me strip off my t-shirt for the stethoscope exams — respiratory, heart, bowels. Next he had me strip off my jeans. I was down to my shorts and socks for the rest of the exam. It was summer, and the room was air-conditioned to (I’d guess) mid-70s, — satisfactory for me.

It was a nuisance to have to interrupt the exam this way — get up off the table, remove my sneakers, and shed my jeans. It would have been more logical, more efficient, and less awkward — not to mention less time-consuming — if the doctor had just had me strip to shorts and socks before starting the exam. Incidentally, he and I worked well together, and I would have gone back to him if I hadn’t moved to another city; but at the next checkup, I would have made clear to him my pre-exam stripping preferences.

According to the experience of the med student/PA (see my earlier post), there are many other patients who, like me, are more at ease just stripping to near-nudity right at the start and not using a gown or drape. That way, there’s no more wondering when we’re going to have to strip off more — and no worry about whether a gown or drape is going to stay in place or fall off. Again, adequate gowning and/or draping should be an available option for any patient who has issues with modesty. But those of us who couldn’t care less about our personal modesty in an exam room have the prerogative to decline such extra coverings.

 
At Saturday, April 08, 2006 11:34:00 PM, Anonymous Anonymous said...

For an examine, I do not use gowns or draps, as the point of going is to be seen. I didn't have this attitude until I had a physical while I having a very odd looking bruise on my side due to a kayak accident the week before. I thought to myself "I wonder what the doctor will make of that". After the examine, which supposedly included a skin cancer check, I realised he didn't mention it because he never actually saw the fist size green lump because of all the fiddling about with my gown to protect my modesty. What else did he miss?

I am naked in front of men I don't know twice a week in the locker room at the gym and it doesn't bother me at all. Once I year I go to my doctor for a physical and he or she insists on covering me up with draps and gowns in the privacy of an exam room. The whole point of going to the doctor is to be seen, so now I make sure I'm completely seen and give them the best chance of not missing something.

 
At Monday, April 10, 2006 10:54:00 AM, Anonymous Anonymous said...

Last January I developed a rash all over my body, I think it was a combination of work related stress and the shower gel combo I got as a Christmas present. I went to my local clinic to see a GP and she was usless. She asked me to lift my t-shirt and that was the extent of the examination. 10 minutes and a prescription later I was out the door.
I was really concerned so I made a second appointment with a different doctor at the same clinic. He had me undress completly so he could examine me properly.
I don't understand why two doctors at the same clinic would behave so differently.

 
At Monday, April 10, 2006 11:21:00 AM, Anonymous Anonymous said...

Dr. Maurice
I appreciate that you show concern for this subject. I was begining to think the medical community did not care at all. From your comments I think you grasp not only the issues, but the ramifications. People are different and react differently, lumping all "men" in the catagory as not caring or being bothered by being nude infront of staff ignores that we are all different. Choosing to err on the side of modesty protects those who do care without harm to those who don't. Males have been condictioned from early on to accept such treatment whether it bothers them or not, so they do so in silence. Females have been told its acceptable to voice concerns and request same sex staff. The result is many males suffer in silence, or worst yet die from embaressment due to avoiding medical attention when they should seek it. As a male I have experienced the double standard. When I asked for a male doctor for a prostrate exam I was made to feel petty and sexist by the staff, the same staff that accomidated my wife's request for a female GYN without hesitation. I had a routine colonoscopy, my doctor and 3-5 female nurses were great but the number and gender difference made me very uncomfortable, embarassed, and emotional stressed....but I wonder if the genders were reversed if it would have been viewed the same, would the hospital hire a male nurse to do mamographies? I know from conversations with other male friends it does bother them.......but the only recourse they see is submit to it, joke about it, or avoid it. Thank you for bringing this issue up, I hope you share it with other professionals......it isn't a question of your professionalism or intentions...its about your patients, you seem to get that.

 
At Monday, April 10, 2006 2:39:00 PM, Blogger Maurice Bernstein, M.D. said...

10:54 AM Anonymous- I think what you observed and experienced is extremely interesting. You witnessed two physicians attempting to arrive at a diagnosis using two different approaches. The first doctor may have "seen enough" with the solitary look under your T-shirt and relied on your history of rash "all over my body" to make the diagnosis. Her behavior may have been tempered by the fact she felt rushed or she felt uncomfortable uncovering all of you. (Some doctors, especially professionally young ones and of the opposite sex may have some shyness to have the patient more undressed.) Even if the small look gave adequate information about the diagnosis of the rash, not looking at the rest of your skin denied her the chance to pick up some other unrelated lesion, perhaps one that you were unaware. The second doctor was professionally compulsive and was disregarding time and schedules and wanted to be sure that he verified your history and also to feel confident that he wouldn't miss anything. You should go to the compulsive doctor!

11:21 AM Anonymous- The whole issue, though not a talked-about subject in medical professional conversation is obviously, even based on the comments to this post, one of patient concern. The trouble is that I think that most physicians really only pay attention to their own comfort or discomfort about patient modesty and really don't understand what the patient may be feeling. I think patients should be encouraged to speak up! The patients should tell their doctors why they are concerned about being too exposed or not sufficiently exposed. Doctors should explain to their patients why what is being done is being done. This is being taught to medical students as they learn to perform the physical exam. Why this doesn't stick with them later on in their careers is uncertain, though it may be related to lack of time and lack of concern of the patient's feelings as the doctor cones down on making a diagnosis quickly. As you gathered from my post, I think about it as I examine my own patients. In part, that is because I also keep in mind that I am supposed to be a role model to the student I teach. ..Maurice.

 
At Sunday, April 16, 2006 7:11:00 AM, Anonymous Anonymous said...

After I was diagnosed at the VA with melanoma a young female dermatologist started a series of "full-body" exams. They were done nude. When I stood down I was completely naked and she even said it was "easier" without a gown. I was fine with the nudity but she was very quiet and seemed uncomfortable with it. But every time I went in she always said, "Take off everything." I now know that a full-body exam should probably done with the patient wearing underwear. I don't like gowns and apparently neither did she. And I believe that she was bothered by male genitalia and it created "sexual tension" between us. I believe this was a case where poor communication was the culprit. She should have discussed everything, asking me what I was comfortable with and above all what she was. Most patients will be happy with a doctor who is cheerful and friendly and does a professional job.

 
At Sunday, April 16, 2006 4:59:00 PM, Blogger Maurice Bernstein, M.D. said...

There is no physical exam rationale for full nudity, none whatsoever. The exam is not a class for teaching or practicing human art painting or sketching. Every part of the external human body can be clinically examined in portions as necessary to protect patient comfort and modesty. And in the case described by Anonymous, presumably doctor comfort. It may be that the female doctor described was compulsively following some inappropriate teaching she had learned in her training and was never comfortable about it. This emotional discomfort is serious since it can cause intellectual distraction with the possibility that the physician may unintentionally ignore or misinterpret significant findings. The takeaway message: talk to your doctor and describe your discomforts about the physician's requests concerning any issue. This conversation will be of benefit to you and your doctor. ..Maurice.

 
At Monday, April 17, 2006 1:10:00 PM, Anonymous Anonymous said...

They shaved all of his pubic hair off. The incesion is one inch above his penis and goes all the way up to his sternim. Now tell me he was covered during all this. I'm sure it was like I have thought all along. Once the patient has verced on board it's a free for all. They didn't even tell us it would be that big. How do you know the person that did this wasn't a deviant? You don't know.
Kim
Kim

 
At Tuesday, April 18, 2006 9:58:00 AM, Anonymous Anonymous said...

Kim,

I had bladder surgery 2 years ago. My pubic hair was shaved off and I now have a scar from the base of my penis to my belly button. The nurse who shaved me was really nice. There is no need to worry, in a medical setting this is a very common occurance. The entire thing was done in a very matter of fact way and I did not feel too embaressed. Post op many different staff helped me bath and use the toilet. I was nude for almost two weeks after surgery because there was a catheter tube directly inserted into my bladder which prevented me wearing pajama bottoms. Although initally I was embaressed, it became so common for members of staff (male and female) to see my body that I stopped worrying. There was never anything sexual in the contact.
I do not mean to trivialise your concern Kim but I think you need to seperate nudity and sexuality. I have been in much more sexualised enviornments while fully dressed in a bar then completly naked in a hospital enviornment. I hope this helps you

 
At Tuesday, April 18, 2006 9:32:00 PM, Blogger Maurice Bernstein, M.D. said...

Kim, It is clear that you are very upset with what you see but seeing is not knowing. What you should know is what you saw is absolutely necessary as part of the preparation for surgery in the lower abdomen. If the pubic hair is not shaved, there is a better chance for infection of the operative wound to occur. I can assure you that, in all probablility, there is no sexual deviant or unprofessional behavior involved. Preparing the skin for surgery is absolutely routine and simply represents an important chore (removing the hair without nicking the skin). There are no sexual interest involved. For your own peace of mind and to prevent you upsetting your already ill husband you should believe what I and the previous Anonymous have written. Your concerns, though I have no doubt they are very much upsetting to you, are out of proportion to what was actually done.
There are many more serious concerns folks have in their lives than what bothers you. ..Maurice.

 
At Wednesday, April 19, 2006 8:16:00 AM, Anonymous Anonymous said...

Maurice,
I have been known to test the people around me. My comment was to test you. You reacted exactaly the way I feered his surgin would react if I had told her my concerns. I knew what was going to happen. I read alot. I am very aware of the precoutions taken for infection. It however dosen't make it hurt any less. I still say the patient should have been warned or told what was going to happen (ie; shaving and the larger incesion). You are at the mercy of the people who take care of you. What they do and what they think. That is why I usually keep my thoughts to my self and for good reason. My husband knows how I feel I don't have to tell him. After the surgery he said "I know this bothers you and I'm sorry" I said "Thanks for understanding now lets just get better. I love you."
You are a true "Doctor" Maurice.
Kim

 
At Monday, April 24, 2006 9:55:00 AM, Anonymous Anonymous said...

When I was in boarding school, we had an annual physical at the start of each year.
This usually involved each year being taken down to te school gym wearing our underware. Perhaps 40 or 60 students at a time. We had the standard hearing and eye tests in the gym before we were taken behind screens to be examined by the doctor. By the end of the exam we were nude. Although this was very embarressing for us as teenagers, we never felt anything untoward was going on. A female doctor conducted the examination and the school nurse was always present.

 
At Monday, May 01, 2006 2:43:00 PM, Anonymous Anonymous said...

Dr,
After an accident and after I was taken from A + E to a hospital ward I was cleaned up and given a bed bath, despite the pain and the medication I had a spontanious erection. I really didn't know what to do so I made no comment. The nurse made no comment. She discretly laid a wash cloth over my privates to hide my blushes and continued to care for me. The only problem was that the cloth would slip and I kept my hands as far from my body as possible so I was not able to adjust the cloth. I felt terribly embarressed and was and am still concerned that the nurse thought I was some kind of pervert.

 
At Tuesday, May 02, 2006 9:18:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous from May 1 2006, you may have been embarressed but I am sure the nurse wasn't and she didn't look at you as a pervert. You and the other visitors here may not know that it is not totally rare that a man may exhibit a spontaneous erection particularly when the penis is manipulated for medical reasons (such as genitalia physical exam, insertion of a catheter, etc.) This reaction is so usual that we teach our medical students (men and women) right from the beginning about this reaction and that they should simply ignore it. Perhaps physicians and nurses should do more than ignore the erection but acknowledge this is occurring and reassure the patient about its normality. Like many problems in doctor-patient relationship, timely communication between parties could prevent concerns which can persist for years after the occurance. What do you think? ..Maurice.

 
At Thursday, May 04, 2006 3:15:00 PM, Anonymous Anonymous said...

What do you do if you think your patient is attractive? I recently had a heart problem and I am sure the doctor thought I was arrtactive. He stated shaking when he did his exam. His voice got shakey. My mother even noticed.

 
At Thursday, May 04, 2006 4:05:00 PM, Blogger Maurice Bernstein, M.D. said...

To today's Annonymous I would answer to the question "what do you do if you think your patient is attractive?" Well, if it is a piece of clothing, it might be professionally proper to say some pleasantry such as "that's a very nice dress you have on. Where did you get it? My wife might like it." However, unlike the suggested acknowledgment to the patient regarding a patient's erection as in my previous comment, I would say if the patient appears sexually attractive to the physician: Keep it to yourself and pay attention to the job at hand which is diagnosing and treating the patient. Since physicians are only mortal human beings, this isn't always easy. However, this issue is also something we discuss with our medical students since there even is a class of patients who are intentionally sexually provocative toward the physician in order, perhaps, to gain some control over the physician in situations where the patient may feel inadequately in control of what is happening to themselves. I hope this answers your question. ..Maurice.

 
At Saturday, May 06, 2006 8:17:00 AM, Anonymous Anonymous said...

The right way to do a male full-body exam by a female doctor is first: what is required, and second, what the doctor and patient agree on. If the patient has a bad skin condition in the groin then the female doctor will have to look at his genitals. Of course, since she's already doing a full-body then the patient will probably have to be naked under a gown, sheet or towel. It shouldn't be difficult for a female doctor to do this, but a resident, who has very little experience, may have trouble with it. Ironically, residents need the experience but yet may become embarrassed. On the other hand, an experienced female practitioner may even be bored with male nudity or may have had a bad experience involving exhibitionism. Where do you draw the line? You can't. Every doctor and patient is different but I do believe that if a doctor can talk her way through the exam in a pleasant manner then everything will be fine. That distracts the patient and shows him the doctor is not afraid of him. "Face time" should make up the majority of the exam. The body is not dirty. Unfortunately many Americans think it is and the proper exam may not take place.

 
At Tuesday, May 09, 2006 5:14:00 AM, Anonymous Anonymous said...

I developed bladder stones some years ago, I'm in my mid-thirties and I was told this is not a common problem for men my age. I was in hospital for 2 weeks under going tests and eventually surgery. Due to the nature of the problem, privacy was impossible to maintain. I was generally nude or naked from the waist down for every examination. It must have been close to exam time because I was frequently asked by students could they examin me or take a history. I was very accomadating because I fully understand the needs in a teaching hospital.
However at the end of the first week I underwent a VUCG examination. I was taken down after my morning wash naked underneath my dressing gown. The technition conducting the exam was really terrible. Her first words to me were to remove the gown and pee into a jug she handed me. After that I had to lie on the table and endure what is a very invasive test. At no point during the proceedings did she ever offer me a robe. I had a small drape layed across my pubic bone which covered my belly and that was it. This woman even left the room to consult a colleague without anything more than a nod in my direction.
I have never before or since felt so de-humanised. My sympathy to every woman who has endured Gyno exams because I doubt I could go through my expierence twice

 
At Tuesday, May 09, 2006 5:33:00 AM, Anonymous tenderhusband said...

Good Morning Dr. Maurice. My name is Mike from Jax. Fla. I am the founder and moderator of a group board called how husbands feel. We have ladies and gentlemen who for the most part belive that the medical profession has dropped the ball on the issue of protectng or over exposing the intimate space between husband and wife.
I would like to make a couple of points.
(1) You mention that exams and surgery is always done with a professional attitude. In 3 short months we have documented and saved over 100 cases of sexual misconduct in our group pages. WE have in our links section a survey done by Vandy. University that showes 1 in 8 DR.'s of their own admission are guilty of sexual misconduct at some point in their carrear. On a side note to this issue, almost all of the DR.'s in the cases we have saved was given little or no punishment and was reoffenders, Dr.'s like yourself should be leading the way for *real reform* as in the first time you mess up you loose your medical credintials for good and you can find another line of work. It would be best for all the good Dr.'s and malpratice insurance would cost less. But the good ole boy system of Dr's policing Dr's keeps these same bad apples in the pool.
(2) To address the double satandrd that has been talked about here. When my wife and I attended our first check-ups at the same time. She was instructed to remove her shirt and bra and put on the paper gown. I was left with my shirt on. What was so different about her heart and lungs than mine that she needed to be in some state of undress?
(3) Last year I was in a high end watch shop and was introduced to a gyno., as Dr. Steve So in So. When I ask what kind of Dr. he was he grinned and said. "I'm a bush Dr." While I'm sure that he does not address his paitients like this the attitude is still in his mind and I'm sure he enjoys having another man's wife at his fingertips. By design the gyn exam by a male provider is wrong.

I extend an invitation to the DR. here as well as any other who might want to come over and check out our group. DR. Maurice, we welcome a chance to give our opinion and concerns to a real madical person. We have many folks wanting to join who pretend to be a MD. Here is the link to our group.

http://health.groups.yahoo.com/group/howhusbandsfeel/

Respectfully Submitted:
MIke

 
At Tuesday, May 09, 2006 9:32:00 AM, Anonymous tenderhusband said...

One more thing. Here is a link to or-live and a gyn procedure on a lady. I'm not sure what you would call professional about leaving a woman with her legs spread wide in sirrups uncovered while not only everyone in the OR goes about their business but with the video camara is running. Finally after a long time some nurse just goes over and covers her up.

This is what the kim here has been saying. " When you are out cold and your loved one is not in the room with you. You have no accurance that your not going to be left exposed for no nessary reason. For the couples who do belive that same gender personal should be used in exams and procedures, the current medical profession looks at them as a nussance. This should be standard procedure and whenever an intimate exam or procedure is required the medical professional should always ask if the paitient and or the couple if married has a gender preference of who handles them.

The medical establishment however it as their right not to be inconvinced and seem insulted whenever a request for a same sex DR., nurse, or tech. is requested. Remember not only are we paitients we are customers and if we as paitient/customer want to be assured of a same sex medical exam or procedure that should be offered every time.

Respectfully:
Mike aka tenderhusband and Moderator at How Husbands Feel.

 
At Tuesday, May 09, 2006 11:16:00 AM, Anonymous Anonymous said...

Thank You Mike
Kim

 
At Tuesday, May 09, 2006 12:22:00 PM, Anonymous Anonymous said...

I have noticed a few people mentioning female patients requesting a female practitioner or a male patient requesting a male practitioner. IT IS YOUR RIGHT TO REQUEST GENDER PREFERENCE IN MEDICAL PERSONNEL. I'm not going to assure you that you won't be questioned why or that you won't have to wait longer for care while they (usually an E.R.) locate a female doctor .. or nurse.

I have had several experiences with male nurses and male doctors relating to my cardiac care that have been inappropriate. (Lifting my left breast 5 times in 30 minutes to look at a fully healed, 2 year old scar from DaVinci by-pass for example.) On my last trip to the E.R. for angina I refused a male nurse and requested a female. From that point forward every E.R. staff person, including the female tech performing my EKG, asked me why I refused the male nurse. I think if I had been asked one more time I would have screamed that it is none of their business why!! I have also had very unpleasant experiences with male gyns when I was younger.

I have worked in the medical field for many years - at teaching hospitals, at private hospitals, and for hospice agencies. I know that there are good doctors both male and female. But for me personally ... I have a female primary care physician who also provides my gyn care. That is where I am most comfortable - and this decision has a lot to do with the issue of nudity/exposure in front of the doctor.
BBB

 
At Tuesday, May 09, 2006 9:33:00 PM, Anonymous tenderhusband said...

I forgot to post the link to the OR-Live gyn procedure mentioned in the above post by me. Here it is.

http://www.or-live.com/hartfordhospital/1353/

Just click on veiw.

Respectfully:
Mike

 
At Wednesday, May 10, 2006 2:05:00 PM, Blogger Maurice Bernstein, M.D. said...

Mike,thanks for the referral to the Hartford Hospital video website and, of course, I witnessed what you did. I have some important comments to make about what was done by the surgeon and hospital and also what you observed.

First, it is clear to me that, though continuing medical educational credits were offered to the professionals, this production was clearly oriented to the lay public. I doubt it was purely educational in intent. I suspect there was some promotion of the surgical procedure and not necessarily simply to encourage other surgeons but to also encourage patients to consider this program at Hartford.

If it was directed to the public and not just to doctors, then there should have been a warning prior to clicking to web-cast of the video. The warning should have indicated that there would be visual images that might not be understood or too graphic for some of the public. Particularly disturbing to some might have been surgical procedures, piercing and manipulation of tissues, bleeding and even more significant for some, exposure and close-ups of female genitalia.

With regard to the visualization of the genitalia, for a physician, there was nothing unusual in the appearance or the way the genitalia was presented. There was nothing provocative or sexually stimulating about the image since this is the way physicians regularly observe this part of the normal human body. Further, I saw nothing unusual in the way the patient was draped or prepared for surgery. The movement and behavior of the nursing staff was absolutely routine. If any layperson saw anything upsetting in the production, this would have been the reason why some disclaimer by the site before visitor viewing should have been made.

Now whether the production was legal and ethical. If the patient was fully informed about the details of the live and later web-cast production, its effect on the surgical procedure itself, that her genitalia would be visible but she would remain anonymous then I think that the production was ethical and could meet legal standards. The question of whether surgeries should be presented to the public for publicity or advertising beyond purely educational intent is another matter. What did others think about the Hartford Hospital production? ..Maurice.

 
At Wednesday, May 10, 2006 6:31:00 PM, Anonymous Anonymous said...

Are doctors, anestheiologist, and nurses thoughtful of their patients when they are unconscious??? Patients are not laid out naked??? What about this lady??? Why wasn't she covered sooner??? Us lay-people meaning the patients find it rude. Is it taught that when the patient is unconscious what they and their spouse dosen't know won't hurt them??? You still don't see what you are asking us. This is how some people feel. You talk abut all this nice nice stuff when the patient is awake because that is when they can tell on you. What about when they can't??? Who protects them???
Kim

 
At Thursday, May 11, 2006 6:13:00 AM, Anonymous tenderhusband said...

