MORTGAGE CRISIS AND DISEASE: STICKING TO BAD HABITS

The current mortgage crisis may be a reflection of human nature, sticking to bad habits. In the same sense, resolution or improvement of chronic medical conditions such as obesity, emphysema, alcoholism, drug addiction may likewise be affected by sticking to bad habits. Why do people stick to bad habits despite knowing they are potentially harmful? According to a study by Dr. Cindy Jardine, University of Alberta and reported in various sources including indiablitz.com, it may be that the public is undereducated in the details of why the habits are harmful and those professionals who want to break the bad habits of others need to look into the underlying social aspects leading to and continuing the habit. Failure to educate, failure to try to change the underlying psycho-social basis for the habit and what I find as the unethical promotion of bad habits will only make the consequences inevitable and likely untreatable. ..Maurice.

Graphic: Photograph taken by me June 2008 of lamp post sign.

MISSING COMMENTS FROM PATIENT MODESTY THREAD (B)

HERE IS THE SECOND HALF OF THE MISSING COMMENTS FROM "Patient Modesty: A More Significant Issue?"
DO NOT ATTEMPT TO MAKE A NEW COMMENT ON THIS MISSING COMMENT SITE. IT WILL NOT BE PUBLISHED. ..Maurice.





js md said...
gve,
Prevaricate?? About what? You lost me there.
I'm not against asking people's preferences. In fact I agreed with it somewhere
above.
But there's no point in asking unless I can do something about it, which is rarely the
case. I have no control over hospital personnel policy and most private offices only
have one tech available.
Providing gender preferences as a routine is just not practical for most institutions
and they have no reason to push it unless they see a big demand.
Monday, October 29, 2007 6:33:00 PM

Plain Jane said...
JSMD,

I think if you will go back and read my post you will find that I said that the
statistics show that as many as 10% of the physicians are involved in sexual
misconduct (or words to that affect). I personally consider “sexual misconduct” in
the medical situation to be criminal which is why I contend that it is an assault.
The Webster dictionary definition of assault is: “a threat or attempt to inflict
offensive physical contact or bodily harm on a person (as by lifting a fist in a
threatening manner) that puts the person in immediate danger of or in
apprehension of such harm or contact”. I refuse to apologize to anyone for my
feelings of what is assault and what is not. That is my privilege as you have the
privilege of believing that physicians have the right to touch women in any context
and manner they desire.

Another point that needs to be made here, the statistics that have been collected by
research groups regarding this very issue are the ones I have used, not ones I have
pulled out of thin air. The Vanderbilt study for example.

Anonymous on October 29th, do a Google search using the words, doctor, sex,
physician, sexual, fondling, misconduct, nurse etc. The best results seem to be with
two word combinations such as “doctor misconduct” to limit the search results to
more manageable numbers. I think you will be surprised at what you find.

JSMD, snide comments about my beliefs and comments are not going to change the
facts. The medical community is in need of reform. Patient modesty, male or
female, is more important than the rights of an individual wanting to work in a
field that will allow them to see and touch a member of the opposite sex unclothed.

Plain Jane
Monday, October 29, 2007 6:54:00 PM

Maurice Bernstein, M.D. said...
KCM, you wrote "I suggest that a lack of effective oversight and discipline is an
important part of this problem. Patients are not in a position to provide this
oversight and discipline, although I will no longer remain silent when transgressions
occur."

I would say that state medical boards in the United States have very little direct
effective oversight regarding the behavior of physicians within their offices. If I was
ever monitored by a representative of the California state board, maybe it was only
once, certainly not repeatedly and I am not sure how a board would accomplish this
task for all physicians on a ongoing basis. (What happened was a "patient" came to
my office for the first time requesting a narcotic but refusing to have a history
taken or a physical performed. Of course, I didn't give him any perscription and on
thinking about the event afterwards I began to be suspicious that the man was a
state investigator.)

My point is that, in fact, monitoring physician behavior within the office or exam
room on a ongoing basis can only be the work of the patients themselves. It should
be the patients who have a responsibility to report misbehavior of physicians to the
medical boards. A couple of such separate reports about a physician should then
initiate a beginning investigation. The patient provides the oversight by their
regular proximity to the physician and the state boards provide the discipline. And
KCM..good for you that you say "I will no longer remain silent when transgressions
occur." I suggest all patients should take that stand. ..Maurice.
Monday, October 29, 2007 7:25:00 PM

Anonymous said...
amr -- I don't know to what article are you referring.

Thanks for the allnurses blog posting. I've heard too many stories of the sort told by
the nurse on this post. I wish I didn't know now what I didn't know then.

My own opinion, for what it is worth, is that it was obligatory for the nurse to
inform the patient and law enforcement about what happened. Nursing ethics also
obligated her to report the nurses involved to the State Board of Nursing. Filing a
complaint with HIPAA and JCAHO may have gotten attention. Of course, as any
whistle blower, she would have run the risk of being treated as a pariah, forced out
of her job, and black balled, as happened to Roger Bojolais who blew the whistle on
NAASA and Morton Thiokol for the Space Shuttle Challenger disaster. At any rate, I
wish I knew the hospital where the event took place so I, my family, and friends
could stay clear of it. I suspect if hospital authorities gave such behavior a wink and
a nod, there were, and probably still are, far worse things happening in the facility.