Dr.M.

I do completely understand that this lady must have signed her life away to cover the medical staff before they started filming. I was in no way implying that what they did was against the law.

What Kim and I was saying that you as well as most othermedical staff misses it that this should be anything other than routine.

This lady should have been completely covered and then when the Dr. wanted to show (the folks at home) her urine leakage then she could have uncovered the nessassary part and rcovered her after the camara shot.

While it is routine as you say for medical staff the see intimate areas of a personal body everyday. It is not routine for the paitient to expose herself or for the husband to have his wife exposed like this everyday. This is where the imbalance lies that the medical profession does not want to address or admitt.

Each paitient is an individual and should be treated as such, not as a peice of medical meat. If one paitinet wants for instance no other man but ther husband to be present at the birth of their child then no male nurses or attendints should be allowed in the room, and without question.

Just my 2 cents worth:

DEr. M. I still invite you to come over to how husbands feel and reveiw the 100 articles we have saved in 3 months about sexual misconduct in the medical field. These is not olny cases of DR.s trading drugs for sex with patients, but anestheiologist fondeling women's breast during surgery, a transportation person fondeling a woman in recovery, even A DR. who put his penis in a woman's mouth while she was still out but was waking up.

MIke

 
At Thursday, May 11, 2006 4:30:00 PM, Blogger Maurice Bernstein, M.D. said...

I continue the discussion of patient modesty on a new posting today. ..Maurice.

 
At Wednesday, May 17, 2006 12:41:00 PM, Anonymous Anonymous said...

Dr. Maurice,

I'm a 36 year old male and I am having a tonsillectomy and septoplasty done. I know I will have to wear a gown and will spend one night in ICU. What I want to know is, for a procedure such as that, will I be naked on the OR table? I'm sure they will have to hook me up to various machines for the procedures. I'm just wondering how much of me will be exposed and who will be looking.

Thanks,

 
At Wednesday, May 17, 2006 9:24:00 PM, Blogger Maurice Bernstein, M.D. said...

To Anonymous writing today May 17, 2006, I don't know for sure the answer to your concern and you may have to ask your surgeon as to what is the policy in your hospital. However, think of this: If you are undergoing surgery under general anesthesia even if the surgery is in the head region and you sustain a cardiac arrest or excessive bleeding and require additional IV sites started immediately or the standard IV sites fail or other potential emergencies, the surgeon and anesthesiologist would need immediate access to your unclothed body. There may be no time to start removing clothing, even just shorts, to gain access to the body to begin resusitative procedures. Remember modesty issues with regard to the unconscious patient in the operating room is always trumped by the need for protection of the patient's life. Most patients would want it just that way. ..Maurice.

 
At Friday, May 19, 2006 12:05:00 PM, Anonymous Anonymous said...

My wonderfull wife and I have been married for 33 years. We were mere youngsters, she 18 and me 19 back in 1973. My problem is that I get very upset when my wife is being examined by a male doctor (intimate exams such as breast and pelvic). It started when we first got married. We didn't want children right away, and needed to get my wife on borth control pills. Of course, that meant she needed to see a doctor and have a pelvic. I had no idea what was involved back then, and when my wife came home and told me in detail, I became so anxiety filled knowing that my wife had to be in the positions she was in and the procedures the doctor performed. What was and remains very upsetting, even to this day, is the fact that this doctor (a male gynecologist)gave my wife, at 18 mind you, the longest and most detailed breast exam she will ever have in her life. I believe he just wanted to view and fondle nice young breasts, as I can't imagine that too many doctors find any medical issues on 18 year old girls to the point that they have to have such a thorough exam where the patient drops the gown and is sitting up and has all the usual palpations done, etc. and then lay down and repeat the procedure. Since then, my wife has never had another doctor, male or female do such a detailed exam. I suppose I'm a little more possessive and possibly jealous as compared to other men, but I also don't believe just because a doctor puts on a white coat, he somehow stops being a man. I don't think there's any amount of training that one can go through to learn how to dismiss sexually stimulating situations. I'm by no means suggesting that all doctors are deviant or have alterior motives, but I strongly believe that men will be men, in spite of their professional intent. My sensitivity to this subject is based on several experiences within my own family. For example, several of us in the family shared this incredible doctor. He was revered by other doctors and they all said we should be glad he's taking care of us. I still believe he was just short of being a God, however, my Mother, who was also under his care, would see him about 12 times per year. Every time she saw him just for routine visits to monitor her heart condition, he would ask to her to remove her bra so he could do a breast exam. There is no history of any breast problems in her family, nor has she ever had any issues before, and Mom sensed that this doctor was a breast man. She could also tell by the way he palpated her that there was more than just a breast exam going on. He did this every time she came in. I have several other examples that support my feelings, but this is not the time to get into that. Can you shed any opinions from the medical profession regarding my concerns.

Thank you,

Andy

 
At Friday, May 19, 2006 5:27:00 PM, Blogger Maurice Bernstein, M.D. said...

Andy, I can't comment about the physician's behavior with your wife beyond telling you the following: The proper breast exam is done in both the sitting and supine (lying on back) positions and palpation is done both in both positions. This is exactly what our medical students are taught and to do less is a potentially inadequate exam. With regard to your mother, a heart exam requires the physician to lay his/her hands on the chest and breast. If this exam was more than simply palpating the heart and was a monthly thorough breat exam, a physician might perform that if the patient did not perform her own monthly breast exam at home. Beyond these reasonable clinical practice explanations, I can provide no other defense. As I have noted to others writing on this topic with similar concerns about physician behavior, patients should simply look the doctor in the eye and ask "Why are you doing all of this?". Then the patient should look for a rational explanation from the doctor. ..Maurice.

 
At Friday, May 19, 2006 7:04:00 PM, Anonymous Anonymous said...

This is a HUGE issue, and I'm glad it was brought up. Patient comfort is the most important thing in an intimate physical exam. Many doctors don't think so, especially when dealing with a young patient. But doctors need to learn that if they do not respect their patients they will start to lose their business.

 
At Saturday, May 20, 2006 8:46:00 AM, Anonymous Anonymous said...

Typical doctor, never gives a direct answer to a direct question. Not to Andy, not to BBB, not to previous posters.

What is the real point in examining the breasts of an 18 year old? The incidence of breast cancer is so low at that age that it is essentially zero. Four out of five breast lumps are found by women themselves, whether they do regular breast self exams or not.

Fortunately, most doctors no longer require a woman to submit to a full gyn exam just to get Rx for birth control.

 
At Saturday, May 20, 2006 10:39:00 AM, Blogger Maurice Bernstein, M.D. said...

Some of my visitors to this posting may think that I am purposefully avoiding to comment on the descriptions of physician behavior that they have experienced or are aware. And in a sense they are correct. A principle in the process of ethical analysis is first to obtain the facts. We must get the facts as understood by all the stakeholders as well as those not involved in the issue. If analysis is not based on all the facts, it can’t be a fair analysis. The written and spoken commotion associated with the last months of the Terri Schiavo case is a perfect example of people expressing and acting on their views of the case without all the knowledge of all the facts. It would be the same if I were to comment directly on specific physician behavior experiences written to this post.

I have no idea why a physician did a breast exam on an 18 year old female patient. I have no idea why a physician examined a woman’s breast monthly. .There is nothing irrational for these actions in themselves if there is a clinical explanation. But that requires facts and medical details regarding the clinical encounter. What I can tell my visitors are principles of medical practice which we teach our medical students but perhaps are unknown by the general public. Yes, monthly breast exams by a physician could be acceptable.. Yes, palpation of the breast is performed both in the sitting and supine positions and even in 18 year old. Beyond that, I have no knowledge of the facts, the details, to warrant saying more. And that is why I keep saying, if those visitors who experience unsettling behavior by their physicians want more of an explanation, it should come from their physicians themselves and not by some remote physician blogger. ..Maurice.

 
At Saturday, May 20, 2006 8:36:00 PM, Anonymous Anonymous said...

Dr. Maurice, I respectfully disagree with you that a breast exam is part of palpating the heart. Neither before nor after my by-pass surgery did I experience a breast exam by my cardiologist. And I might add that I will NOT accept a breast exam as "routine cardiac care." ...BBB

 
At Saturday, May 20, 2006 9:53:00 PM, Blogger Maurice Bernstein, M.D. said...

BBB, an examination of the heart by palpation does NOT require a breast exam and is NOT a breast exam. I never wrote that palpating the heart was a breast exam. The doctor may have his/her hand lying on the breast or lifting the left breast and putting a hand beneath the breast to palpate for thrills, lifts and apex impulse. Now, it may be that the patient thinks that this is a breast exam but it is not. I believe that many patients really don't really know procedures make up a physical examination and this adds to the confusion especially with patients who are particularly conserned that they might be being abused by their physicians. The performance of a physical exam is no secret and all patients should be aware of what is going on. I hope that discussions like we are having here will help. ..Maurice.

 
At Sunday, May 28, 2006 6:04:00 AM, Anonymous Anonymous said...

A major question I have concerning privacy and ethics at the doctor's office is that other person in the room. The last several times I've been to the doctor I've had to strip, for full-body dermatology and rectal exams. Because I was naked there was a female assistant in the room. I am male and the doctor, in every case, was female. My genitals were exposed at times. Is that right? A female assistant helping a female doctor during a male nude exam? I thought chaperons were only used for female patients when examined by male doctors. That would make sense. But assistants are almost always female and with female doctors where does that leave the male patient? Should I ask the doctor for more privacy? Do doctors just automatically think that men are less sensitive and less vulnerable than women? Most men probably have been in more nude situations than women. I was a member of a club once when men just walked around naked in the locker room. Army experience and sports also teaches men to be natural with nudity. But when you walk into an examination room with a female doctor and she tells you to strip, that can be daunting. An assistant or chaperon looking on can only strengthen the doctor's position, not the patient's. I would prefer only the doctor in the room. Should I demand the assistant leave? What are your thoughts?

 
At Sunday, May 28, 2006 7:16:00 AM, Blogger Maurice Bernstein, M.D. said...

To Anonymous from today 5-28-06: As I have commented here before, tell the doctor your discomfort with her order and don't obey it. Emphasize to her your need for privacy when strangers are in the room. If you can, insist that your wife or other person with whom you feel comfortable viewing you when you are undressed be present at the time of the exam. When a doctor is examining a patient's skin, a doctor is still examining a whole person and if the doctor appears unaware or resistant to this fact, then that doctor is not for you and you should leave. If any of my visitors are physicians of either gender, I urge them to write here to this issue particularly if they have an opposing viewpoint and can explain the value of having a patient exprience modesty discomfort! ..Maurice.

 
At Tuesday, May 30, 2006 7:22:00 PM, Anonymous Anonymous said...

Wow! I have never seen so many people worried about being seen nude. First of all, I have no doubt that there are some unethical doctors. There are unethical people in every profession. For the most part, the medical profession is, because of the insurance industry, a production line. They see a considerable amount of nudity every day and for the vast majority of them, there is no sexual connotation to it. I imagine, it is really gets quite boring. Imagine, when a man has been cut open from his penis to he belly button or sternum, do you really think somebody is trying to catch a quick peek of his genitals?

I have had surgery that left my genitals exposed during and after the surgery. The nurses also offered to help me bathe. I did refuse, but out of stubbornness about doing things for myself, not embarrassment.

Having lived in Europe for over 20 years, I have seen an entirely different attitude to nudity including unisex changing rooms in government run swimming pools. Europeans, unlike us Americans, have little difficulty in separating nudity from sex. We could take a lesson.

What I have found really surprising about this blog is that, for the most part, the patients are uncomfortable to COMMUNICATE with the medical practitioners. And maybe, the medical practitioners could address the situation a little better. For example, “To do this exam, I will need you to examine all parts of you body. The easiest way is nude except for a gown that we will move to expose the different parts of your body as required. How do you feel about that?”. That is pretty simple and the patient has the option to state their preference. Sure, some people will not want to tell the doctor that they are uncomfortable with the approach, but at least they had the option. For the most part, the medical profession is over sensitive to this issue. However, for all their talents, they are not mind readers. If you don’t express your concerns, you have no right to complain about techniques. If a clear crossing of the line takes place, that is a different matter. - JAS -

 
At Sunday, June 04, 2006 10:53:00 AM, Anonymous Anonymous said...

Why do doctors insist on male patients wearing gowns? It has been probably a century since men wore gowns as part of their sleeping attire. I can understand women wearing them to cover their breasts. But men are legally clothed being naked from the waist up so why are they still around? They're awkward, not specific and can lead to problems. They're also humiliating to wear. What's wrong with boxer shorts? Do they expose too much waiting for the doctor? They're simple, specific (they cover the sensitive areas) and men are comfortable with them. In other words, you don't "feel naked." I refuse to believe it's because of tradition that gowns are still around. I believe that doctors like to have their patients in a weakened state to give them more power. As a doctor, do you still have your male patients put on gowns, and if so, why would you do that?

 
At Sunday, June 04, 2006 6:46:00 PM, Blogger Maurice Bernstein, M.D. said...

To Anonymous of today June 4, 2006: The only reasons I would give for having a male patient wear a gown would be 1) IF THE PATIENT REQUESTS BEING COVERED WITH A GOWN DURING THE EXAMINATION 2) OR IF THE ENVIRONMENT WHERE THE PATIENT WAS BEING EXAMINED WAS COLD AND THE PATIENT MIGHT CHILL AND SHIVVER IF HE WASN'T COVERED. In a previous comment on this post, I explained about the problem in obtaining a satisfactory exam when a patient was cold and/or shivvering. These 2 reasons would be the only ones I can think of which applied to the action. In my experience, it has been rare for a male patient of mine to be wearing a gown since usually the exam room environment was warm and there was no request for a gown by a patient. All male patients, for routine physical exams, will wear their shorts. There is no need to expose genitalia until the genitalia exam is actually being performed. ..Maurice.

 
At Tuesday, June 13, 2006 10:56:00 AM, Anonymous Anonymous said...

There appears to be a lot of confusion between nudity and sex in a lot of the comments posted here. I live in Europe and attitudes are much less uptight. My gym is co-ed sauna, steam room etc and nudity is compulsory.
When I visit my Dr or have a physical it is normal to be totally naked. It's really sad that so many Americans appear to be uncomfortable with there own bodies.
That is just my observation

 
At Wednesday, June 14, 2006 10:29:00 PM, Anonymous Anonymous said...

Let me first comment about nudity and Americans. As an attractive woman, I know when a man is visually raping me. It's a disgusting feeling. It's a feeling of violation and no one has the right to violate another's space in that way.

I've been to Europe and I've seen European women cover themselves on the beach because of sexual glares from American men. American men are conditioned to view females as sexual objects. Look at tv, print ads, movies. Women are nothing but saline injected dolls off assembly lines. It is insulting that American cinema always shows full frontal nudity of women but almost never show the same of men. Until the American culture changes, nudity will always be equated with sex.

Now for why I am really posting... I had a bad experience at a clinical trial unit in New Jersey a week ago. This unit tests healthy subjects for pharmaceutical companies. I've participated in two studies over the past 14 months and I have screened nearly a dozen times there. At no time did I feel uncomfortable with my exams.

But last Monday, the screening involved a breast exam. First, I was never told over the phone in the initial consultation that a breast exam was required.

Secondly, once I arrived the breast exam was never explained. The only mention was that it was routine when an oral contraceptive was given in a trial. I asked who would be performing the exams. The nurse stated she didn't know.

I knew if it was the male doctor, that he would be curt, quick and very clinical, never smiles, yadda, like he always is. This doesn't bother me, as I like doctors to keep a professional distance. But he was a completely different person for the breast exam.

He was smiling and laughing and being too personable. Before I had my exam, he examined about 7 women. He was alone in the room with each woman. I was shocked. I went to the nurse and her response was, "most girls don't mind". I had to demand a female be present during my exam.

Before the doctor examined me, I told him I had lumpy breasts and they were diagnosed normal by my family dr. He had me go into detail about where they were and how long I had them, if they changed in size, yadda. He then examined my breasts very, very slowly. I've never had a breast exam done at that speed.

Then he asked me if I knew how to examine my own breasts. I said yes. He asked me to point to where I would start. When I did not point to the correct position, he took my hand and pressed it with his own onto my breast. I have never had a doctor do that to me.

When he finished the exam, I asked him if lumps in the breast were an exclusion from the study. All of a sudden he became curt and stated he did not know, that only the drug sponsor could decide that.

I felt very uneasy about his touching me. I felt something was wrong. Because of this I called management and demanded to know if I was pre-excluded from the study because of my lumps. I was told yes. I was told that I should have been informed about the breast exam and that I would be instantly excluded for breast nodules.

I told the doctor before he touched me that I had 'nodules'. Right away he should have told me I was excluded from the study and given me the option of walking. He instead decided to give me an unneccesary breast exam.

What he did to me sickened me. I felt dirty and violated. I believe he 'got off' on touching me. Got off on the power and the thrill.

I filed complaints with the FDA but they referred me to the drug sponsor, the internal review board and the attorney general. I have filed with all except the atty general.

Currently the clinic has suspended the doctor from screening patients. When I screened there this Monday I noticed that 2 female techs are present during ecg exams and now a female chaperon is present during the dr.'s exam.

I just read today at the Medical Examiner's site, that by law, a patient must be given notice that he/she can request a chaperon during an intimate exam. I was never given notice.

I contacted an attorney and he said I have an impossible case because the doctor could always say that he wanted to make sure I had lumps. Or he could say that my inclusion in the study depended on the size or amount of lumps. So I'm SOL.

I know in my heart he sexually assaulted me. If he had been his typical distant self, I never would have thought twice about his examination of my breasts. But he became a different person when he touched my breasts.

I know people will ask, 'well why go back to that clinic if you believe you were assaulted?' Because when someone has wronged me, I confront them to their face. Why should I be made to feel ashamed when I did nothing wrong. If I don't speak out, then this behavior will be allowed to continue.

The first rule in the medical profession is to do no harm. It's amazing how many so called professionals forget this oath.

In closing I would like to comment about draping. I am shocked and appalled that so many people have had such negative experiences with draping by medical professionals.

I graduated from massage therapy school. The first and always repeated lesson involved draping and client modesty. It was drilled into our heads. We were instructed to always inform clients about our touch and draping. Since all clients are different, we always took the cautious route and proceeded accordingly. For instance if a client started undressing while we were in the room, we simply stated 'please wait until I leave the room before undressing'. That's it. No muss, no fuss.

Maybe since there are far more laws regulating legitimate massage, massage therapists respect clients bodies far more than doctors or nurses. On a few occasions, I have had a male client with an erection. I simply say, 'it's a normal physiological response' and they are put at ease and don't feel embarrassed or perverted.

We were also instructed on our intentions when we touch a client. We had a lesson on energy. We thought negative and positive thoughts when massaging each classmate. We were all able to tell from the touch, the intention of the therapist. Amazing.

To wrap this up, what I want to bring home is that sexual assault, even in it's most subtle form can be very harmful and damaging to the unsuspecting patient. Patients must be made aware of their rights to object. Communication works both ways. Doctors must fully disclose what they are doing and why and patients must voice their concerns.

K-

 
At Thursday, June 15, 2006 8:31:00 PM, Anonymous Anonymous said...

K:

Glad you spoke up and complained about what happened to you. Have you or your attorney considered contacting the 7 women who endured breast "exams" from this guy prior to you? The same thing likely happened to them as did to you, and together a strong case could be made against this creep.

 
At Monday, June 26, 2006 4:28:00 PM, Anonymous Mikey said...

I'd be really interested in your interpretation of this.

Some time ago I had a groin strain from lifting. I wanted the problem looked at right away so I opted to see a (female) student Doctor at my practice. She was polite etc, and asked to explain the problem. I was asked to stand in front of her and lower my trousers. She had a check for swelling in the groin area then without warning she pulled down my underwear. I was quite shocked but thought she would carry out further checks but she didn't. She merely looked/checked visually which I found a little odd. I was told to 'dress' and she told me to rest for a couple of weeks.

I returned to my normal Doctor after 2 weeks still suffering from pain. He carried out further checks without removal of my underwear. This made me think about the actions of the female student Doctor.

I'm not suggesting the student Doctor acted improperly but it seemed odd that:
a) she lowered my underwear herself, and;
b) she didn't physically check anything when my underwear was lowered.
I don't know if you have any comments about this.

 
At Friday, July 07, 2006 7:30:00 AM, Anonymous Anonymous said...

Many doctors, whether male or female, will tell a patient to undress and then won't do a proper examination. In other words, I have had female doctors tell me to strip (I'm a man) and then won't go through with it. I take off my clothes, probably leave the underwear on, and then she doesn't really look beneath the underwear. I believe young doctors are encouraged to look at patients naked not only to gain experience but to disarm, or weaken the patient. Or to give the doctor more power. Every time I have a skin exam I am told to strip and then the doctor does not even look at the buttocks or genitals. Don't doctor know that it's humiliating to strip off your clothes and don a gown? Should I say, since malanoma (I have had it) can occur anywhere, that since we've gone this far to please check the rest? I might feel funny saying that. That doctor and/or assistant might think it perverse. What are your thoughts, and should residents be encouraged to experience nudity?

 
At Friday, July 07, 2006 4:27:00 PM, Blogger Maurice Bernstein, M.D. said...

I think that Anonymous from today July 7th had brought out a good point. I believe some doctors, even doctors in practice a long time, have a sexual or genital aversion which prevents essential sexual history taking or proper and complete examination of the genitals or skin beneath the underwear.

You should be aware that virtually all medical students as they start medical school have this aversion. We have to explain to them the,at times serious consequences,of not taking or taking an inadequate sexual history or not performing adequate inspection or further examination of the genital area. They need support regarding their concerns about the propriety of asking the patient personal questions about sexual activity and symptoms. "But we are just medical students", they may say. Later on, perhaps, some students faced with a patient with seemingly a non-sexually related medical problem will not even consider whether or not to take a sexual history, but just leave it out. And then leaving it out, even when they should be asking, becomes chronic. Of course, similarly genital exams and exams in the genital area on a stranger is another new experience and one which may be associated with ambivalent feelings. I have no doubt that some practicing physicians may carry along some of these same feelings which they had as students. By then, perhaps, physicians also become concerned about issues of patient modesty as fully described on this blog and the consequences of patient misinterpretation of their questions or touching. So what should patients do about doctors who seem to the patient shy to look and examine? Here the patient should then take the lead and speak up to the doctor about what the patient expects should be a proper history and physical exam and, believe it or not, actually be supportive and show understanding of what might be the concerns of such a doctor. Say to the doctor "I am concerned about that spot on my penis, please check it, it will make me feel better" or " I have a brown spot between my buttocks, I will sleep better tonight if you took a look" or "I would feel much better if you could carefully check my parts out under my shorts" and so forth. To make these requests in any seductive manner will turn those physicians off but if you talk as a concerned patient, this may give the physician the support he or she needs. Now if there any physicians out there visiting this posting who think my answer to points raised by Anonymous is all wrong, please write about that here. ..Maurice.

 
At Wednesday, July 12, 2006 6:55:00 PM, Anonymous Anonymous said...

I came across this site while collecting information to help me prepare for an upcoming medical procedure. I would like to take this opportuntiy to share an experience that I believe, does fit in with this obviously controversial topic.

I found myself in a hospital one time, with extreme stomach pain. The doctor decided a barium enema would be in order as a diagnostic. I had no idea what that was. I was taken into the radiology room by a female tech. She told me to sit on the cold metal table and wait, then left the room. (I never saw her again). The radiologist, a male, came in and instructed me to assume a knees and chest on table position. Got the picture? In sexual terms it's called doggie style". I was not given a robe or a drape. There I crouched, shaking, my butt and genitals basically in his face. Then into the room came a group of young, male interns or students, I can only assume that's what they were in hindsight. Let me tell you, they did NOT stand in a spot which would afford them a view of the x-ray monitor. No. they stood behind it facing my naked privates. I screamed and cried as the enema nozzle was inserted and continued throughout as I was forced to "take it". Let me tell you, this was the first time I had been penetrated in any way anally. I know that barium enemas are an effective diagnostic. However, the way that it was done to me I believe amounted to abuse. I saw the grins and smiles on those guys faces. I was too young and naive, trusting in authority, to complain. I felt scared, ashamed, humiliated...and went on to exhibit, what I now know as, classic symptoms identical to a rape victim. I know there are wonderfully respectful doctors of both genders, out there. But wake up! I, no-one deserves that kind of exploitation.

 
At Thursday, July 13, 2006 5:47:00 AM, Anonymous Anonymous said...

Anonymous of July 12 here again.

I just realized that I did not identify my sex in relating my story above. I am a woman. That is why, at least for me, it was especially distressing that I was the only female in the room. Also, important to me at least was the fact that while I had had intercourse prior to that experience, my bottom shall we say, was still "virgin".

 
At Thursday, July 13, 2006 11:31:00 AM, Anonymous Anonymous said...

TO Dr. Maurice,

I had two "complete" physical exams,about a year apart, one by a female MD and the other by a female PA. In each instance, the the examination did not include an examiniation of the genitals. I am a 59 year old male. How can this be considered a competent examination?

 
At Thursday, July 13, 2006 9:42:00 PM, Anonymous Tony said...

I would say that in the past 10-15 years I have experienced an unusual degree of concern about my body modesty, to the point of being ridiculous. I, too, have had the physical exams where I wasn't asked to take anything off. Especially since I am single and live alone, this is troubling because I could have a skin cancer the size of Montana on my back and never know it !

Personally, I feel that gowns are silly for men. When I go to the swimming pool I am more exposed than when you make me wear a gown. I would be more comfortable staying in my boxers and skipping the gown. The paper ones are especially annoyging and I am quite sure the next time I am given one I will not wear it. If I'm not shy, why should the doctor be?

 
At Thursday, July 13, 2006 10:30:00 PM, Blogger Maurice Bernstein, M.D. said...

I am concerned about the comments by Anonymous and also Tony both from today about incomplete physical exams. As I noted in my comment on July 7, you must request that the doctor perform the complete exam including the genital area. You have the right to have a proper exam done and if not you should be told the reason why.

To Anonymous on July 12th- If you undergo medical procedures and you witness any unprofessional behavior or behavior which makes you uncomfortable, you must ask the doctors in charge for an explanation. Do not feel intimidated, you have every right to have that explanation. ..Maurice.

 
At Sunday, July 16, 2006 2:40:00 AM, Anonymous Anonymous said...

Dr. Bernstein, thank you for your insights. Until recently, I had seen a doctor only rarely and almost never in a situation that required the exposure of my genitals. Seven years ago, I had a hernia repair and received no prior information regarding the procedure except the cursory overview of the actual repair. When I woke to find my entire pubic area and scrotum had been shaved I was surprised, but recognized the necessity of having it done.

One year ago, I began to experience several physical problem as we often do when we cross the 50-year-old barrier. The first problem seem to indicate a urological source, so I went to a local family clinic to secure a referral to a Urologist. The male doctor was insensitive, recommended STD testing, which I told him was entirely unnecessary, and was not particularly interested in anything I had to say. The kicker at that clinic came when he had an Q-tip shoved into my penis. While he was inserting the Q-tip, a female nurse or clinic staff member casually opened the door and stood in the doorway for 30-45 seconds talking to the doctor. She continued to stand and watch while the doctor removed the first Q-tip and inserted the second. No apology came from either for the interruption, the fact that no less the three people peeked into the room from behind her or for the doctor's insensitivity.

That experience, as well as a general dislike for having another man handling my "equipment," has caused me to strongly prefer female doctors and nurses. The suggestion by some on this blog that it is natural for men to want male providers and females to want females is just wrong. I've had two female Urologists, a female pain mangement doctor and now a female family doctor. Every one of them and all of their female nurses have seen me naked and, except for a little fleeting anxiety, I have never felt uncomfortable. I have spoken to many women who have told me that they prefer a male OB-GYN. The preference for opposite sex medical services providers has NOTHING to do with titilation or sexual arousal. It has everything to do with comfort.

Even when I experienced a "physiological response" while being prepped by nurses for two different procedures, I was never made to feel uncomfortable. While holding my penis to swab it for a biopsy, one nurse heard my deep sigh upon experiencing the erection, detected my embarrassment and comforted me by saying," Don't worry, honey. It happens all the time. It's just a physiological response. Now, we now that that's healthy." I just loved her for her reassurance at such an awkward time. The other time, the nurse just ignored it, which was fine with me because I was mortified. She must have figured that the best way to handle the situation was to continue to go about her business professionally, which was how she acted in every way.

I could give a half dozen other examples of having to have my genitals exposed for an examination or procedure in the last year. In each situation, the doctor or nurse treated me with respect and dignity. I was told what to expect and, when the situation called for it, my nudity was handled with professionalism.

If I had a preference, my genitals wouldn't be exposed to any human being other than my wife. But it's a fact of life that I am a physical being that will required medical attention from time to time and that means that sometimes some of those health care professionals will have to see me naked. I can choose to be overly anxious about that or I can choose to realize that, while there may be some sickos out there, the overwhelming majority of medical services providers are responsible professionals and are more interested in providing the health care I need than in checking out my genitalia.

 
At Friday, July 21, 2006 8:33:00 AM, Anonymous Anonymous said...

Dear sunday July 16, 20062:40:16 AM,

I understand you are ok with females seeing and touching you but how does you wife feel about it? Have you even told her another woman has handled you erection?

 
At Friday, July 21, 2006 4:31:00 PM, Anonymous Anonymous said...

Dear sunday July 16, 20062:40:16 AM

I've started to respond to your question several times, but each time I've deleted my post. It's difficult to know how to answer because I'm unsure what it is you are asking exactly.

Of course, my wife knows I have female doctors and she's very supportive of that. And of course she knows what happened at the Urologist office, because I told her as soon as I got home. It seems you suggest that I somehow did something wrong. Show me the man who won't get an erection when his penis is grabbed by the glans, stretched out, then swabbed repeatedly with the antiseptic solution. Let me repeat --- IT WAS A PHYSIOLOGICAL RESPONSE! At no time during this was I having even a fleeting sexual thought. I can't even imagine that scenario, since at the time,I was too worried about the possible cancer that I thought I might have. The other situation happened when I was mildly sedated (on my way to being heavily sedated) while being prepped for a heart catheterization. Now I don't know about anyone else, but lying on an operating room table nude, while waiting to find out if you have arterial blockage is not my idea of a good time OR a place to meet chicks. I was sedated, shaved and being washed down in my groin area and the nurse kept repositioning my genitalia to shave or wash the area. You think my wife should be angry because I had a physiological response that was beyond my control? Please.

Many of the posts on this blog seem to be made by people with real issues. I don't know what their problem is with their body, their spouse's body or their doctor, but I'd hate to know I was so worried that someone might see my wife's genitalia during an exam or procedue. Do you think she should get my premission before seeing her male OB-GYN? Maybe I should have asked the guy that delivered my son to look the other way when he was being born.

Folks, in spite of that one guy's preoccupation with the sordid few that practice medicine and abuse their position, the vast majority of doctors, nurses and technicians are professionals trying to do a job -- provide you with the best health care they are capable of providing. I understand those who have apprehension about preserving their own modesty or even privacy when it's warranted. But I do not understand the stress level some have expressed over things that hardly matter as much as our loved one's and our own health.

 
At Friday, July 21, 2006 4:43:00 PM, Anonymous Anonymous said...

LOL! I posted as if I was responding to my own earlier post. I was actually responding to Friday, July 21, 2006 8:33:53 AM. Sorry for the confusion.

And Tony, I know what you mean about the gowns, but I have no problem complying. Some doctor's office's are rather chilly and I don't mind a little modesty myself. The problem I have is that I'm a pretty big guy and a lot of gowns just don't do the trick. I'm over 6'4 and 280 pounds, so my big neck, chest and shoulders don't fit some gowns well. The best I've had are the ones that tie at the neck (if the strings are long enough), but most feel like a t-shirt that's a couple of sizes too small. I too would probably just rather wear by polo shirt and boxer briefs, then take off what's necessary when the time comes.

 
At Saturday, July 22, 2006 8:35:00 AM, Anonymous Rick said...

Hello Dr. Maurice, thanks for opening this important discussion. The issues of having a spontaneous erection during an exam and the question of a doctor being attracted to a patient have been on my mind recently, based on my most recent physical exam experience, last month.

First, just an observation. I went in for a complete physical and check-up, and the doctor used the strip-as-you-go method, to use Jim's phrase. By the end, when he was doing the genital exam, I was completely nude and standing in the middle of the exam room (which I did not mind at all). As luck would have it, I began to have an erection while he was examining my scrotum. I was a little embarrassed, but not a lot, though I felt a little sorry for him because he was sitting on a low stool facing me and my erection was beginning to invade his personal space around his face. I took hold of it and pulled it over to one side, against my leg. He said a simple "thanks." A simple acknowledgment that I found completely professional, and I realized later that his saying thanks actually made me feel more comfortable than if he had simply completely ignored what was going on (which would have been an understandable reaction).

Second, I'd be interested to hear your take on what happened next, from a doctor's perspective. After he finished my testicular exam, the doctor got up from the stool and started talking to me about what the next steps were - prescriptions he would write, etc. When he stood up there was no hiding the fact that he had at least the beginnings of an erection himself. I could clearly see through his pants that he had dressed with his penis pointing down, and now it was tenting his trousers out in front. He looked down at himself to check whether it was showing, and as he kept talking to me he shifted his weight from one foot to another, shaking each leg a bit as he did, in an apparent attempt to move things a bit. But his little dance did not help; in fact it seemed to make him even stiffer. He gave up on his leg movements and finished our conversation standing there facing me. Before he left the exam room, he reached down (with his back to me) and adjusted himself before opening the door and walking out.

My question for you is: Should I have said anything about what was happening? A brief little acknowledgment, as he had given me, which actually put me more at ease and made me more comforable? I was very tempted to say "Don't worry doc, that happens all the time. It's a completely natural response!" And sometimes thinking back on it I wish I had. Would this have been crossing a line? An ethical question from the patient's perspective for you. Thoughts?

 
At Saturday, July 22, 2006 11:27:00 AM, Anonymous Anonymous said...

Dear sunday july 16,
I didn't mean to sound like you had done something wrong. I'm sure you were scared to death. And yes I have some issues but I am working on it. I was trying to see how normal women react. It's hard for me to get the concept that some people just have that much trust in others. I'm Kim by the way. Go back to thursday May 11, 2006 4:30:58p.m. hit the link and you can read the rest of what I have wrote. I keep thinking if I talk to people some day I'll get it. I have often wondered because my husband had the washing, shaving, and a foley befor his surgery if he got hard. It shouldn't matter. It's his health that really matters. I know this but I still can't get it out of my damn head. Sorry if I hurt your feelings. Kim

 
At Saturday, July 22, 2006 11:44:00 AM, Anonymous Anonymous said...

I forgot something. I have been talking to a mental health professional who I think is very good. She has a good reputation with the regular doctors in my town. You said you couldn't understand the stress level some of us feel. Thats because you must have grown up in a family that gave you that basic level of trust most people learn as a baby. I didn't. I was repeatly abused by my mother in a medical/sexual way. I am semi smart though and realize when I am not thinking right but I second guess myself alot. So I am constently wondering what medical people are thinking when they see you nude. I know it's not fair to assume everyone is a bad person. But it is hard for me to just roll with it. I have also had some really bad experiances with doctors and nurses both male and female. I am now 39 years old and am much careful who I let do anything to me. Maybe this will give you a better idea where I'm coming from. Kim

 
At Saturday, July 22, 2006 9:13:00 PM, Blogger Maurice Bernstein, M.D. said...

Rick, I would say, if both the doctor and the patient should be on the same level playing field.. and that is how the doctor-patient relationship should be, I would think there is nothing wrong to be supportive of what you observed as your physician's reaction in the manner that the physician was supportive of you. Both patient and doctor are human beings. Though a physician erection is probably unusual, who knows? ..Maurice.

 
At Sunday, July 23, 2006 7:29:00 PM, Anonymous Anonymous said...

Rick,
Your doctor was wrong!!! Guys get erections by being handled or by thinking something. He was thinking something to get one. That my friend is a problem.

 
At Monday, July 24, 2006 9:38:00 PM, Anonymous Anonymous said...

Kim,
I'm sorry you were abused as a child and that you have had bad experiences with some in the medical profession. It's certainly a very positive thing that you are receiving the therapy you need.

Rest assured you did not hurt my feelings as I am not hurt by people on the internet that I do not know who have expressed an opinion or asked questions.

If I were you, I would discuss my preoccupation with negative aspects of nudity, especially your husband's nudity in a health care setting.

My question to you is "What's the worst thing that could happen?" If someone sees you or your husband nude in a medical treatment setting, what is the worst thing that could happen? Now I'm not talking about one of those abuse situations where someone takes advantage of a sedated patient. I'm simply asking you to tell me the worst thing that could happen if someone observes your or your husband's naked body during the course of providing you with medical attention. Is there one thing that would change about your life of your husband's life because someone caught a glimpse of one of you during a procedure, examination or surgery?

While I am concerned about your mental health, I believe you will eventually get past your unfortunate experiences as well as your obsessions through the therapy if you continue to go and truly want to get over them. I am more concerned that you or your husband may delay or forego needed medical attention if you don't get control of this fairly quickly. It would be sad indeed if you or your husband needlessly suffered because you were overly concerned about nudity in a health care setting.

For me, any anxiety I feel over the nudity that comes with the territory in seeing some health care professionals is completely outweighed by my desire to live a healthy life with my wife, our five children and six grandchildren. I could be wrong, but I'm willing to bet most people diagnosed with terminal cancer would appear nude weekly on primetime television if it meant they could continue to live a long healthy life with those they love. It's a matter of relative importance and priorities.

I wish you well.

 
At Tuesday, July 25, 2006 9:06:00 AM, Anonymous Anonymous said...

My husbands health does come first. I won't let him not get good care. I make all of his appointments I resurch everything about his condition. I lost my father 5 years ago to cancer. He was 57 and I am sure he would have ran around nude to stay even another day with us. My husband went with me to see the lady I talk to. Togther we decited that if it would make me feel better that I could voice my concernes to any doctor or nurse. He inturn would ask for a male for intamate exames. Except for emeragencys and well lets just say in the OR we don't have enough male nurses. The only problem is sometimes I get treated worse than if I had just kept my mouth shut. You asked what is the worst thing that could happen. You said it, that someone would take advantage of him when sedated or have a sexual though. You never know what people are thinking. Years ago I tryed to forgive my mother and couldn't. I ask God to do it for me until I could. It seems that is what I need to do here. I just need to let him take this until I can handle it. Thanks for your comments. They have helped.
Kim

 
At Wednesday, July 26, 2006 10:41:00 PM, Anonymous Anonymous said...

Kim,

Ask yourself "How am I harmed by what someone else thinks?" You are even stressed by the POSSIBILITY that someone MAY be thinking something. Have you ever had a sexual thought or fantasy about someone that was not aware of your thought? Were they harmed by your thought? You cannot control what others think, but unless there is an action that takes place because of that thought, there is NO possibility that the thought can harm you.

Assuming your husband was exposed during his surgery, what causes you to think he would have looked so sexy on that operating table that a female doctor, nurse or technician would get aroused? And with several persons working in the operating theater, I find it extremely unlikely that he could be sexually abused in a sedated state or that anyone would be motivated to risk their careers on such an action. Yes, abuses can be cited, but in spite of evidence presented by others here, I believe those incidents to be the rare exception. So, if thoughts can't hurt you and sexual abuse is unlikely, why obsess?

IMO, you need to separate the unfortunate abuse of your childhood from the realities of today. Try to enjoy your life and recognize the medical necessity of periodic nudity in a health care setting. The medical professionals are just trying to do a job -- a job you WANT them to do, I might add -- so why not accept that they probably couldn't care less about your husbands genitals or yours either.

 
At Thursday, July 27, 2006 11:21:00 AM, Anonymous Anonymous said...

any idea where a copy of the article Naked” by Atui Gawande. M.D. Dr. Gawande can be found

 
At Thursday, July 27, 2006 12:20:00 PM, Blogger Maurice Bernstein, M.D. said...

The article "Naked" was published in the New England Journal of Medicine August 18, 2005 issue. It can be obtained from your local hospital or college library or perhaps even from your local public library can access it. ..Maurice.

 
At Thursday, July 27, 2006 5:11:00 PM, Anonymous Anonymous said...

It's also about control. Someone having control over you or someone you love. Very hard for me to except. I must be very hard headed. I wish it was as easy as you make it sound. I still can't stand the thought of another woman doctor or nurse touching his genitals. I doubt I will ever feel any other way. Yet I am so glad he is alive. Maybe in time it won't bother me so much.
Kim

 
At Friday, July 28, 2006 10:49:00 PM, Anonymous Anonymous said...

i went in for a colonscpy once and when i woke up the nurse said they werent able to finish it , no explanation why , told me I 'd be taken to radiology for a bariume enema , got me in a wheelchair and off I went . Mind you , I was stil l groggy from whatever theyd used to knock me out for the colonscopy . anyways , my girlfriend was with me , since I was told I 'd need someone to drive me home . We get to the x ray lab and 2 girls that hardly looked old enough to drive sort of rough -handle me out of the wheelchair and get me on the table . one of the girls walks out of the room and disappears down the hall. she also happens to leave the door wide open . a minute later ,in walks some supervising nurse who tells the x ray tech to get me off the table pronto beacuse she 's afraid I 'l l fall off and hurt myself since i 'm still (obviously ) waking up from the drugs they'd knocked me out with for the colonoscopy . The supervising nurse makes some snide comment about how she doesnt want the hospital to get sued in case I fall and hurt myself . the tech says , no, he' ll be ok . But the nurse wont let up . at this point , my girlfriend joins in the fray, demanding that they go ahead with the x rays , adding that there was no way she was going to let them force me to go through that awful " prep" again just so they can reschedule this for another day . All this time , I 'm siting there watching them go at it . and then , to my horror , I notice a crowd of nurses gathered just outside the door in the hall . they all appear quite interested in watching the arguments fly back and forth . ( actually , I found it pretty interestng myself ). long story short ,the supervising nurse finally gives in and says , ok go ahead and give him the x ray-- with one important compromise ( i'l l get to that in a minute ) . By now I expected a loud cheer to go up from the nurses in the hall , but they just stood looking, nobody saying a word . the supervisor talked to the tech for a moment prvately , then swished out of the room . The tech looked at me with what I would call a look of compassion , then announced , not only for my girlfriend to hear , but all the nurses assembled in the hall, " Since you 're still waking up , I 'm going to use an inflatable nozzle , that way you we 'l l be sure none of the barium will leak out .." Believe me , by now I was awake enough to be thoroughly humiliated that she 'd just broke the news to me in front of my girlfriend and half a dozen strangers . Anyway ,my girlfriend was told to leave the room and , thankfully , she closed the door behind her . the tech did her thing and before long the x rays were underway . the only other thing that happened that further blew my mind was when , in the middle of taking the x rays , she door opens and in walks the hottest looking nurse I 'd ever seen ( no , i 'm not making this up ). I watch , stunned , as she saunters over and leans against the wall , arms crossed , and simply "watches " as I undergo this bone -grinding humiliation. the tech took no notice of her , and it the nurse never said a word . she just seemed interested , I guess , or maybe she was getting off , watching . When it was over , the nurse made a fast exit and the tech helped me to the bathroom . once I was through in there , the tech came back in and marched me down the hall to a room where they 'd put all my clothes . I realized as I was dazedly making my way down the crowded hall , that the back of my hospital gown was flapping open and ,basically , my ass was hanging out in the breeze . when we got to the little " locker room " where I 'd left my clothes , the tech hung around while I dressed and then ( I thought this was really kind of touching) handed me a blanket she 'd found on top of the locker . She said I could have it, kind of like a consolation prize . I tucked the blanket under me arm and went out in the hall where my girlfriend was waiting .. . The whole experience was really weird , but it turned out I didnt have anything seriuosly wrong with me and I was damn grateful to know that . I guess my only question is , is it usual to have the nursing staff in a hospital turn into a bunch of on -lookers when a patients going through something as awkward and embarrasing as a barim enema ??? ? I didnt feel like they showed much respect for my privacy . oh well , atleast it turned out I was ok ..

 
At Monday, July 31, 2006 1:17:00 PM, Anonymous Anonymous said...

My concern about nudity in front of a female doctor is basically the opposite of others who have posted above.

About four years ago I developed a number of "pre-cancerous" growths called Squamous cell carcinoma. I was told these are non-life threatening as long as they are monitored. Accordingly, I have undergone semi-annual skin exams by a dermatologist ever since.

Being clueless about what to expect, I researched the procedure on the Internet beforehand where I learned that it is standard for these examinations to include the genitals. I admit I was very uncomfortable with the idea but reminded myself it was important, that the doctor has “seen it all” before, the body is nothing to be ashamed of, etc., etc. For the first exam I was asked if I would prefer to wear a gown OR shorts (I chose shorts). I was more or less relieved but somewhat surprised when the doctor never asked me to remove them. She always asks if I have noticed anything unusual in the genital area but, when I say no, she has never suggested looking for herself.

Last year, though, my view of the situation changed after she found two spots on my arm for which the biopsies came back as Bowens carcinoma. Although almost always treatable, this is a more serous form of skin cancer and it was necessary for them to be cut out (about a 2-inch incision, an inch or so deep).

This made me realize how much more important my good health is relative to any concerns about modesty. If it reduces my risk even a little of developing life-threatening cancer, I want her to do whatever she thinks is beneficial. This is especially true in light of the fact that neither of the spots on my arm had looked to me like anything more than small birth marks or freckles.

But after four years, I would now feel like the proverbial dirty-old man in a trench coat saying “hey look at what I got under here.” This is especially true since I have done self-examinations and I don’t see anything that concerns me. Also, it would be extremely humiliating if I suggested a genital exam, she agreed to it and then I got an unintentional erection in the midst of it. I would feel like a pervert and be concerned that would think the same.

Right now my inclination is to assume that, in her best judgment, my situation does not warrant a genital exam. I will continue to do self-exams and bring the issue up ONLY IF I spot something that concerns me. If, on the other hand, SHE asks me to drop my shorts during some future exam, I would do so without the least bit of reluctance given my medical history and the risks associated with skin cancer.

 
At Tuesday, August 01, 2006 7:17:00 PM, Anonymous Anonymous said...

I do get the impression that there are double standards in this area, a woman can ask to be seen by other another woman and will be seen as exercising her basic right to chose, a man asking to see a man will be see as petty and sexist.

When I eventually got my act together and went to see about a spot my penis, I asked to see a man, was told I might have to wait, and then was called by a woman. I told her I’d rather wait and see a man, so five minutes later I was. It was nerve wracking enough having to explain the situation before removing my trousers and having a woman examine my genitals. On subsequent visits I always made the same request, ultimately always lucky usually lucky but not always first time and once was told in a very correcting tone that it may not even be possible to make such a request – clearly as I was an evil sexist male. I very much doubt a female would have been talked to in the same way (and there is no reason for her or anyone to be treated so badly).

Later, at I was at a dermatology clinic and was called out by a female registrar. I had issues with this but thought it would be no worse than a woman seeing a man and if she was professional it would be ok. But she wasn’t, instead she was extremely rude, snarling and unpleasant. I was very uncomfortable but survived the exam. However I was then told that for the consultant I would have to be fully naked. I really felt like saying fine, but I don’t want you here. Thinking that she’d already examined my penis it wouldn’t matter being nude, but it did. It was a far more traumatic and humiliating experience.

Unlike some people here, I’m generally very relaxed about being naked around others. I shower naked, sauna naked, swim naked and have even holidayed in places where nudity is the norm. But there’s a huge difference between choosing to be naked in nude environment and lying down in front of two strange adults, one of whom you dislike and being talked down to. I discussed this with friends – in a sauna, so naked, and all said that they would feel the same.

Unlike the other clinic here they are always very accommodating when I ask to see a male registrar before seeing the consultant, apart from one occasion when I was barked at by an aggressive female “You don’t wan o see me” to which I replied that wasn’t he case and it wasn’t personal, often I go straight to see the registrar as there a few males – as it is a penis clinic this seems rather unfair.

Once I had to get a skin sample and a photo. He very politely asked if I was OK with this, I was and she was very good at putting me at ease. However when I walked into the surgery room, a nurse pointed me to a cubicle, told me to undress and come through to the table. When I asked for something to wear there was a sigh, though it did come. Again would a female be told to undress and walk fully naked into a room with two men – and wait some more to come? I actually asked for the nurse to leave while the photograph was being set up – there was no reason for her to be there, though she had been standing looking at the end of the bed ! She didn’t come back when the sample was taken – there were tow doctors but did appear later, though by then I was back in my paper gown so not quite so exposed.

What is missing in all this is that as a guy there’s always the possibility of an erection springing up. I’m old enough that its only happened once, the doctor was fine in that he said nothing, it would perhaps have been easier if he’d said something along the lines of it being good to see that things are in working order, though someone else may not like that. If that happened with a woman there’s always the danger that she’d take offence – men have been trained to be so careful not that this cannot just be forgotten.

My conclusion, men seem to get a raw deal when it comes to being naked at the doctors, not always but often enough for it to be a problem. Some doctors seem to think that their position entitles them to be rude and dismissive of patients’ feelings in a way that would never be tolerated if they were, for example, lawyers or accountants.

 
At Thursday, August 03, 2006 1:30:00 PM, Anonymous Anonymous said...

Someone recently asked about where to get a copy of the article "Naked". It is online at:

http://www.uhmc.sunysb.edu/prevmed/mns/mcs/2/sched/Boundaries_SG/Boundaries_RS/boundaries_rs.html

 
At Thursday, August 03, 2006 2:32:00 PM, Blogger Maurice Bernstein, M.D. said...

Thanks to Anonymous for the link to "Naked". Going there, I found the direct link to the pdf file.I previously was unaware that the full article could be obtained without NEJM subscription. Again, thanks. ..Maurice.

 
At Thursday, August 03, 2006 5:45:00 PM, Anonymous Anonymous said...

Great to read the article - sadly it confirmed my view that men get a raw deal, a woman having her breasts examined will be shown far more care than a man having his penis looked at.

As noted in the article she won't hesitate to complain - in the instance cited for the doctor follwing her use of boob - meanwhile a man who politely asks to see a male doctor is talked down to and on occasion this is ignored.

Even before the patient is naked (or partly naked) more thought needs to be given to the way in which they are treated and their wishes respected.

 
At Friday, August 04, 2006 8:54:00 AM, Anonymous Anonymous said...

I believe the tension between female doctors and male patients comes from a rather short tradition of widescale women physicians. Male doctors have learned over time to deal with nudity and know how to control assistants who also view nudity. I don't believe there are many women doctors who can casually examine a man's genitals and not be affected. In fact, women doctors will skip the genital exam altogether most of the time, based on what I've read here and my own experience. On the one hand you can say, "Well, they wanted to be doctors. Nobody forced them." But on the flip side a male patient could help the female doctor along. My experience is to be forceful with men and kinder with women. Female doctors may walk into an examination a little nervous and a patient's kindness and patience could make the exam a success. But there's going to be a lot of weeding out of female doctors over the next several decades. Smart girls may handily whip their fellow male students in med school then freeze when confronting a completely naked man. They may find it distasteful being a doctor. They may not like the job. In conclusion, many female doctors just don't know how to do the job yet and doubt whether they want to. So male patients are going to get a much wider range of personalities among women doctors than men. One final thing. If you really like your female doctor, stick with her. You may not find another one that good.

 
At Friday, August 04, 2006 10:40:00 AM, Blogger Maurice Bernstein, M.D. said...

There is much with which I agree in the last comment by Anonymous. As a teacher/facilitator of physical examination skills for first and second year medical students, On this thread, I have learned alot about the observations and concerns of the public regarding how physical examination is practiced in the United States and also from UK visitors. This learning is going to substantially improve my teaching of the examination process to the students. I now think that the patient concerns, for example, about penile erection during the exam is not a trivial issue. In my school, I know that this concern has not been stressed sufficiently to the students. While the patient's erection during the exam by a male physician may be a bit disconcerting to both parties, when it happens or even anticipating that it might happen during an exam by a female doctor I could see much potential anxiety and embarrisment for the patient and physician. An erection obviously has sexual connotations and for the female physician, she is suddenly faced with an interpretation of either the erection represents sexual stimulation and interest or is purely reflexive. This conflict of interpretations is all the more unclear since the patient usually is in a "non-clinical" position standing up in front of the female physician with genitalia fully exposed unlike in virtually all female genitalia examinations, the patient is in a "clinical" lithotomy position on the exam table which is obviously less sexually provoking. The patient on the other hand will know what is going on with him emotionally and may be simply and truely embarassed for his behavior. I can understand why female physicians might easily abort a male genitalia exam because of the sexual discomfort. The more often the exam is avoided, not only can pathology be missed and the patient developing doubts as to the physician's competence, the less the opportunity for the female physician to "learn" to be indifferent to her sexual concerns and proceed as a male physician would to complete a standard of practice examination. Perhaps the presence of a male chaperone at the time of the genitalia exam might be more supportive to all parties. Anyway, I think it is important for me to discuss all this with my medical students so right from the beginning they will be aware of this issue that they will face at one time or another. Thanks to all the visitors to this thread who are helping "educate" me! ..Maurice.

 
At Friday, August 04, 2006 7:37:00 PM, Anonymous Anonymous said...

Maurice,
With the last few comments. Can you see why a wife would be up- set for a female doctor or nurse to handle her husband? Everything these people have commented about has happened at one point or another during my husbands illness. So many of the comments sound similar to things we have been through. Even more so than a man asking for a male doctor. Think what it is like for a wife to express her dislike. I am viewed as rude, or crazy. Why is it so hard to understand?
Kim

 
At Friday, August 04, 2006 8:57:00 PM, Anonymous Anonymous said...

"I am .....crazy. Why is it so hard to understand?"

Becuase you are crazy ? Perhaps your posts would be better directed on a site for neurotic women than here.....

 
At Friday, August 04, 2006 10:35:00 PM, Blogger Maurice Bernstein, M.D. said...

Please Anonymous, let's avoid ad hominem remarks on this blog. Kim, I think those of us who have read your posts on this thread have a reasonable understanding of how you feel. Your concerns are important to you personally even though some of the medical workers you have found failed to appreciate it. However, you must return and continue to have direct help by a professional who can help you relieve yourself of your upset. I think it is important both for you and your husband. ..Maurice.

 
At Saturday, August 05, 2006 9:47:00 AM, Anonymous Anonymous said...

Dr. M Anonymous Aug 01 hit it on the head. There is a double standard, I posted comment before on a visit for a follow up scrotal ultra sound my doctor required, while they complied the hospital staff...all female...could not hide their disapproval when I requested a male tech perform the proceedure. I would suggest very few mamograms are performed by male tech's and understandably so. A male physician would not bring in a male chaparone to examine a female patient. Yet a female physician will bring in a female nurse to examine male patients. The deversification of physicans is a positive thing, but it brings in issues that were not previously present, patients and professionals need time for policy adjustments. The challenge will not only be educating physicians, but all health care workers to not only accept, but perhaps ask if there is a preference. Most patients don't feel they have a choice and are afraid to ask. The more comfortable the experience, the more likely they are to seek further help. From experience I can say I almost skipped the imaging my doctor requested becasue the first time I did not ask and the proceedure while done by a very professional female tech casued me so much anxiety I was planning to not go back. I read your blog and it gave me the knowledge that I did have the right to ask. The procedure was so much less stressful with a male I no longer fear going back for follow-ups. I understand to the provider this may seem petty, and to tell the truth, I don't know why I feel so strongly about it....but I do. Part of your challenge will be not only to educate your students on what they need to do, but on educating them to recognize this and educate thier patients. An intersting other side of the coin for other readers is a blog "allnurse" where nurses discuss simular gender issues from the medical side. You will notice while many feel their patients should accept them regardless of gender, many admit they themselves prefer same gender preference. We all realize there will be cases where preference can not be accomidated due to staffing restrictions, but when it can, it should be respected, and I think that is the issue many express here,the issue could have been avoided or lessened, it just wasn't recognized or important enough to the provider. Your blog helped me take control of my visit. While we may help educate you, you are helping us do our part in this. When the providers and the patients both address this, we will make some real headway.

 
At Saturday, August 05, 2006 12:58:00 PM, Anonymous Anonymous said...

Friday Aug,4, 2006 7:23:23 pm,
Do you even know what you are talking about? It's so nice to know a complete stranger is that sure of him or herself to judge me and how I feel about my husband. I don't judge others. It's not my job last I looked. I hope you never have someone you love go through what we have. What have we as a couple done to make things better?? We have both learned (just like your last comment) that it is ok to voice your opinion in most situations. Some medical people respect it some don't. What more can you do. What I ment... and apparently I need to SPELL IT OUT is that most doctors and nurses will understand your up-set and some don't seem to care. Thay are the ones who will treat (lets not say CRAZY) but badly. Lets hope you don't have enough medical problems to figure this out for yourself.

MauriceI am doing much better I still have bad days. but time heals. My husband just got out of the hospital again for an obstruction and he lucked out no surgery. One Day at a Time. Today we are headed to the lake. Swimming seems to make his muscles feel good. With a life jacket of course. Thanks for sticking up for me. I'm still getting all the help I need. This whole thing has brought us much closer together. In a strange way I think it was ment to be. No matter what any of the readers think. We are a team. I take care of him and he takes care of me. Kim

 
At Saturday, August 05, 2006 4:21:00 PM, Anonymous Anonymous said...

Dr M.,

You said "in virtually all female genitalia examinations, the patient is in a "clinical" lithotomy position on the exam table which is obviously less sexually provoking". This statement is ludicrous on its face given the number of male gynecologists who sexually abuse their patients! According to the Texas State Board of Medical Examiners (Spring 2002 Newsletter) of the ONE OUT OF TEN doctors who sexually abuse their patients 19% are gynecologists. Obviously, a fair number of your colleagues find the flat on the back, legs spread position to be quite sexually provoking!

 
At Saturday, August 05, 2006 7:58:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous, I am not sure that you can support all that you wrote based on the article in the newsletter you identified. I went to the TSBME website and looked at that particular newsletter. There was an article written by Cynthia Playfair, M.D. “Just Say No” Still Applies: Doctors and Sexual Boundaries". In one paragraph is the following: "The prevalence rate of sexual misconduct in physicians is estimated at 6-10 percent but this phenomenon is likely under-reported in physician surveys and by patients. It is believed that the number of false claims made by patients is very low. A 1992 study indicates that only 4-8 percent of patients report a doctor’s sexual misconduct". Unfortunately no references are given for the source of this information. In a later paragraph the following is written: "The physician most at risk has a mean age of 53, has been in practice roughly 25 years, has a substance abuse history, has frequent use of nonsexual touch with patients, is male, in the midst of a life crisis, and is in private practice. One third of male therapist offenders are currently experiencing divorce or separation. The breakdown by specialty is as follows: 19 percent in obstetrics/gynecology, 13 percent in primary care, 12 percent in internal medicine and 10 percent in psychiatry." Again, no references to the origin of the data was given. Finally, at the end of the article the Board identifies Dr. Playfair with the following: Dr. Playfair is an Austin psychiatrist. She spoke to the Board on the issue of physicians and sexual misconduct in February, and the board appreciates her assistance. "

From reading my own California State Medical Board bulletins, I am aware of the problem of sexual misconduct by physicians and am not trying to deminish the importance of the issue by this comment. However, Anonymous,to be fair, every one of your conclusions seemingly attributed to what was published in the TSBME Newsletter, Spring of 2002 cannot be supported by what is actually written in the newsletter. ..Maurice.

 
At Sunday, August 06, 2006 6:48:00 AM, Anonymous Anonymous said...

I am amazed that an 'official' newsletter could print a study that gives no sounds basis for the conculsion. It would seem to be a basic premise for any study that the sample and sampling method are given.

9 out of 10 cats may prefer fido flavoured cat food - but when the survey was done by the manufacturer of said cat food and the interviewees were not the cats but the owners and the 10 people came from 3 families each owning 1 cat, the result is in fact fairly meaningless (although in the circumstances it is difficult to see how it could be anything else).

In this case the author would seem to be manufacturer with a product to sell (i.e. treatment of damaged people). She talks to not a randomly chosen sample of the polulation but the few damaged individuals she sees, who perhaps are slightly biased ? Now they may really have been affected by certain treatment, or like the cat owners this may just be a belief, but it is not possible to to more than say that this is their experience, it is wholly wrong to extrapolate to the general population.

At least the cat food survey is correct in saying 9 out of 10: it is a basic rule of statistics that % is used to make large numbers more understandable, thus 456/912 is 50% but 1/2 is just that, one out of 2, not 50%. For any sample size of less than 100, it is wrong to 'inflate' the sample size to 100 - how large was the sample here, we don't know but it could have been very small indeed.

As Dr M says no support is given for what is in the newsletter, it is therefore only of interest in as much as it reflects the authors thoughts.

 
At Sunday, August 06, 2006 6:59:00 AM, Anonymous Anonymous said...

"Perhaps the presence of a male chaperone at the time of the genitalia exam might be more supportive to all parties."

Or perhaps just give the male patient the option of a male doctor, particularly if the exam is fundamental to his visit (i.e. urology, penile dermatology otr STD) ?

As for the erection, I do wonder if it would be better to say something along the lines of: don't worry about it, it's perfectly healthy, a sign that everything is working and the real problem is not having one - something that lots of men have to seek treatment for so you are lucky not to be one of them?

 
At Sunday, August 06, 2006 3:10:00 PM, Anonymous Anonymous said...

Well Dr. Maurice, I can see why you would not want to believe the assetions of Dr. Playfair in the TSBME newsletter, because they are so disturbing. It is hard to swallow the idea that so many of your fellow physicians can be sex offenders. I expect Dr. Playfair got much of her information from a Vanderbilt University study, which is available for review, along with copious references, at:

http://www.mc.vanderbilt.edu/root/vumc.php?site=cph&doc=742

Another article with documented references can be found at:

www.pulsus.com/members/sex/03_03/Pdf/assa_ed.pdf

In this article, the authors give essentially the same figures: "In another survey on nearly 1900 family practitioners, obstetrician-gynecologists, internists, and surgeons, 9% of the sample ACKNOWLEDGED having sexual contact with their own patients. Boundary violations and sexual misconduct are estimated to occur in 3% to 10% of the overall physician population."

 
At Sunday, August 06, 2006 4:20:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous, that's better! I'll accept the Vanderbilt paper which is thoroughly referenced. Of course, a thorough meta-analysis of the data would require careful review and consideration of each study. However, in a practical sense, I don't think that is necessary for this blog since as I have implied the issue of physicians crossing sexual boundaries to me is significant and not a trivial concern. Since I am not in the position to discipline those physicians who cross boundaries (but only responsible to report), my main responsibility as a facilitator of first and second year medical students is to provide education and the necessary advice about this unprofessional behavior. Well, it looks like I have my work cut out for me starting later this month when medical school teaching begins. And
I realize it will not be solely to stress the importance of this topic to the students but also to the other teacher/facilitators of these students. The first two years of medical education is a critical time to talk about sexual boundaries since these are the years that the students first begin to evaluate patients with their "hands on".


I think it would be informative to present here the previously established sexual boundary definitions as published in the Vanderbilt University Medical Center, Center for Professional Health bulletin:

In 1996, the Federation of State Medical Boards of the U.S., Inc. accepted the report from the Ad Hoc Committee on Physician Impairment regarding sexual boundary issues. (Federation Bulletin 1994)

This Committee described two primary levels of sexual misconduct for physicians: sexual violations and sexual impropriety.

Sexual violation may include physician-patient sex, whether or not initiated by the patient, and any conduct with a patient that is sexual or may be reasonably interpreted as sexual, including but not limited to:

1. Sexual intercourse, genital-to-genital contact;

2. Oral to genital contact;

3. Oral to anal contact, genital to anal contact;

4. Kissing in a romantic or sexual manner;

5. Touching breasts, genitals, or any sexualized body part for any purpose other than appropriate examination or treatment, or where the patient has refused or has withdrawn consent;

6. Encouraging the patient to masturbate in the presence of the physician or masturbation by the physician while the patient is present;

7. Offering to provide practice-related services, such as drugs, in exchange for sexual favors.



Sexual impropriety comprises behavior, gestures, or expressions that are subjective, sexually suggestive, or sexually demeaning to a patient, including but not limited to:

1. Disrobing or draping practices that reflect a lack of respect for the patient's privacy; deliberately watching a patient dress or undress, instead of providing privacy for disrobing;

2. Subjecting a patient to an intimate examination in the presence of medical students or other parties without the explicit consent of the patient or when consent has been withdrawn;

3. Examination or touching the genitals without the use of gloves;

4. Inappropriate comments about or to the patient, including but not limited tomaking sexual comments about patient's body or underclothing, making sexualized or sexually demeaning comments to a patient, criticizing the patient's sexual orientation (homosexual, heterosexual, or bisexual), making comments about potential sexual performance during an examination or consultation, except when the examination or consultation is pertinent to the issue of sexual function or dysfunction, requesting details of sexual history or sexual likes or dislikes when not clinically indicated for the type of consultation;

5. Using the physician-patient relationship to solicit a date;

6. Initiation by the physician of conversation regarding the sexual problems, preferences, or fantasies of the physician;

7. Examining the patient intimately without consent.


I must say that some of the second group of behaviors catagorized as "sexual impropriety" rather than "violations" could be open to some honest disagreement in certain specific situations; other behaviors, clearly not. What do you think? ..Maurice.

 
At Sunday, August 06, 2006 6:28:00 PM, Anonymous Anonymous said...

Dr. Maurice,

I am still rather dismayed by your attitude concerning physician sexual abuse when you say your role in stopping the problem must be limited to reporting doctors who commit such abuse and giving your students "necessary advice about this unprofessional behavior." What would you be doing if 1 out of 10 teachers in your local school system were pedophiles or admitted they had had sexual contact with students?

As far as the second group of repulsive behaviors, no. 7 is not simply "impropriety" it is sexual assault!

 
At Sunday, August 06, 2006 9:19:00 PM, Anonymous Anonymous said...

10 in doctors is a deviant - I'm amazed by this statistic, as I've never come across any one who has been abused by a doctor nor ever heard of any suggestions of it !

Of course if "examining the patient intimately without consent" is sexual assault that will make a difference. But if the patient has undressed and not said stop, I think that can be taken as consent. Perhaps not fiarly given, but consent none the less.

Perhaps they were never asked if they were OK for the doctor to handle their genitals - and perhaps instead of just saying "Please undress", the doctor should specifically ask "Are you happy for me to examine you" but failing that I really don't think that having a medical examination by someone you don't like and wouldn't choose but didn't take the opportunity to say NO to, and however difficult it is at the time most people here have had that opportunity and not taken it, is quite sexual assault if the examination is done for standard medical purposes and does not overstep boundaries.

 
At Monday, August 07, 2006 8:05:00 AM, Anonymous Anonymous said...

Well you know, I don't personally know anyone who has been sexually abused by a priest, but I know such abuse is real. The Roman Catholic Church has paid out millions and millions of dollars in lawsuits arising from such abuse. Which brings up something else from the TSBME Newsletter article, which Dr. Maurice didn't quote, namely that settling claims of physican sexual misconduct accounts for $20 out of every $100 the malpractice carriers fork over. Keep that in mind when you hear some doctor whining about the high cost of malpractice insurance!

 
At Wednesday, August 09, 2006 11:34:00 AM, Anonymous Anonymous said...

(Post 1 of 2)

Dr. M.,

It strikes me that the discussions on here have been bouncing back and forth between what are actually TWO separate and distinct areas of concern: 1) unethical behavior (i.e., various degrees of right vs. wrong) and 2) the differences in the approaches used by ethical doctors when examining sexually sensitive areas.

What the first topic deals with is unethical or deviant behavior which includes nearly all of the Vanderbilt list of sexual violations and sexual impropriety. We’re primarily discussing sexual deviancy of various degrees of severity.

The second topic, though, deals with concerns about nudity that does not relate to ethical issues. Instead, it is a matter of what examination practices make a particular patient uncomfortable and how to minimize the potential stress. As we’ve seen above, there is no one best way that works for all patients and/or all situations. Some patients prefer to wear shorts rather than a gown while others prefer a gown, some prefer being uncovered progressively vs. all once, some strongly prefer a doctor of the same gender while others don’t care, etc., etc. I think a lot of problems are caused by medical professionals who, although completely ethical, are lacking in good "bedside manner." They approach things too mechanically and lack the "people skills" of sensitivity and attentiveness to pick up on an individual patient’s preferences, discomfort levels, cultural background, etc. They are not, however, acting "unethically."

Both of these topics are very interesting but I think you might get a more meaningful and clearer debate if you split this into two distinct threads.

 
At Wednesday, August 09, 2006 11:43:00 AM, Anonymous Anonymous said...

(Post 1 of 2)

Dr. M.,

It strikes me that the discussions on here have been bouncing back and forth between what are actually TWO separate and distinct areas of concern: 1) unethical behavior (i.e., various degrees of right vs. wrong) and 2) the differences in the approaches used by ethical doctors when examining sexually sensitive areas.

What the first topic deals with is unethical or deviant behavior which includes nearly all of the Vanderbilt list of sexual violations and sexual impropriety. We’re primarily discussing sexual deviancy of various degrees of severity.

The second topic, though, deals with concerns about nudity that does not relate to ethical issues. Instead, it is a matter of what examination practices make a particular patient uncomfortable and how to minimize the potential stress. As we’ve seen above, there is no one best way that works for all patients and/or all situations. Some patients prefer to wear shorts rather than a gown while others prefer a gown, some prefer being uncovered progressively vs. all once, some strongly prefer a doctor of the same gender while others don’t care, etc., etc. I think a lot of problems are caused by medical professionals who, although completely ethical, are lacking in good "bedside manner." They approach things too mechanically and lack the "people skills" of sensitivity and attentiveness to pick up on an individual patient’s preferences, discomfort levels, cultural background, etc. They are not, however, acting "unethically."

Both of these topics are very interesting but I think you might get a more meaningful and clearer debate if you split this into two distinct threads.

 
At Wednesday, August 09, 2006 11:48:00 AM, Anonymous Anonymous said...

(Post 2 of 2)

On the subject of ethics, there have been quite a number of instances described on here that, in my mind, are serious breaches of ethical conduct yet nobody has branded them as such. I am referring to doctors who are less than thorough as a result of their unease with nudity.

Dr. M., in response to one of these you stated, "I believe some doctors, even doctors in practice a long time, have a sexual or genital aversion which prevents essential sexual history taking or proper and complete examination of the genitals or skin beneath the underwear."

Here’s where I’m coming from. I happen to be high-risk for developing skin cancer (family history, very fair skin and dumb enough to have gotten quite a few very severe sunburns as a teenager). For this reason I have undergone skin examinations by a dermatologist twice-yearly for the past 6 years (for the last 4 the doctor happens to be a woman). Every medical pamphlet, news article, medical reference, etc. that I have ever seen says that such exams are comprehensive and include the genitals. They don’t say "should," or "might," or "could." Yet we’re hearing here that some doctors omit it simply to avoid discomfort!

In these situations, failure to detect a cancerous growth at an early stage could be potentially life-threatening. Don’t you think it is unethical for any doctor to give a less than complete exam (and thereby potentially jeopardize a patient’s wellbeing) solely because they are a little shy about male anatomy?

I am a bit surprised by your comment that many doctors have such an aversion since anatomy is so fundamental to the medical profession. Regardless of the frequency, though, it is understandable that some doctors feel this way and I don’t condemn them for doing so. However, they still have a moral responsibility not to shortchange their patients’ medical treatment. I believe they have a duty to either a) suppress their personal feelings and be diligent in doing what needs be done or b) refer the patient to another doctor who will. Anything less is unethical. Would you agree?

 
At Wednesday, August 09, 2006 3:57:00 PM, Anonymous Anonymous said...

Wow, a lot of area covered. I agree with your list and the people who followed in number 7 could be arguably assult, but as a subsequent posting pointed out it could be a situation where the doctor informed the patient what they intended to do and assumed the patient not protesting implied consent, or assumed the patient understood the intmate exam was part of the overall procedure. Defining what exactly what constitutes assult and improper behavior is really difficult in some borderline situations, it is different things to different people. I read a study that stated 60-70% of all women had been abused by thier spouse, only to later to determine that abuse could be defined as broadly as rasing ones voice, looking or staring in an unfriendly manner, or insulting, berating, or offensive remarks. I would be surprised if 100% of all people had not been abused at one time with this definition. I personally have never known anyone who was assulted by a physican. I rural Indiana we still have a high opinion of physicans and trust in them is pretty high, so it is a struggle for me to accept 10%. That said I have no doubt at all it does happen, but I would have to see a lot of imperical data to accept the number.
The other point of two threads is pretty accurate, including the statement it is a lot to do with bedside manner AND patients stating thier wishes. I think the concept of patients emotional comfort in this area is relatively new to the profession and to patients. The profession hasn't learned to recognize or ask, and patients haven't developed the confidence or ability to make thier concerns known. I have had numerous occasions lately to interact with the medical community and by and large find them to be overwhelingly caring, compassionate, and professional.......but I still stress out over being exposed to a member of the opposite gender. The medical community knows this is common among thier patients, they just haven't figured out what to do about it or do not recognize it as being as big and issue as it is. If this isn't so, explain the open back mini skirts jokingly called I.C.U. gowns, patients are forced to wear when there is no real medical reason when something more modest would not work.

 
At Wednesday, August 09, 2006 5:33:00 PM, Anonymous Anonymous said...

A couple of comments:

The list seems like an excellent and comprehensive description of proper sexual boundaries with two exceptions:

1) “Disrobing or draping practices that reflect a lack of respect for the patient's privacy” should only be considered a “sexual impropriety” if it was done knowingly and/or intentionally. A particular situation that a patient interprets as a “lack of respect” could simply be the result of poor communications between the doctor and patient, an unusually high level of sensitivity by the patient, inattentiveness or carelessness by the physician, and so on. Although these are all undesirable situations, they hardly constitute improprieties.

2) As was said by the previous commenter, item 7 is an assault and belongs in the first section as a “violation” and is NOT a mere “impropriety.”

Lastly, regarding a later post, any doctor who fails to properly complete a routine part of an exam due to his own personal aversion is being negligent and, hence, unethical.

 
At Thursday, August 10, 2006 9:54:00 AM, Anonymous Anonymous said...

Dr. Maurice, would you share your thoughts on this? You are obviously involved daily on the medical side by profession, and have had a lot of feedback though your efforts. Why do you think the medical community as a whole does not address some of the things they know are problems with many patients. Some things seem so easy to fix yet are not. For example everyone knows the open back gowns are hated by most patients, I have see gowns that over lap and tie at the side providing more modesty, but are not used in a majority of health care applications. The same with same gender providers, while we realize it is not always possible, sometimes for imaging and other procdures both gender staff are available to conduct intimate and potentially embarassing procedures, but there appears to be no attempt to match genders for these procedures even though there appears to be universal knowledge patients prefer same gender? I was curious as to why you think the issue isn't addressed. Do you think it is convienience for the provider over comfort of the patient, do most providers not recognize or understand, is it economics, do a lot of providers take it personal, or thats just the way its always been done? I would like to hear why you think this hasn't changed dispite the obvous new focus by health care on the emotional as well has the physical side of patient experience.

 
At Thursday, August 10, 2006 7:13:00 PM, Blogger Maurice Bernstein, M.D. said...

To Anonymous from today August 10: I think you have certainly asked me questions which are quite pertinent. Actually, I may have already answered them previously but I will restate them now. The answer to most of your questions is that there really hasn't been any specific complaints to physicians about virtually all of the patient modesty issues presented here and the issue of physicians being so hesitant to examine genital areas that such inspection is avoided. Therefore if the physician is unaware that the patient is unhappy or unsatisfied--nothing remedial will happen.
Again, why the patients don't communicate their concerns may be because of feelings of intimidation or the patient feels there is a difference in powwr between the patient and the physician and is afraid to speak up for fear it isn't appropriate or might lead to physician anger or degrading the professional help the patient desires for their health. Of course, the patient should speak up. There should be no intimidation and these concerns are appropriate concerns.

So what happens is that patients are obviously coming to blogs like mine and generally in anonymous or pseudonym identification are pouring out their observations and upsets about physician behavior. My concern about the response, for example to the "Naked" thread, is that if this truely represents the feeling of a substantial part of the patient population or even not substantial but more than a rare group of unhappy patients, doctors should be aware and we in the teaching of medical students and residents and the medical profession in general should try to correct and mitigate those practices which patients find upsetting and unsatisfactory. This means more attention to anticipation of the patient concerns, to proactively talk to the patient about what is to be done, what will be done as part of the examination and to determine if the patient understands and is comfortable with the plan. This means the physician should take a moment to invite the patient to express their desires about the exam. This means to be ready to provide a chaperone of the gender desired by the patient or to try to provide physician or staff of the desired gender. This means the use of gowns or undraping procedures which are appropriate to the modesty desires of the patient. It will be through openness and a sense of collaboration in the performance of the physical exam between physician and patient that should be attained.

With regard to the timidity of some physicians to do genitalia exams even when it is strictly necessary or the physicians who perform genital exams but in a crude and seemingly uncaring manner (leading to thoughts by patients that there is being done in a sexual context), better training or retraining in the proper approach to genital exams is necessary.

I want to do my part in correcting the situation. Hopefully, in the next few days all six of my second year medical student group I am facilitating with regard to physical examination will be reading this thread as I directed. Next week we will discuss what my visitors have written here and discuss these professionalism issues which have been brought up. I hope to encourage other teachers in my medical school to direct their students to do likewise. Hopefully, with our paying more attention to these patient concerns along with other physicians, life in the examining room will be happier and more comfortable and in ways more productive. ..Maurice.

 
At Friday, August 11, 2006 12:15:00 AM, Anonymous Anonymous said...

Above sounds good - a shame that it is only being applied to 6 students somewhere in the US but I suppose progression has to start somewhere.

 
At Friday, August 11, 2006 7:35:00 AM, Anonymous how husbands feel said...

DR. M. Glad to her that you will be sharing our thoughts and feelings with your students. It is a shame that you are only one Dr. who actually has cared enough to do something about it. I hope you look back years from not and see that starting this blog was really worthwhile.

On a side note over at the how husbands feel group we have just had two of our members involved in serious examination. One for a spot that showed up on a mamogram and one for heart problems.

In both cases the couples was treated by a Male M.D. not as a married couple working as a team but as if he was treating a single woman. This lead both couples to seek another Dr. who happened to be in both cases a female.

Both Female Dr. treated the couples as husband and wife teams and this makes healthcare better for all concerned.(paitient-Spouse-&Dr.)

Please relay this concept to your students as well.

Thanks again Dr. M.

Respectfully:
Mike aka tenderhusband and moderator at how husbands feel

 
At Friday, August 11, 2006 8:56:00 AM, Anonymous Anonymous said...

Dr. M.,

I think your preceding post is right on the money. Areas where I think you especially got it right are:

1) Every patient is different: A particular approach that is the least upsetting for one patient may be abhorrent to the next patient and vice versa. So, the idea broached by some people that universal “standards” will eliminate problems is seriously flawed.

2) Communication: a) A doctor should let a patient know beforehand what to expect so that the patient isn’t caught by surprise in the midst of the exam, and b) ASK patients about their preferences and then accommodate them to the extent that makes sense. By the way, although the patient has a responsibility to speak up, most of us won’t (too timid or embarrassed) unless the doctor initiates the discussion. Then, I think most people will let their preferences be known.

3) Physicians shouldn’t be so timid that it causes them to provide less than the level of thoroughness that it is medically appropriate. Keep in mind that most patients are unlikely to know for themselves in which situations a genital exam is or isn’t appropriate. Therefore, the burden of assuring that an exam is complete rests primarily on the doctor rather than expecting the patient to speak up.

My only experience with having my genitals examined has been with just two different doctors, both of which were conducted by dermatologists performing skin exams. I’ve now been through it over a dozen times. I hadn’t realized how relatively skillfully they dealt with this sensitive situation until reading this thread. When my first exam was scheduled, I was given a pamphlet that explained in detail what to expect. Prior to the commencement of the exam I was asked whether I prefer a gown or a robe. I was also asked if I had a preference for a male or for a female doctor. The exams are always conducted with an air of professionalism without coming across as either aloof or overly informal.

 
At Saturday, August 12, 2006 8:58:00 AM, Anonymous Anonymous said...

Dr. Maurice your explaination was very well put and as the previous poster put it "on the money". They also nailed it, we should ask but probably won't so the Physician asking would be great. While we as patients suspect such is the case, we rarely get the other side of this. The question then becomes how to comunicate this, patients are intimidated to ask, providers don't realize how big the issue is, you have a good idea, a good start, now how do we make it more widespread. Hospitials are doing a ton of advertising to gain "customers"....but don't seem to grasp this simple concept that increases the patient positive experience which in turn...brings people back more often, who tell others, who drive the bottom line. Thanks again for your effort, I hope I get doctors who come from your mentorship, they should get it.

 
At Sunday, August 13, 2006 8:03:00 AM, Anonymous Anonymous said...

Maurice,
Last night I was thinking. When a woman has a baby even if it is a c-section. The husband is included. Even in the OR. Now I know most people would not want to see there spouse's operation but in some cases other things that are done all the time. Would it be better for the patient and spouce to be treated as a team? I have experanced some medical people who are ok with it and some are very against it. How come it's ok for a husband to be allowed to enter an OR for a childs birth but not ok for me to have been with my husband when they put his gallbaldder drain in?? But It was ok for me to see his pick line put in. Keep in mind I do think it is very important for a father to see his child being born but I also feel giving emotional support to someone going through something like a gallbladder drain while awake would be important too. What would have been the big deal? How do you feel and what do your students think? Is it too much pressure for the doctor? What is the real reason they make the family member stand in the hall?
Kim
I am moving on from all of this I'm just thing what if there is a next time. How do I handle it and how much can I have the right to ask for??

 
At Sunday, August 13, 2006 9:40:00 PM, Blogger Maurice Bernstein, M.D. said...

One aspect of patient modesty which has been only slightly touched upon on this thread but brought out in the New England Jounal of Medicine article “Naked” is the cultural differences between the United States and other countries with regard to modesty. Perhaps part of the culture, could there be any factor which early on in the person’s life makes an imprint on how the person, later as a patient. will react to undressing for a physical exam? On thinking about this a bit more, I wondered if undressing or not undressing in a communal setting while in school could make a difference later. I went to Wikipedia to get some help on this theory. Here are some excerpts from the Wikipedia presentation of nudity in physical education. Please go the above link to read the entire description along with the references.


Nudity in physical education

In the United States

In the United States, public school students historically have been required to shower communally with classmates of the same gender after physical education class. In the United States, public objections and the threat of lawsuits have caused a number of school districts in recent years to choose to make showers optional for students [3]. However, many[citation needed] US secondary [4] and elementary [5] schools continue to require all students to shower as part of their school's required physical education curriculum.

Compulsory communal showering remains a controversial subject for many worldwide. However, throughout much of the world, students in physical education classes undress and shower together on a daily basis. For better or for worse, school showers have been most youths' introduction into communal nudity


Outside the United States

Europeans have generally been more insistent that all students shower communally [21].In certain cultures, nudity in public, such as all male locker rooms or showers, is considered appropriate, and is commonly accepted. In saunas or steam rooms, men may be nude around strangers of the same sex as well. Some people, however, may experience difficulties while being around men in the nude, things such as involuntary erections or sexual attraction. In most Scandinavian countries, erections or other male-related affairs occurring between men are most often considered natural and therefore perfectly normal. However, this is not valid all over the globe. In the United States, for example, teenage boys or children may not feel quite as comfortable around older naked men due to the differences in their sexual organs.



In conclusion, it would be interesting to know if any studies have been performed to correlate the modesty related responses of adult patients to undressing for an examination to the experiences of the patient as children in school physical education classes. ..Maurice.

 
At Tuesday, August 15, 2006 4:41:00 AM, Anonymous Anonymous said...

It is possible that in countries with a relaxed attitude towards nudity people will be more relaxed about being naked with doctors. However I think this is by no means certain and the manner and attitude of the doctor will remain crucial. I speak as someone who is comfortable with nudity, whether at home, in the changing room at the gym, in a sauna or even in more unusual situations, such as staying at a nudist resort where people are naked all day, in shops and restaurants as well as on the beach.

Being told by an abrupt doctor to get naked in a small and uncomfortable medical examination room is a world away from this. Even when one knows that she is examining one’s penis there is still a huge difference between having that specifically examined and having to strip entirely naked.

In the same way as Brazilian waxes now seem de rigeur for women many men now get a “back sack and crack” wax – that involves complete nudity and during the process and erection is quite likely. That can be embarrassing but the good waxer will make light of it – telling you that it is usual and also that by stretching the skin it makes the waxing easier. They realise that although the client has gone there knowing what is involved, they may still be nervous and need to be put at ease. As they’re working in small salons they probably know too that if they were rude and inconsiderate they wouldn’t get much repeat business. Unfortunately doctors don’t seem to suffer from this constraint.

In many business situations role play is used – perhaps if this were tried here, doctors may be slightly more accommodating of their patients’ feelings ?

 
At Tuesday, August 15, 2006 7:58:00 AM, Anonymous Anonymous said...

Maurice,
I asked you a question. Could you please answer me?? What are a spouses rights to the patient? When can they legally ask you to leave?
It also seems to me that boys in locker rooms are diffrent than girls. I had this discussion not to long ago with my kids. Now 18 & 17. My daughter very uncomfortable with it and my son did not seem to care. I think it has something to do with how wemon are constently trying to have the body society says they should. You know the barbie syndrom. This is also why we have so many young girls with anorexia.
I am a cosmetologist as for the waxing. This is something you willing do usually there is some jokeing going on to ease the client. It's much diffrent to strip at a doctors office. It's serious. Hope you understand what I mean.
Kim

 
At Tuesday, August 15, 2006 8:58:00 AM, Blogger Maurice Bernstein, M.D. said...

Kim, there is no set rules or laws regarding the presence of a spouse when a patient is being examined or some other procedure is being carried out. For example, some institutions allow a family member witness cardio-pulmonary resusitation of a loved one, usually in the presence of a nurse or spiritual advisor who can explain what is going on. Other institutions or CPR teams are uncomfortable with the presence of a relative during this most trying and emotionally laden activity. The issue often is whether the spouse or family member will interfere with the process or even suddenly collapse and be a patient that needs attention themselves. This latter concern also has been considered regarding husbands to remain with their wifes in the delivery room. I would say that if a situation arises where the visitor is creating harm or a hazard or unusal burden to the proper carrying out of a procedure, it may be appropriate, with explanation, to have the visitor leave.

I think your expression about the "barbie" syndrome might be appropriate not only with regard to women nude together but perhaps is involved in the female patient modesty issue in a doctor's office. Could the female patient be thinking about what impression her woman's body or breasts were making on the physician of either gender.. perhaps concerned about not appearing attractive or sexy? I don't know..just a thought.

I also want to ask Anonymous from today and other visitors who are experienced and comfortable with communal nudity whether there is some displeasure observing a fully dressed person in the group who are undressed? If so, could a patient who is comfortable with communal nudity find some anxiety in a doctor's exam room when the patient is undressed and exposed and the physician is dressed and covered? Or more than that, the patient believing that unequal power exists between patient and doctor, unlike the equality in the communal experience, leads to modesty issues if the patient is uncovered. What do you think? ..Maurice.

 
At Tuesday, August 15, 2006 11:22:00 AM, Anonymous Anonymous said...

Maurice,
Thanks for the answer. It was along the lines I thought. In other wards stay calm and out of the way and you have a better chance of getting to stay.

I don't know about a patient feeling not attractive enough. I myself (not to brag) but am afraid of being too attractive to the doctor. I once had a client tell me she liked getting older because she didn't feel like she was turning the doctor on anymore. So for her being less attractive was more comfortable. It could go both ways though. Do they feel too attractive or not attractive enough?? I also feel girls in the locker room setting are judging each other. Men from what I understand don't do that. At least that is what the men in my house say.
Kim

 
At Wednesday, August 16, 2006 1:36:00 AM, Anonymous Anonymous said...

From anonymous yesterday: That “unequal power exists” is fundamental to the discomfort of the patient who is comfortable with communal nudity but uncomfortable when naked in certain doctor patient situations. However there is far more to it than just the clothed/naked distinction.

This is clearly seen in the waxing example – there too the ‘patient’ is totally naked, with someone who is fully clothed and the ultimate fear for many men, an erection, is very likely to be realised, yet dealt with properly this can be a positive experience and not a problem. In a male-male situation the worker can give the client support and the client will always know that a male worker may well have been in the same position, that he is not at that time is not a particular issue. (The same may go for a massage where the person being massaged may be naked but unlikely to ever see the masseur nude.) The doctor in the same position is far more likely to be distant and either unable or unwilling to make the patient comfortable. No one would question my right to chose who to wax my body, why should choosing a doctor be any different ?

Returning to the dressed person in a naked group, is there dis-pleasure ? I think the answer is that it depends. One person wearing swimming trunks in a sauna where everyone else is nude is more likely to be seen as stupid than anything else. However I have been to a naturist club were someone’s partner always wore something – nudity being compulsory only in the pool and sauna- and yes this caused unhappiness. It was naturist environment and there was no reason not to be nude, people would put up with someone wearing something until they were relaxed enough to strip but if after a couple of visits this had not happened, they should have been asked to leave. Gawkers on a nude beach always cause discomfort. Modesty is not the issue, people on the beach are comfortable with nudity but a feeling of vulnerability exists as the gawkers are there to exploit this comfort. The doctor is not exploitative in the same way, the discomfort and vulnerability comes from other factors and the way in which the relationship is wholly unequal, the patient may not have chosen the doctor, may not be comfortable with the doctor and yet can be told to get naked and often in a rude and peremptory way.

Manners maketh the man, they go a long way to making a good doctor too.

 
At Sunday, August 20, 2006 4:12:00 PM, Anonymous Anonymous said...

I sympathise with many of the comments here.

I'm a male, mid 30's and not particularly shy but I do question the role of a chapperone when nudity is required for an exam - especially when the chapperone is female (and younger than me).

It happened recently at my dermatologist. For most of the exam I was in boxers, I was then asked to remove them by the Doctor (who was female) and she left the room saying she needed the nurse for this part of the check.

So I was completely naked in front of the two women as they walked in and the Doctor continued the exam as the nurse watched/overlooked. It was a little much having both of them there and I did unintentionally become aroused which I felt would not have happened had the nurse not been there. The Doctor was really good and told me not to worry and she did not seem put off at all which was reassuring as it was a very embarrassing situation.

Why the chapperone? I can see it for male Dr's examining female patients - but the other way round? If anything, surely a male chapperone would be better.

As I mentioned, I was ok with being naked in front of just the Doctor - but with a nurse there too - seemingly for no real reason - it was too much.

Many thanks,

Embarrassed in the UK!

 
At Monday, August 21, 2006 10:15:00 AM, Anonymous Anonymous said...

Embarrassed in the UK, you have hit on a couple things that have been common in other postings, one while we understand Doctors especially Male doctors with female patients wanting a chapperone for comfort of the patient and for self protection, bringing in a chapperone of the opposite gender of the patient only intensifies the patients discomfort, it does not help it. In this case the patient should have been given the option of the chapperone knowing it was a female and given the choice to deny one or if the doctor felt they absolutely needed one present, provide the patient with a gown or covering,and done the exam in a manner that provided a degree of cover (i.e. turning back to the nurse during the exam. The other aspect of this, if a male doctor had brought in a male chapperone during this procedure on a female patient, and had her standing naked when they walked in...what kind if backlash would he have faced? I used to be silently embarassed, I now make MY preferences known and am much more comfortable.

 
At Wednesday, August 23, 2006 8:44:00 PM, Anonymous Anonymous said...

Why does stuff like this go on and on?

http://www.nashvillescene.com/Stories/Cover_Story/2006/08/24/Dr_Feelbad/index.shtml

 
At Wednesday, August 23, 2006 9:48:00 PM, Blogger Maurice Bernstein, M.D. said...

To answer the question "Why does stuff like this go on and on?" after reading the report from the Nashville Scene, the answer is: doctors in essence are human beings with human failings, medical school admission committees make wrong decisions, aberrent medical students are not always identified by their teachers and if identified may not be removed from school because of legal concerns by the school, patients are often too timid to squeal on bad doctors and state medical boards like the one in Tennessee deliver only "slap on the wrist" punishment. Anonymous from today, that is the answer to your question. Period. ..Maurice.

 
At Thursday, August 24, 2006 9:49:00 PM, Blogger bp said...

Recently I relocated and had to choose a doctor. During my initial visit he asked a few questions and advised me he would perform a hysical (it had been many years). When he told me to undress, he said it would involve the "whole nine yards." Sice I was not offered a gown, I simply stripped to my underwear and waited for him to return. Upon his return he looked at me weirdly and told me that it was a full examination and I needed to take off my underwear, too. Was that necessary? I found out later e was from Germany. Is this a common practice in Europe? I don't see why he w ouldn't have just performed what he needed to initially and THEN asked me ti remove my underwear. Would most people have done differently if they wer in my shoes? I have been in locker rooms ona regular basis since high school and this hasnever really been an issue for me until now. Perhaps it is something to do with the imbalance of power?? I need some advice from another professional.

 
At Tuesday, August 29, 2006 10:02:00 PM, Blogger Maurice Bernstein, M.D. said...

BP, you asked:"Would most people have done differently if they wer in my shoes?" I think you really meant "my underwear". I think you should have told him that he should explain why you had to be totally nude. As I have explained in other posts, total nudity is not necessary for medical examination and indeed it is detrimental if it associated with mental anxiety or chilling. The human body can be examined, even by dermatologists, in uncovered sections. General medical exam of a man can be performed with a bare top and abdomen but in shorts. when genital or rectal exam is to be done, the shorts can be dropped and then pulled up after the exam. As I have noted previously, the time to complain is after the physician's request and not much later to a bioethics blog! ..Maurice.

 
At Wednesday, August 30, 2006 8:24:00 AM, Anonymous Anonymous said...

I have had many full-body skin exams done by young doctors, mostly female, at the VA. Only one of the four doctors looked at my genitals and she had problems with it. Since then chaperons and gowns became mandatory and a simple skin exam turned into a big production. Recently, however, I had the best and simplest total-body exam I have ever had. There was no gown, no chaperon and I did not strip, at least I was never completely naked. This doctor did the exam in portions (a first for me) and absolutely everything was looked at. Now, one thing I failed to mention was that the doctor was a man. However, there was a female observer, in her third-year of med school, who didn't miss anything. I took off my shirt, then stood and dropped the pants, then the shoes. All I can say is it worked. No gowns or chaperons and no hassles. The doctor and observer didn't even leave the room. I'm a firm believer, at least for now, that this is the way to go. I asked the doctor if melanoma could occur anywhere and he said yes. So can those female doctors, who didn't look at everything, be considered negligent? Is American society so prudish that it invades hospitals? Or was it just fear or laziness? Did a fellow-resident say, "Oh, you don't have to look at that."? The head of that department (Emory) once told me, "Men and women [doctors]are the same." Well, they're not. Or somebody is teaching them the wrong way. What is going on?

 
At Wednesday, August 30, 2006 9:13:00 AM, Anonymous Anonymous said...

Good one Dr. M., humor with education. It has been stated and restated responsibility falls on the patient and the doctor. I picked that up from the this blog, have applied it and it has made a huge difference in my comfort level during medical visits. My question is, given this blog is viewed by a small portion of patients and providers, is there a forum to reach a larger group of providers who could pass this on to patients. While it would be great to educate the masses, I don't know where that media would be. Any suggestions.

 
At Friday, September 01, 2006 3:55:00 PM, Anonymous Anonymous said...

“£145,000 for ‘intimate’ prison searches

A FEMALE prison officer was yesterday awarded £145,000 compensation after being forced to make intimate searches of male inmates at a high security jail. An employment tribunal agreed two years ago that rules covering searches at….Prison..discriminated against Carol S…Male officers were barred from searching women inmates but male prisoners could be searched by officers of either sex. Mrs S….said comments such as ‘higher, miss, higher’ left her feeling physically sick and angry.”

This was in a UK paper today – from the comment quoted at least one male prisoner enjoyed the experience (in contracts to the medical patients taking part in the discussion here). However at least one male patient, me, was left feeling “physically sick and angry” after examination by an unpleasant female doctor however somehow I think I won’t be receiving any compensation !

 
At Tuesday, September 05, 2006 8:24:00 PM, Anonymous Anonymous said...

I recently had a hemorrhoidectomy with a surgeon who has shown a great deal of professionalism both pre- and post-surgically. My issue is not with the surgeon, but with the rather uncomfortable situation with which I was presented in the surgical suite.

I am female. The anesthesiologist, surgeon and nurse were all male. I awoke after the procedure, as the nurse and anesthesiologist were turning me over onto the gurney for transport to recovery. In doing so, my gown was pulled completely away, exposing my genitalia. I remember groggily lifting my head to inspect the length of my body, and my hand feeling too heavy to cover myself.
My next memory was of the surgeon chastising the nurse to cover me. This episode has plagued me ever since as one of life's most embarassing moments. My question to you is this: Do you feel that this episode is of enough import to report to the surgicenter, not only the slow response time of the male nurse in considering my modesty, but in having a male nurse in the procedure room at all?
Miserable in Phoenix

 
At Tuesday, September 05, 2006 9:34:00 PM, Blogger Maurice Bernstein, M.D. said...

Miserable in Phoenix, my answer to your question is: "your should report". To me what has happened can be looked upon as a "complication" of the surgery. Even though the hemorroidectomy surgery itself might be considered satisfactory, especially if you have no further hemorrhoid symptoms, a hemorrhoidectomy is an operation and not simply related to what the surgeon cuts. It is also involves anesthesia and the behavior of the anesthesiologist and all the other functions that are involved in a safe trip to and from the operating room. For example, supposing you were dropped as the operating room folks moved you to or from the operating table to the bed. That would be an operating room incident. Other incidents, though not so much physical as psychological include the behavior which you observed. All incidents related to surgery should be reported to appropriate authorities who can act to prevent such incidents in the future. I am pleased that you expressed your concerns to my blog but it is more productive to express your concerns to the surgeon (captain of the ship) and the surgicenter officials who have the capacity to do something. ..Maurice.

 
At Wednesday, September 06, 2006 5:32:00 PM, Anonymous Anonymous said...

Being a shy person myself, I have chosen to deal with the problem of discomfort around doctors, especially regarding "intimate" parts of the male anatomy by...simply not dealing with it. A valid solution. I have some medical conditions for which I purchase medications from overseas, and I have eliminated all doctors from my life.

Nobody is guaranteed a specific amount of time on this earth, but one can control their own bodies, and not expose it to strangers if it makes them uncomfortable.

 
At Wednesday, September 06, 2006 6:01:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous from today Sept. 6th- You are raising an important issue that we should specifically address: should an individual patient's modesty trump established standards of medical care for that patient? Should this decision be encouraged? I cannot argue that a mature, competent individual doesn't have the right to define their own quality of life as long as this poses no harm to others. That means if one, because of modesty, wishes to avoid physicians and practice self-medication, I doubt we should prevent that person from exercising their autonomy. However, if this personal decision can lead to harm to others such as with regard to serious communicable diseases as an example, there should be a limit to patient autonomy.
Should the decision that Anonymous made be encouraged? No. I think that the issues of patient modesty can be easily mitigated by good communication between patient and physician and physicians who will comprehend the concerns of the patient and tailor their approach to the diagnosis and treatment of patient with the patient's concerns in mind. Anyone have some other views? ..Maurice.

 
At Thursday, September 07, 2006 7:39:00 PM, Anonymous Anonymous said...

Dr. Mauruce:

Further to my above post, no argument concerning communicable diseases. But I have simply decided that as a diabetic, the testing and treatment is worse for me than the disease. I have never met a doctor, who with the best of intentions, didn't manage to upset and frighten me more that the condition did. I can get Lipitor, Lopressor, Glucotrol and anything else I might need, and not even have to suffer the stress of a blood pressure cuff, or worse a blood draw, something I decided I would never allow again.

Clearly people will disagree with my lifestyle, but I am not hurting anyone. An anonymous doctor doctor that you could just talk about your symptoms and have him, recommend a medication, with no liability would be a terrific idea.

I am generally an outgoing person, but I really cannot even speak with a doctor--no less undress in front of one. If prostate cancer takes me out, so be it.

 
At Saturday, September 09, 2006 7:06:00 AM, Anonymous Anonymous said...

I think most people would agree when a persons actions endanger others, a certain amount of choice has to be compromised whether that be the speed we drive or in medical treatment. The problem comes in defining those boundaries. The case of the female prison guard is a good example. There was a court ruling that male guards were PROHIBITED from searching female prisoners but female guards were permitted to search male prisioners. Now you have a female bringing a suit becasue she was required to search a male prisioner. How do you legislate a common policy that addresses such a diverse population. Clearly the public deserves protection from someone spreading communicable diseases, but with our PC society, how does it get applied. We have restrictions on AIDS testing even in cases of rape due in part to it's association with the gay community, etc. so this is the mine field our medical community must navigate with a legal system that is swayed by political correctness and the individual rights vs those of society. Without intending to judge i think the above poster may have a more extreme case of what many of us have stated in this and your other blog. I have taken a lot away from this dialouge including requesting same sex providers and expressing concerns when things were not as I thought they should have been. One way I have found to partially overcome my inherent tendency to suffer in silence or avoid is to use e-mail or other less intimidating methods to comunicate and make these things known. The face to face comunication of these concerns is still hard. Sitting on an exam table is an uncomfortable environment and seems to inhibit open conversation, the power difference comes into play. If I am going to have exams, testing, or procedures with providers other than my family doctor who has me figured out, I e-mail the facility before I go in and inquire can you address these concerns for me and what do I need to do. It has worked pretty well, I think as a whole providers are willing to accomidate if we ask, and will address issues if we let them know. I still think providers need to be more aggressive in addressing this but we need to be part of the solution. The above posting shows the severity of the issue that many providers simply may not understand or recognize.

 
At Sunday, September 10, 2006 10:25:00 PM, Anonymous Anonymous said...

The real cost to me. I am very shy, although I don’t show it when being examined by my doctor. I have asked the nurses at the hospital near me in Delaware if I could have male nurses in the OR. They said that would not be possible.
I recently had a Green light PVP (Prostate vaporization) procedure because my urologist said the Flomax was no longer working for me. It had worked fine for several months, then suddenly I was getting up several times a night, a problem I did not have before starting the Flomax. The doctor told me I needed the procedure, or I would ruin my bladder.
The doctor asked the usual questions, allergies, meds etc a week before surgery. The night before the surgery, I looked at the Laserscope web sight out of curiosity. The had a video of the procedure. I was a bit shocked to see the patient lying there, genitals completely exposed the whole time, unnecessarily. The size of the cystoscope was unbelievable. I had been told it would be a small fiber optic strand going in me. I thought I would just see the lasering in the urethra. There were a lot of people in the OR. The doctor removed the cystoscope unbelievable fast. He just yanked it out.
After my surgery the doctor came into recovery and I asked him if the blockage of my urethra, due to my swollen prostate, had been very bad. He said not really. He said my bladder must “suck” or it’s on of the medications your taking. Afterwards I learned that in fact one of my meds causes urinary retention, which was the problem I was originally diagnosed with.
There wasn’t great physical pain from this procedure and my insurance covered most of the costs. I felt the greatest cost was my modesty. I was willing to give this up to save my bladder, I had no other choice. Now, considering it seems like this was unnecessary surgery, HOW DO I GET BACK WHAT I LOST IN DIGNITY?
I had to take my wife to the 2 week follow up just in case I lost my temper with the doctor and did something regrettable. Do you think that all the OR nurses and the doctor would give me their nude pictures so I can post them on the bulletin board at the hospital, so we can call it even?

 
At Thursday, September 14, 2006 4:58:00 AM, Anonymous Anonymous said...

While the above persons post may seem sarcastic in suggesting posting pictures of the nurses & doctors, it does in a round about way bring up a big point of contention. Whether being nude in nedical settings is a big deal or not depends on your point of perspective. Dr. Bernstein, I would be interested in your thoughts. I would assume you have asked your students if they feel patients should accept them as professionals regardless of gender, I would assume most or all feel we should. I would suggest that if you told them as part of the teaching process you were looking for volunteers among them to do opposite gender exams on each other including breast, genital/pelvic, and rectal. I would bet you would get few if any volunteers. When you listen to medical providers the whole thing looks different depending on which side of the gown they are on. They are still the same people, still the same professionals, the only thing that changed is what role they were in the relationship. That puts some perspective on it. While staffing limits accomidation, I would bet more often than not failing to met requests for same gender nurses etc. is as much don't/won't than can't. Many times historical way of doing things, extra effort, and taking it personal against them instead of making it about the patient all come into play. Your thoughts?

 
At Thursday, September 14, 2006 10:59:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous from today September 14: As I have noted on other posts, medical students don't practice breast and genital/rectal exams on each other. They learn the procedure and the proper communication with the patient by performing the exams on skilled both male and female teachers who are the subjects. These subject provide the students with detailed feedback about their technique and behavior. In the first and second years of our medical school the students rarely perform these exams on hospitalized patients. Most of this learning is done in the third and fourth years when they are performing their clerkships on the hospital wards. It is hard to say what the explanation is regarding any failure of the physician to follow the patient's request for gender-specific healthcare workers. In my 40 years of internal medical practice, the gender requests were never brought up by my patients. That is why, for me, this whole discussion about patient concern about the gender of those professionals attending to them is remarkable, very interesting and for me an education. ..Maurice.

 
At Friday, September 15, 2006 5:18:00 AM, Anonymous Anonymous said...

I read in your earlier post about the professional patient-teachers and have immense respect for them. My thought was more to the point where if the students would put themselves in thier patients place, they will see the contention that providers are professionals and therefore thier concern is unfounded, seems a little different. This issue is not anything against providers, but when they are in the patients gown, it feels a lot differnt. Not that it can always be accomidated, but at least be aware it is a valid issue.
I think the gender issue has always been there, but no one felt they had the right to speak up. Until I read your blog, I never made requests or said anything, I just sucked it up and stressed out, and I am 50. I think as people start to realize they have the right to request, more will. I also think if people get more comfortable with this, they will have a more positive view of visits & procedures experiences, and will be more comfortable seeking health care. As irrational as it seems, some of the earlier posts would indicate a percentage of people avoid health care rather than subject themselves to this. Irrational...probably, unhealthy, maybe even fatal...yes.....a real issue....definately.

 
At Friday, September 15, 2006 5:19:00 AM, Anonymous Anonymous said...

I read in your earlier post about the professional patient-teachers and have immense respect for them. My thought was more to the point where if the students would put themselves in thier patients place, they will see the contention that providers are professionals and therefore thier concern is unfounded, seems a little different. This issue is not anything against providers, but when they are in the patients gown, it feels a lot differnt. Not that it can always be accomidated, but at least be aware it is a valid issue.
I think the gender issue has always been there, but no one felt they had the right to speak up. Until I read your blog, I never made requests or said anything, I just sucked it up and stressed out, and I am 50. I think as people start to realize they have the right to request, more will. I also think if people get more comfortable with this, they will have a more positive view of visits & procedures experiences, and will be more comfortable seeking health care. As irrational as it seems, some of the earlier posts would indicate a percentage of people avoid health care rather than subject themselves to this. Irrational...probably, unhealthy, maybe even fatal...yes.....a real issue....definately.

 
At Friday, September 15, 2006 11:38:00 AM, Anonymous Anonymous said...

An interesting follow-up on the above observtion. Google nude patient modesty nurse-on the 2nd page is an articel "final end to Beka's manuscript" it is an article by an ICU nurse as she prepares for neuro surgery. She states that maintaining her modesty was as much or more of an issue to her than her surgery. In fact she brought a pair of scrubs, but didn't need them as the team brought her a pair for her comfort.
An accomidation they would not have made or even thought of for us normal patients. If we were treated as one of their own, it might not be such an issue. "do unto others"

 
At Tuesday, September 19, 2006 12:29:00 PM, Anonymous Anonymous said...

Don't know if its the right place to discuss this but what is the etiquette where wearing gloves is concerned to carry out a male genital exam?

The reason I ask is that in the past 6 years or so I have been examined twice for possible hernias - both times by female doctors. One (younger one) used gloves to do this. The other (slightly older in her 40's) said she didn't really need the gloves to do it and just washed her hands before and after. Is there a set rule?

I'd also like to contribute my comment to the chapperone issue. I personally don't see the point of having another female nurse present if a male patient is being examined by a female doctor. If they are only there to watch nothing untoward goes on then it is more embarrassing for the patient.

John UK

 
At Tuesday, September 19, 2006 5:55:00 PM, Anonymous Anonymous said...

John UK
I am almost sure it is NOT legal to touch you there without gloves. I'm not sure I would go back to that provider.

 
At Tuesday, September 19, 2006 7:24:00 PM, Blogger Maurice Bernstein, M.D. said...

Jonn UK, although the obvious rationale for using gloves would be to perform a sanitary examination, I believe this is not really the main motivation for their use. I am sure that those physicians using gloves use them primarily for making the physician's contact with the patient's genitalia as "clinical" as possible. For example, doing a pelvic exam particularly by a male physician with bare fingers without gloves might be misconstrued by the patient or others in a sexual context. The young female physician may have been motivated by this concern when examining a male patient whereas the older female physician may have been more confident that her exam would not be misinterpreted. In my years of practice, I have never routinely used gloves to perform a male genitalia/hernia exam with no comments by the patients. I did use gloves for rectal exam in males for sanitary reason and gloves for all female pelvic/rectal exams for both sanitary and "clinical" appearance reasons. There are no legal requirements in California as far as I am aware. There are, of course, legal repercussions for "examining" the patient for sexual motivations. ..Maurice.

 
At Thursday, September 21, 2006 6:39:00 AM, Anonymous Anonymous said...

Why would you want to touch a mans gentials with your bare hands? Do you teach your students to use gloves until they are comfortable? Most men are not going to tell you when they are uneasy with what you are doing. It would be best to look a little more professional than that.

 
At Thursday, September 21, 2006 9:48:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous from today 9-21, you should know that except in the case of patients who are under isolation procedures because of infection, it is acceptable medical practice to touch and handle all skin areas with our bare hands. There is nothing different about the skin in the male genital area except it is the male genitalia. That means that if the physician and patient are comfortable in the examination performed without gloves there is no reason to wear gloves. It would only be necessary to wear gloves in this particular exam if it was important for reasons of psychologic discomfort or concern over propriety by either the physician or patient for an exam without gloves. Although we should wear gloves for rectal and vaginal exams for both sanitary and propriety reasons, this is not necessarily an absolute rule for male genitalia exams. There is no question that for palpation (the feeling, touching and manipulation of tissues), using gloves impairs sensitivity of the tips of the examiner's fingers. ..Maurice.

 
At Friday, September 22, 2006 5:42:00 AM, Anonymous Anonymous said...

Do doctors wear gloves when they do female breast exams? This would be for patient comfort rather than sanitary reasons, just curious.

 
At Friday, September 22, 2006 7:17:00 AM, Anonymous Anonymous said...

Your not listenign. Male patients arn't going to say no to you. They just take it. How do you know if they are ok with no gloves. If you ask they will just lie and say sure what ever. Most of them just want it over with. Wemon have been given the more respect with intimate exames because of liability. Men just get overlooked. Besides what if they had warts or herpies and didn't tell you for reasons of embarasment. Arn't you puting yourself at risk???

 
At Friday, September 22, 2006 11:54:00 AM, Blogger Maurice Bernstein, M.D. said...

After virtually 40 years of medical practice and uncountable number of male genital exams performed without gloves and no comment to the contrary by the patient, I feel thoroughly satisfied that I did perform the exam to the benefit of the patient without their concern about the propiety of the process of my exam.

Of course female breast exams are performed WITHOUT the physician wearing gloves and we do not teach our students to put on gloves when there is no communicable disease aspect to the exam. Think about this: physical examination is not play, it is not a game, it is a serious effort on the part of the physician and, of course, the patient (through the patient's cooperation) to establish whether the patient is healthy and if unhealthy what is the most likely diagnosis so that the illness can be treated. Of course, physicians should be attuned to the physical as well as the emotional comfort of the patient during the exam and this we go over again and again with the students. To wear gloves to examine the breast of a woman is to create a barrier to the physician's best skills of palpation and a detriment to the goal of the patient--to find pathology in her breast if present. Sure, if the patient wanted me to wear gloves, after discussing the harms to a thorough exam with her, I would go ahead and examine her, despite the handicap, but put a disclaimer in the chart regarding the results of my examination. Again, over a 40 year period, this has never happened.

Just as examining a patient in tiny pieces of exposed body with a screen between the patient and doctor as may be done in some cultures as described in the article "Naked" by Atui Gawande. M.D. (the basis for this thread) doesn't make this kind of approach to examination as a standard of best medical practice. A physician doing exams with gloves for purely non-sanitary reasons, despite some who might consider it necessary, certainly couldn't be considered the best either. ..Maurice.

 
At Friday, September 22, 2006 3:14:00 PM, Anonymous Anonymous said...

I still say you should ware gloves for male genital exams. It would provide the same respect you give when doing a female plevic. On a breast exam you are right. With gloves you couldn't feel the very small abnormalities you need to. My husband said he has never had an exam wothout gloves. He also said gross.

 
At Sunday, September 24, 2006 1:58:00 PM, Anonymous Anonymous said...

Interesting read here so just wanted to comment on an earlier post.

I wondered if there is a policy on removal of underwear by female doctors on male patients - say in the case of the male patient holding other clothing out of the way?

I refer to an exam I had last year where I had some pain in the fold of my groin. My female doctor asked me to lower my trousers and hold up my shirt. Without any comment she then slid down my underwear herself and I can only assume she did this as my arms were holding up my shirt. I suppose the other thing to note was that she was a young doctor who I was informed at the booking of the appointment as a student doctor.

She only lowered my underwear to look over the area and didn't feel the need to physically check me. I did feel quite exposed but put it down to 'one of those things.'

Almost bizarrely (and I would say unprofessionally) she seemed to be containing a broad smile after she had examined me.

 
At Sunday, September 24, 2006 8:59:00 PM, Blogger Maurice Bernstein, M.D. said...

It is general accepted practice for the patient themselves to perform the undressing and not the physician. There, of course, is a major exception and that is if the patient is unconscious and is therefore unable to participate and needs a prompt examination. In that case, appropriate undressing is performed by the healthcare workers. Also another exception would be because of injuries, the undressing must be carried out in a systematic way to avoid further injury and which even a conscious patient would not be able to perform.

In the example related by Anonymous from today Sept. 24th, it would appear that Anonymous needed assistance. In this case, I would have hoped that the female doctor would have explained why it was necessary for her to lower the underwear or better allow Anonymous first to lower the underwear before holding up the shirt. If I were Anonymous, I would have asked her why she was only inspecting. Diagnosing pain in the inguinal region is not performed solely by inspection. A hernia or inflammed lymph node or other painful mass may show nothing on inspection but can only be detected by palpation (touching) or standard hernia exam by palpating the inguinal ring. If this was a unsophisticaed student, I have seen a "nervous" smile while examining a patient so that might not have been totally bizarre.

One other thing that may be atypical of an encounter with a medical student is that Anonymous did not see the physician preceptor for that student. For the student's experience to be of value, there should be a physician to enter the room and check the student's technique and findings. ..Maurice.

 
At Monday, September 25, 2006 5:44:00 AM, Anonymous Anonymous said...

Anonymous for sept 15th. Please post a link to the stor of the nurse who was provided with "extra" care during her surgery. I would like to read it but could not find it googeling. Thanks

 
At Monday, September 25, 2006 4:02:00 PM, Anonymous Anonymous said...

Hi, anonymous from 24th Sept here.

Thanks for your thoughts.

To be honest the exam still bugs me a little, primarily as at a later follow up I saw a male doctor who did physically check the groin area - but left my underwear on.

I'm not suggesting that this student doctor (she may have just 'qualified') wanted to see me without my underwear but it does seem strange that she decided not to physically check me - as you point out in your reply.

A strain was the overall outcome anyway.

As regarding the smile - it didn't appear nervous but I could be wrong.

I did consult someone in the profession about the incident and they said it was probably that she lacked a 'caring, bedside manner' and I should just try to forget about it.

If it is worth noting, she was Chinese in origin and I have a work colleague who had similar experiences with an oriental doctor - in that the examinations were very 'functional.'

 
At Wednesday, September 27, 2006 5:14:00 AM, Anonymous Anonymous said...

reply to ann. sept. 25th, I googled "nurse patient gender modesty" or you can go to allnurse.com and go through the various topics. The issue comes up frequently where nurses make comments regarding not wanting caregivers of the opposite gender, but later state they are professionals and feel they should be accepted as such by patients. Dr. Maurice, from your experience do you feel there is a double standard in how male/female providers interact with male/female patients of the opposite gender?, I would include nurses in this. The topics has surfaced several times in this blog.
Regarding the above, as a male with a male doctor I have never even noticed if he wears gloves for genital exams. Obviously he wears them for DRE's, and I would assume all would wear them for female pelvics for the same reason. I wouldn't think they would have to wear them for male genital or female breast, but given the issue of what is appropriate or give the professional appearance, didn't know if they felt pressure to do so for appearance.
Dr. Maurice from your experience would you give us your opinion, have you observed providers including nurses having different opnions of modesty when they are the patient from when they are the provider, and have you seen different standards in the way opposite gender care is viewed depending on the genders of the patient and providers, in paticular do you feel there is the perception that male patients do not need the same level of accomidation.

 
At Thursday, September 28, 2006 7:58:00 PM, Anonymous Anonymous said...

ok so first of all...i m only 16 nd i had to go to a gynecologist for the first time because i missed my periods for 7months...i was sooo nervous nd scared that i started shivering...The gynecologist asked if she cud bring in my mom...but i felt extremely uncomfortable nd said no....I was asked to undress completely...it felt soooo weird cause i m a type of person who likes to cover up a lot nd like being modest...I dressed up in a gown nd waited for doc for half an hour...i was getting more nd more scared as the time passed...then she knocked on the door nd came in...she asked me questions like..:did i hve sexual intercourse etc etc.." i got more nd more nervous cause it was never true...She then asked me to lay down on the examination table nd she opened the front of the gown to check for my breasts nd i was having such a weird feeling...she pressed on them nd then she pressed on the other one...then she checked my nipples...nd after closing the front , she came back and reopened it...and checked my heartbeat.she never smiled...which made me more scared...then she opened the gown so tht she cud check my labia. at that moment...i was compltely naked lying in front of her...she didn't cover me up for 5 minutes...nd then she looked at my whole body nd found some black spots nd asked me to go c another doc for that....Then came the most scariest part ever...She asked me to move down a little...she still hasn't covered me from front...I guess she was enjoying looking at my my naked body...then she asked me to open up my legs as i was hesitating to open them up fully. she said c'mon i know u can do it...then i opened my legs as much as i had a potential to...she touched my genitalia...nd a weird feeling came by me...she touched my labia nd moved it so she cud see fully for any abrasions or lesions...i was looking at her face and checking her facial expressions...she didnt look up but her eyes were stuck between my legs. She stucked her fingers into my vagina and used speculum to check more of what is wrong. Then after she was done, she wanted to check for black spots on my body so she asked me to get up from the examination table. I got up.She ripped apart the back of the gown and it was like she almost took it off and there i was completely naked. I didn't know what to do or say...but i guess it was necessary for her to do that in order to examine me better. It was the first time ever when i had to stand up completely naked in front of the stranger...

 
At Saturday, September 30, 2006 12:32:00 PM, Blogger Maurice Bernstein, M.D. said...

Of course, I think that physicians bear different considerations when examining a patient of the opposite gender. It is only realistic in this era of medical boards' physician scrutiny and legal suits against physicians. And with regard to the detailed description of a gynecologic exam, there is no practical excuse or rationale for a patient to be fully naked. This is either a juicy made-up story or if a description of a true experience, for a physician to behave in that manner with no explanations, she should be fired. Hopefully, Anonymous from Sept. 28th will not return to her. ..Maurice.

 
At Monday, October 02, 2006 4:37:00 AM, Anonymous Anonymous said...

I guess I either wasn't clear with my questions or didn't fully understand your answer. What I meant to ask was.

(1) Do you observe a difference in the amount of concern or accomidation for a patients modesty depending on if the patient is male or female?

(2) Have you observed a difference in how the issue of modesty is applied or viewed when the caregiver (doctor, nurse, tech) becomes the patient.

Really enjoy your blog, provides a lot of food for thought and has helped me personally, it also has helped me understand some of the other side.

 
At Monday, October 02, 2006 8:09:00 AM, Blogger Maurice Bernstein, M.D. said...

To Anonymous from today Oct. 2nd: In answer to your first question, I have no direct observational experience as how other physicians behave since I am not inside their exam rooms. I do know that I have equal concern regarding modesty issues for both genders. This is also stressed to our medical students. In fact, at first the students' concern for the patient's modesty actually goes beyond the views of the patient. As an example, I have seen repeatedly that the student tries to examine the patient's feet, either gender, but without removing the stockings. And yet, when I join the examination,I find that the patients were quite willing to have the stockings removed if they were only asked.

With regard to your second question: The answer is YES based on my own personal experience, but more than this observation, it is a commonly understood in the medical profession that the doctor or nurse may be looked upon and treated as a so-called VIP (Very Important Person) patient. The patient may then get an incomplete examination because of the examining physician's unrealistic concern and discomfort about the modesty of the patient or their own modesty issues. With regard to nurses caring for a VIP patient, I think they practice in a more standard manner but are definitely more attuned and responsive to any orders given to them by their physician patient. ..Maurice.

 
At Monday, October 02, 2006 2:35:00 PM, Anonymous Anonymous said...

I was wondering if anyone has ever come across any issues with female personnel carrying out intimate checks on male patients.

Besides the issue of nudity, there is potential for a male patient to become aroused when examined by (or maybe just exposed in front of) a female Doctor or nurse. From personal experience this causes great embarrassment to the patient even though the examiner may stress it is a perfectly normal reaction and the patient may apologise several times.

Has anyone else had experience of this and how have they dealt with it?

And does anyone know if female (and I suppose male) medical students are 'briefed' about the potential for this to happen?

 
At Monday, October 02, 2006 4:05:00 PM, Anonymous Anonymous said...

Dr.M
Go back and read what you wrote on Aug, 6th about golves. I don't get it.

 
At Monday, October 02, 2006 8:38:00 PM, Blogger Maurice Bernstein, M.D. said...

To Anonymous who was concerned about erections during an exam, go back to May 1, 2006 comment and the subsequent comments on that issue. Also look through the entire thread comments for your other concerns.

For Anonymous who wrote: "Dr.M Go back and read what you wrote on Aug, 6th about golves. I don't get it." I didn't write anyhing about gloves on August 6th. What is it that you read in a comment and what about the comment is difficult to understand? ..Maurice.

 
At Tuesday, October 03, 2006 7:33:00 AM, Anonymous Anonymous said...

You wrote on Sunday Aug. 6, 2006 at 4:20:20 pm.
1996 Federation of State Medical Boards of the U.S.,Inc.
(Federation Bulletin in 1994)
Sexual impropiety comprises behavior, gestures, or expressions that are subjective, sexually suggestive, or sexually demeaning to a patient, including but not limited to:
#3 Examination or touching the genitals without the use of gloves.
It dosen't say for wemon only.

 
At Tuesday, October 03, 2006 1:15:00 PM, Blogger Maurice Bernstein, M.D. said...

I get what you are getting at: that examination or touching of genitals without gloves for a male examination would be considered "subjective, sexually suggestive, or sexually demeaning to a patient." Well, notwithstanding whether that is the opinion of the Federation of State Medical Boards regarding the examination of a male patient, unless the male patient expresses that the exam without gloves is "demeaning", there is nothing in the routine exam that is considered "subjective or sexually suggestive" and can represent an acceptable standard of medical practice. Of course, wearing gloves is also acceptable but may potentially impair the sensitivity of palpation. It is true, however, that a pelvic exam in the female without gloves is not equally acceptable. But it not unheard of to find gender differences in many venues, so to speak. ..Maurice.

 
At Thursday, October 05, 2006 11:14:00 AM, Anonymous Anonymous said...

This is some very personal stuff and it's important to remember that some people out of intimidation either of the situation, the practitioner or a parent or guardian may suffer silently no matter how embarrassed they feel. Practitioners should be sensitive to this. An earlier writer discribed what was probably a D&C proceedure which was understood and authorized by her mother who was present, routine to the Doctor but unfortunately not explained or sensitively done and therefpre mortifying to a pre-adulesent girl. Of course your not doing anyone a favor treating them differently if they are a doctor or nurse. They are the patient now. They know more and don't need as much explained, but aren't objective.

My personal problems in receiving medical care are about rushed careand office culture.I am hyper-sensitve and often need to be treated for more than one thing at a time, some times not understood by my Doctor.She will focus on this interesting aspect then rush off to see other patients without explaining things to me.Nurses don't take enough time either.If I take the trouble to make a list of concerns, take off my clothes to free the doctor to examine and free myself of the distraction from pain and itching so I wont forget, it is all wasted if the staff rush off after a limited exam. Limited by time and culture, not by patient needs and concerns.Bioethics? Listen to the patient attentively. Then explain everything,plainly. Teach him your language so over time each acquires the knowlege they need. You may have 10 to 30 years if you don't scare them away through callousness that you thought was professional detachment.

As far as nudity goes, everyone should be seen totally nude at least in an initial clinical exam so the practioners can see minor abnormalities of structure, colour, movement and gait.For me I can't wear unerpants if they aren't over a tee-shirt of coton or silk to protect me from the elastic or drawcord band and all gowns and drapes are annoying and some fabrics,laundry processes and disposable materials are torment for me. I decline them and prefer to be seen nude.I got used to it.I still get embarrassed, especially when a nurse or doctor makes a big deal of it. But if a Doctor or P.A. isn't O.K. with the nude body male or female, or if they are fixated on sexuallity or Political Correctness they may be in the wrong line of work or in this line for the wrong reasons.As I sit here, naked because it hurts far to much to wear clothes today, a vurtual prisoner because I can't go out naked for my modesty or public tolerance I can only hope that when I get to a Doctor's office or hospital I'll be given my dignity while I'm wearing no clothes. From what I've read on this page most patients don't feel they have dignity when they are fully dressed.

If I could have my wish it would be that every person, before a medical need establish for themselves how they will do what they must do to be seen by a doctor. Get used to the Idea early on that your going to be seen and be seen in every physiological state. Need a chaparrone, O.K. nude, underwear, gown, pyjamas or work around clothes as needed. The important thing is that this is medical need or we wouldn't be here. You'll all get used to it whatever side of the exam your on and it will be easier on everyone if you just get into a routine whatever your patients needs are.

 
At Thursday, October 12, 2006 3:32:00 PM, Anonymous Anonymous said...

I recently went to the dermatologist (for the first time) for a skin cancer check (I am male, Dr, is female). From what I have read, it seems like most people are examined naked. I was surprised that she did not check everywhere. I was in my underwear all of 5 minutes or less. When I asked about checking everywhere, she said that was not necessary. I am going back for a follow-up appt. If I ask to be checked everywhere, I may seem like a pevert. If I don't say anything, perhaps I am missing out on a complete check. any suggestions??

 
At Thursday, October 12, 2006 5:12:00 PM, Blogger Maurice Bernstein, M.D. said...

If you are concerned about the condition of the skin in the genital area, it would seem wise to go to another physician who will inspect that area. Your female physician, for one reason or another, doesn't appear interested, so I would advise not to return. ..Maurice.

 
At Thursday, October 26, 2006 9:56:00 PM, Anonymous Anonymous said...

i wanted an advice about something. I have some black spots between my legs and on my breasts. I am embarrassed to show them to my doctor. She asked me to visit a dermatologist. I have been delaying that for many years. I think I need to make an apptment with the dermatologist but I am nervous. Do you know if the dermatologist will ask me to take off my entire clothes or will I have a gone to wear???

 
At Thursday, October 26, 2006 9:59:00 PM, Anonymous Anonymous said...

Today I went to the doctor for a checkup. she was specialized in internal medicine. She did not check my breasts and nipples as I wanted her to. Do the doctors who specialize in internal medicine also do a breast exam?? If so,then do one has to completely undress?

 
At Thursday, October 26, 2006 10:03:00 PM, Anonymous Anonymous said...

I missed my periods for 5 months. I was told to visit a gynecologist. I am so intimidated. Can some one tell me how the exam is conducted? Thankyou.

 
At Friday, October 27, 2006 7:35:00 AM, Anonymous Paul said...

Hello Dr. Maurice,

You raised an interesting question a while back (Aug. 13, with your Wikipedia citation) about how personal history with being nude may affect one's attitude in the doctor's office. In my high school we were never forced to shower after gym class, although showers were available and some did use them. I was on the swim team, however, and also usually took swimming as my gym class, so as a result I was nude in front of my peers in the locker room with great regularity. And for what it's worth I have no problem with nudity in the doctor's office. I always follow the doctor's instructions, so sometimes it's been underwear pulled off at the last minute and and sometimes it's been totally nude. No big deal to me either way, although just getting nude at the outset seems more sensible to me as long as the patient is comfortable (and warm enough!).

Experiences of nudity among peers may be a factor, but I think even more relevant is the dynamic with the same-sex parent and with other adults or authority figures.

My family belonged to a swim club for many years. My father always took a nude shower after swimming, and regularly encouraged my brothers and me to do the same (but he never forced us to). While I rarely joined him and the other men in the shower, I certainly was instilled with the feeling that being naked in front of one or many males of any age was just a part of life, and after about age 5 I never really even gave it a second thought.

I'm also reminded that in high school, when I opted for swimming as my gym class, for part of the year I was teaching elementary age kids swimming lessons. We student teachers changed with the young kids. Sometimes there were giggles at the sight of our more developed bodies, but those died down after the first day, especially because we acted as if there was nothing to giggle about.

I would guess that some folks just didn't have any kind of opportunity to normalize the act of being naked around others, especially those older than them.

 
At Friday, October 27, 2006 7:52:00 AM, Anonymous Paul said...

I forgot to add - an interesting twist to this thread:

My old doctor used to belong to the same health club as me. He and I spent many hours nude together in the sauna. We were two of the regular gang who relaxed in there after working out, swapping stories and solving the problems of the world. I knew his body almost as well as he knew mine!

 
At Saturday, October 28, 2006 4:56:00 AM, Anonymous Anonymous said...

Nobody has talked much about race on this blog but I think, based on my experience, that there is a distinction between white/African American doctors and Indian/and or foreign doctors concerning complete nudity. I have had a lot of full-body skin exams and the only dermatologists to examine every inch of me were either Indian or Asian. Recently, I saw a very smart Indian woman doctor (I am male) and she openly discussed everything up front. She told me that because I'd had melanoma that she needed to examine me thoroughly. She asked if that was a problem. I said no but was very surprised when she told me to go ahead and get undressed completely. She and her female assistant stood behind me while I stripped. I turned around naked and the doctor came right up to me, very nice and not at all afraid, and began to examine me. I have to admit I was a little aroused and embarrassed but the doctor was so engrossed that I let her do everything she wanted and after a minute of watching them unaffected I relaxed. She even examined (basically fondled) my testicles. I didn't have any covering at all for at least 10 minutes and I even walked around the room naked. It was a very sexual experience for me but both women seemed nonplussed. I was very surprised at all of this because other female dermatologists have never come close to this kind of nudity. Two other doctors were not as brazen but did look at everything, and one was Asian and the other Indian. All the other so-called full-body exams were done by either white or black doctors and none looked at everything. I kept underwear on had a gown as well. Any feelings about this? Could be a coincidence but I've had 10 full-body exams, five done nude by ethnic doctors, the other five done very cautiously (and incompletely) by white/blacks. Is our culture preventing the appropriate exam? Or was that Indian American doctor acting inappropriately? I'm confused but that last exam was thorough and I don't believe anybody in the room was uncomfortable with it.

 
At Saturday, October 28, 2006 8:28:00 AM, Anonymous Anonymous said...

I have had prostate and bladder problems for years. In the past, I was prescribed Cipro which worked well at first but, later became ineffective. I was referred to an urologist by my HMO doctor. The urologist, a young woman, (younger than me, I’m 47) prescribed the usual medications (flomax, avodart, etc.) with no affect. She suggested I have a flexible cystoscopy. The day of the procedure I arrived with my wife at her office and was led into an exam room by the nurse. I was instructed to take everything off from the waist down and get on the exam table. The nurse pointed to a stack of paper drapes which I was to use to cover my genitals. I unfolded the drape which was about 4 foot square and got on the table wearing only a t-shirt which I pulled down as far as I could and covered the rest of myself with the drape. When a different nurse came into the exam room she pulled off the drape and tossed it into the trash can. She then told me, “You probably want to pull that shirt off or it’ll get covered with antiseptic and KY jelly.” I mentioned that the first nurse told me to undress just from the waist down, but she insisted that the shirt would get stained if I left it on. I pulled of the shirt thinking she would put a drape over my chest and stomach but she didn’t. She cleaned my penis with antiseptic soap and then injected an anesthetic jell into my urethra. This was very uncomfortable. A penis clamp was used, a cover (the size of a paper towel) was placed over my middle and then the nurse left the room. I was lying there naked, in some discomfort, embarrassed, and a little scared. I had been given a brochure about cystoscopy, but the description of the procedure was different from my experience so far. There was definitely no mention of a penis clamp. When the nurse returned she pulled the small drape off my genitals and removed the clamp. She held my penis upright in her gloved hand. The urologist and another nurse entered the room. At this point, I covered my eyes with my hands. I was never told what was happening or to anticipate any pain or discomfort. The procedure seemed to last forever. I know they measured the size of my prostate and examined inside my bladder. Finally, I could feel the tube being pulled from my urethra. When I finally looked up, all three women were still in the room. I could see I was covered with drops of KY jelly. The doctor tossed me a paper towel (to clean myself up) and began telling me her diagnosis from the procedure. I sat up on the table (still completely naked) and wiped my stomach and penis with the towel. I finally had to interrupt her and tell her I needed some time to calm down and that I would like my wife to be present when she gave her diagnosis (laser surgery of the prostate.) I moved my legs off the table and stood on the floor. I needed another paper towel and had to reach over to the table to get it myself. I was still wiping my self when the doctor said, they’d have my wife come in, when I was ready, and the three left the room. On the ride home I told my wife my experience. I never had any sense of any inappropriate sexual behavior but I felt they were very inconsiderate of my feelings and comfort level. My wife was very upset, as was I, and I did not return to the same urologist. By the way, my new Urologist, made a different diagnosis and I am having a bladder neck incision procedure next week.

 
At Saturday, October 28, 2006 9:35:00 AM, Anonymous Anonymous said...

It would be nice if nurses and doctors took into consideration the patients feelings. It seem most don't. They are more concerened with the physical. What they must keep in mind is mind and body go hand in hand. Patients have overcome great injuries with a positive outlook. My sugesstion to the last writer is make them let your wife in with you. There is no reason this should not be allowed and what ever reason they try to give you it's usually BS. They just want to get the job done and on to the next patient. Being kind takes time. Not only that it will give you emotional support. You will feel more like a person and not a proceuder. It is time to put the person back in the patient.
Dr. M I have a book for you. Its called Privilged Presence. You can find it on The Insitiute for Family Centered Care. Its a good read. I have introduced this web based center to 3 hospitals now and told them my story. I hope to effect at least some for the better. Readers If you are having trouble with a hospital and their level of thoughtfull careing go talk to someone. I chose the Director for Pastoral Care. Tell them about the web sight and about the book. Healthcare is a scary thing for most of us. There is no reason for anyone who has chosen this profession to be inconsiderate to the feelings of a scared patient!!
Kim

 
At Tuesday, October 31, 2006 12:31:00 PM, Anonymous Anonymous said...

Sat. 28, I hope you will take the advice Dr. Maurice has given on numerous occasions and comunicate your displeasure to the Dr. and or the health care facility they work out of. If not verbally, please send a letter to the people incharge so some other patient may not have the same experience. I still feel most people in the field are caring and compasionate, sometimes they just loose touch with how the patient feels. If you just change doctors, they won't be forced to consider the effect of thier actions. Women have made more progress in this area than men, we just take it and change doctors or just don't go. Women have done a better job addressing this directly. Us guys need to learn from them and bring the transgression to thier attention, otherwise we can expect more of the same. I hope you will at least send a letter, even if you conceal your identity for comfort. Good luck with your procedure and care givers, may they both be better than the last.

 
At Friday, November 03, 2006 4:54:00 PM, Anonymous Anonymous said...

Hi I was reading this blog and I noticed that someone in Europe said when he visited his doctor or had a physical exam it was normal to be totally naked. Is total nudity for physical exams common across Europe or common only in certain countries?

 
At Sunday, November 05, 2006 4:07:00 PM, Anonymous Anonymous said...

Follow up to: Saturday, October 28, 2006 8:28:42 AM post. I had my Bladder Neck Incision procedure along with a T.U.I.P last Thursday. I am in some discomfort, still wearing a catheter with a bag attached to my thigh. The catheter comes out tomorrow, thank God! I am surviving, using two different pain medications. The Vicodin is to die for! “Tuesday, October 31st post” mentioned writing a letter to the hospital to complain about the insensitive urologist who performed my flexible cystoscopy. I agree. I may still do so however, she is no longer employed at the hospital. I did inquire about the move (was she asked to leave, where did she go, etc.) but they would not give me any information. Attempts to “Google” her has been unsuccessful.
My procedure on Thursday was quite a different experience. Done in a surgical center, the nurses and attendants were very kind and caring. They went out of their way to explain everything to my wife and me. After being wheeled into the operating room I was anesthetized, my gown was lifted up over my chest and my legs placed in stirrups. My genitals were cleaned and then a drape that covered everything except my genitals was placed over my body. In the recovery room the nurses were very attentive. It was necessary for me to be totally and partially naked at some time during my recovery, but again, it was done very professionally. My wife was called in so she could be instructed on how to empty and clean my catheter. The nurse had to be there, while I was naked, and had to handle and clean my penis with my wife present. Because of some swelling in the groin, ice was used to help ease the pain. It was necessary for the nurse to relocate and replace the ice now and then. When it was time to leave (yes, this was an outpatient procedure) because of the catheter, my wife was hesitant to dress me herself. So she left to warm up the car as two nurses helped me out of bed and put on my clothes. I asked her later if she was uncomfortable having the nurses seeing me naked and handling my penis in front of her and she said no, not at all. It was clearly not the nudity or the handling of the genitals that set the tone of my hospital/doctor experiences but, the atmosphere create by the doctors and nurses. There was no embarrassment, no sense of being an “object” for the nurses and doctors. I was a person who needed physical and emotional assistance and in this case, I received both. The next few weeks will be a struggle. It can take up to four weeks to see the results of the procedure. Later, John

 
At Monday, November 06, 2006 8:04:00 PM, Anonymous Anonymous said...

I am a 44 yr old male and have chosen female doctors for my annual exams. Female doctors in my experience have better listening skills and will try to address my concerns. The prostate and genital exams are usually so quick that I cannot comment on what exposing myself to the oposite sex matters. The main concern is how important that the doctor makes me feel and how comfortable I am with the exam. It is much easier for me to undress and be examined by the opposite sex anyway.

 
At Wednesday, November 15, 2006 2:21:00 PM, Anonymous Anonymous said...

I was wondering if medical students ever have to carry out intimate examinations on each other? As surely this would give them first hand experience of being in a state of undress and therefore able to better understand patient feelings.

I'm pretty sure they still do here in the UK. I remember some years ago (at University) being quite friendly with a female med student who I would often bump into in one of the cafe's on campus. I distinctly remember her being concerned about having her breasts examined by a male colleague but she understood the rational for doing it. Likewise - she was supposed to perform a genital exam on the same male colleague.

I gather at that time (and still?) this practice was the norm in medical training - where students will pair up and examine each other. Surely this would be the best way of ensuring students know 'how it feels' to be naked/partially naked for medical purposes.

I don't know all the ins and outs of the training (not being a med student) but it seems a common sense approach - does it not?

Louise, UK

 
At Wednesday, November 15, 2006 3:32:00 PM, Blogger Maurice Bernstein, M.D. said...

Louise, as I already noted upon in my Sept. 14 2006 comment here "As I have noted on other posts, medical students don't practice breast and genital/rectal exams on each other. They learn the procedure and the proper communication with the patient by performing the exams on skilled both male and female teachers who are the subjects. These subject provide the students with detailed feedback about their technique and behavior. In the first and second years of our medical school the students rarely perform these exams on hospitalized patients. Most of this learning is done in the third and fourth years when they are performing their clerkships on the hospital wards."
Students do examine each other's chests and in the case of female students, they wear sports bras. The student's understanding of personal modesty is acquired during these student exams on each other but also from their own personal experience as a patient during physicial exams. ..Maurice.

 
At Thursday, November 16, 2006 4:42:00 AM, Anonymous Anonymous said...

I think many of us are thinking the same as Louise, while medical staff feel we should simply accept opposite gender givers or whatever comes our way, they have the same concerns we do when it comes to their own care. If they each had to perform these on each other in the class room and then discussed how they felt as the patient, it would drive home how we feel. What would they think if a female patient wanted to wear a sports bra during a chest exam. If they expect us to truely accept it isn't a big deal, they should be able to accept the same. While they also have some experience on thier own, they are all pretty young and likely had little reason for full physicals or procedures. They also do not get the focus or teaching on this issue during regular visits. Don't expect this to change, but I would be interested in hearing the results of asking for volunteers for this or even seeing the reaction if you told them you were considering it.

 
At Thursday, November 16, 2006 8:05:00 AM, Anonymous Anonymous said...

I am a male. I have always preferred female doctors. I've just always perceived them as more caring. As some others have said, I have had the distressing experience of a female dermatologist failing to check everywhere during an exam. In my case, it is particularly silly because I had several dangerous moles removed from my buttocks five years ago. Even knowing that, the last dermatologist I went to never asked me to remove my underwear. As others have said, I am really afraid to ask a dermatologist to check that area if she does not do it on her own. I'm just afraid it will make me sound like an exhibitionist.

I was so angry that I actually considered filing a formal complaint against her. Must I really risk death by skin cancer just because a female dermatologist is too prudish to look at my penis? Why on earth would anyone become a dermatologist if she has issues with nudity?

The first dermatologist I had was so much better. After checking the rest of me, she asked me to remove my underwear. Despite my being totally nude for several minutes, neither I nor she nor her (female) chaparone had any issues about it. Unfortunately, I can't go back to her because we live in a different state now.

I wish there was a way to know in advance whether a dermatologist does a truly thorough examination. I really don't want to ask about it. I just want the doctor to do the exam right so that I can leave her office knowing that I don't have any problem moles anywhere.

 
At Friday, November 17, 2006 7:33:00 AM, Anonymous Anonymous said...

We seem to be placing providers in a no win. Perhaps the dermatologist wasn't protecting her feelings, she might have been trying to protect yours. Many of the males posting here indicated they would have been uncomfortable with a female chaparone and female doctor with a full nude exam, you were offended they didn't do the full exam nude. The key seems to be they should ask, BUT when they don't we should tell them what we want. If she is offended by your asking for a full exam, then for sure she is the problem, just as she would be if the patient says no and she demands, it's still a personal choice.

 
At Friday, November 17, 2006 1:21:00 PM, Anonymous Anonymous said...

Surely in a situation (as directly above) the obvious thing would be for the practitioner to ask if the patient would prefer to:
a) wear some sort of cover for the exam or
b) be completely naked

That way the intention of the practitioner to examine everywhere is implicit from the start. Then those that prefer to be naked and just to get on with it - can. Those that feel better with some covering can have that while having everywhere checked.

However, I fail to see why a female practitioner - who is examining a naked or near naked male patient would need a female chapperone. As one poster stated they would be comfortable being undressed in front of their female Doctor - but less so if a female chapperone was present - seemingly for no reason.

Surely a chapperone is less appropriate or needy with female practitioners - Dr Maurice?

 
At Friday, November 17, 2006 8:28:00 PM, Blogger Maurice Bernstein, M.D. said...

Yesterday the chief dermatologist at the medical school I teach showed our 2nd year clincal medicine faculty how he educates his dermatology residents how to perform a full body examination of the skin with attention to patient modesty and bodily comfort. He uses an open-back gown worn by the patient and a large cover sheet. Each inch or centimeter of the patient's skin is exposed in small segments but in a systematic and thorough manner. A full exam can be performed in 10 minutes. The benefit of looking at small segments of bare skin is that the eyes and brain can achieve greater attention, focus and capacity to make fine distinctions of apparent abnormalities to be seen in the exam. This latter benefit is one which if not attained can lead to missed diagnoses—and a missed melanoma is not a very happy happening. You know, I think what he said ending his presentation to us is very significant. He told us that dermatology is a medical discipline where attention is not directed to the whole body as in other specialties but attention must be directed to small regions of skin at any one time. What that means, pertinent to the discussion on this thread is-- full nudity is an unnecessary and unwise approach to diagnostic inspection, inspecting in segmental uncovered areas is the more likely to do good both in terms of accurate detection and patient modesty. ..Maurice.

 
At Friday, November 17, 2006 8:47:00 PM, Blogger Maurice Bernstein, M.D. said...

With regard to Anonymous question: "Surely a chapperone is less appropriate or needy with female practitioners - Dr Maurice?" I can't give you an absolute answer since as Dr.Atui Gawande wrote in the journal article "Naked", the basis for this thread, standards of practice regarding patient modesty issues in clinical exams is not yet clearly defined but should be established. For the present, until there are such standards accepted, who should be in the room, if anyone, should be determined by a consensus discussion between the patient and examining physician regarding comfort or discomfort of either party, regardless of gender. ..Maurice.

 
At Saturday, November 18, 2006 6:21:00 AM, Anonymous Anonymous said...

I agree and disagree with the post of Friday the 17, It still comes down to personal choice. Just becasue we are patients, we do not give up the right to self determination. If I choose to have a dermatologist examine my body but choose to not include portions of my body, that should, and is my choice. While common wisdom would be to do a complete exam, as a rational adult I have that right. Having a doctor say I WILL or I AM GOING TO...as the post stated does not give me that option. The doctor should explain I am going to do the following you have the following options...I would add are you comfortable with that. Adults have the right to assume risk, however unwise it may be, it is still individual choice. Even in life and death choices it is the patients decision. I have known people who decline chemo to prolong life, a much more serious decision. You are Ok with being naked, fine, someone else says I'm leaving my underwear on and don't want that part done, not real wise, but thier choice.

 
At Monday, November 20, 2006 7:39:00 AM, Anonymous Anonymous said...

First off, let me say that I am the same poster from Nov 16 that was disappointed that my dermatologist did not check everywhere.

It does not matter to me in the least HOW a dermatologist checks everywhere as long as he or she does. I am perfectly fine with being nude throughout the exam or with being uncovered piece by piece.

In my view, the key is that different people are comfortable with different things. I think that this basic fact comes through loud and clear from this discussion. Some people absolutely do not want opposite-sex medical personnel viewing certain areas of their bodies. As the previous poster said, this should be the patient's choice.

On the other hand, there are some patients (such as myself) that are not the least bit embarrased by any amount of nudity in the context of a doctor's examination, and that care only about obtaining a full, thorough examination.

I had a discussion similar to this with my relatives a few years ago. One relative said that he greatly prefers to be completely nude during an examination. His reason was simply that being nude to begin with made him "forget" about his lack of clothing. He felt uncomfortable only when he was asked to sequentially expose every part of his body. He said that it made him feel like he was "flashing". Another person said that she was comfortable with nudity, but hated having the idea of a doctor pulling her underwear down.

It seems clear to me that there are a multitude of different attitudes about nudity in the context of a doctor's examination. That simple fact leads me to think that it should be standard practice for doctors to state what needs to be done and then simply ask each patient about their attitudes towards modesty, rather than wrongly assuming that there is such a thing as an approach that will be comfortable for every patient. The examination could then be done in a way that respects the sensibilities and concerns of each individual patient.

 
At Monday, November 20, 2006 1:17:00 PM, Anonymous Anonymous said...

Well said. I guess this is one time when perhaps we need to educate some of the providers rather than the other way around. Hopefully, if for no other reason than a good patient experience increases the bottom line, providers and facilities will listen.

 
At Friday, November 24, 2006 12:34:00 PM, Anonymous Anonymous said...

Recently my wife had an endometrial ablation (basically destroys the
lining of the uterus). I felt like I did due diligence by
researching the procedure and talking at length with the surgeon.
However, I neglected to research the anesthesia options, or spend any
time with the Anesthesiologist who I met only moments before
surgery. Before being wheeled off to surgery my wife put on a gown
which had two ties in the back - one at the neck and one in the small
of her back. I tied these for her as they were difficult for her to
reach. I know I tied them well. When she came back from surgery
they were both undone.

Question - why were they undone ? The gown only came down to above
her knees and could have been easily moved up for the surgeon. I
assume the Anesthesiologist would only need to attach a heart monitor
tab somewhere high up on her chest which might not need the upper tie
undone, and certainly wouldn't need the lower one undone.

Here is my question - is it standard procedure to strip the patient
as they move from the gurney onto the table and then put the gown
back on when they are returned to the gurney on the way out of the
Operating Room ? Or, is there some other reason these would have
needed to have been undone ? Help from anyone with knowledge from
the medical profession would be greatly appreciated.

 

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