I wonder how this nurse knew that the patient wasn't harmed by what occurred. Did
she conduct a follow-up? If the providers involved had so little integrity to do what
they did, only someone living in Pollyanna land would think they would respect
confidentiality rules. To illustrate, a friend of mine received surgery at our local
hospital awhile back. Sometime following the surgery, a friend of his told him that
a nurse at the hospital was talking to her friends about the size of his testicles. He
was so humiliated that he filed a complaint with hospital authorities who dismissed
his complaint, siding with the nurse who, of course, denied everything. He tried to
get attorneys involved without any success because even if they won the case, they'd
lose money.

I shudder whenever I hear someone attribute deviant behavior to "human nature."
Unlike you, many people confuse explanation with justification and use the "human
nature" assertion to dismiss, justify, or resign themselves to the deviance. Nursing
students did just this to defend the sexual battery I described in my last post. To
contend that behavior is a consequence of human nature is to contend that it is
biogenic -- i.e., caused by biological/heredity factors (the nature argument).
Furthermore, when people assert that a behavior is due to human nature, it is
usually presented as a tautology -- human nature causes the behavior and the
behavior is used as evidence that human nature caused it. I prefer the nurture
explantion to understand the deviance of the sort described by the nurse in the
allnurses blog. I suspect that the deviance as described was a consequence of both
culture and social structure -- of cultural beliefs, values, neutralization techniques,
rationalization, etc. that licensed the deviance concomitant with the
depersonalization, impersonality, and efficiency-orientation characteristic of
bureaucratic organizations. George Annas recognized these factors in "Judging
Medicine" in which he dubbs the hospital a "human rights wasteland" writing: "Civil
libertarians have little difficulty appreciating the plight of prisoners or mental
patients. But tell the average civil libertarian that there are significant and
unnecessary restrictions on the individual rights and liberties of patients in general
hospitals, and you are likely to encounter a blank stare. There are a number of
reasons for this. One is the genral misconception that the problems are minor, or
that crertain temporary restrictions on individual liberty are essentiasl if hospitals
are to treat sick people properly. An unconscious desire not to perceive ourselves at
risk may be another reason; we seldom seriously think we will ever be either
prisoners or mental patients. But almost all of us have been hospital patients at
least once, and each of us will be a hospital patient an average of seven times
during our life. By not dealing with the issue, perhaps we are seeking to avoid
thinking about our own future hospitalization, an event which is almost always
traumatic and undesired." Personally, I don't think Annas knew the half of it; were
he an active scholar today, he might consider at least some hospitals to be human
rights abattoirs.

Regarding filming patients or their body parts for educating healthcare providers,
my experience is that one can refuse without repercussions. To force patients to
provide such a service violates AHA standards, JCAHO standards, medical ethics,
and, possibly, civil law. If the hospital posts patient bill of rights documents and
advertises that it treats patients with respect and dignity, to put patients without
their consent on display to benefit others may be construed to be a contract
violation. And, to demand that patients provide such a service without
remuneration of some sort is patently exploitative.

What is particularily odious to me is a hospital inviting in a film crew to film
patients in emergency rooms and emergency vehicles without their consent. For
physicians, nurses. and hospital administrators to provide film crews with
information about patients and to give them access to patients' bodies without
patients' consent are obvious breaches of confidentiality. I used to prepare
healthcare facilities for JCAHO accreditation visits (when it was called the Joint
Commission for the Accredation of Hospitals). Back then, a facility would not be
accredited if it breached confidentiality in this way. The only case I know in which
such a breach was litigated occurred before the California Supreme Court. The case
is Ruth Shulman v. Group W. Productions, Inc.

I appreciate your call for research to answer the questions you pose. Unfortunately,
those who are interested in doing such research may not get approval for doing so,
especially if they are not physician researchers. About three years ago I wrote up a
research proposal to replicate with osteopathic students a study on ethical behavior
and beliefs done with allopathic students. My proposal passed muster with my IRB
but one individual at the osteopathic school made a unilateral decision to refuse me
access to students in classes. His refusal was not based on anything unethical but on
his impression that people in medicine never do things like that, this in spite of the
fact that I referenced everything. With the help of a faculty member at the school, I
was, nevertheless, able to conduct the research via e-mail. However, the response
rate was so low as to preclude generalization. Ironically, my analysis resulted in
findings favorable to osteopathic students. However, the most frequent response I
received was that physicians never do things like that.

js md -- You wrote the following: "When you contrast those percentages [4% to 12%]
with the percentage of married couples who have had 'illicit' affairs, somewhere
between 30-50%, it's hardly surprising." In other words, using the figures you give
(and assuming you're correct when you write, "these were consensual relationships,
not a legal assault in any way") the likelihood of American citizens having affairs is
between 2.5 and 12.5 times greater than having "consensual" sex with physicians.
Why else would one use this comparison unless it was to demonstrate that sexual
misconduct of the sort referenced in the Vanderbilt study was relatively rare?
However, although comparing adulterous affairs with the latter is not quite as
preposterous as "comparing physician sexual improprieties with criminal assaults,"
it comes mighty close. Again, the more apropos comparison would be with the rate
of "consensual" sex among those in occupations where power imbalances exist.

You also write, "So in short you are in very little danger of a sexual assault in
medical surroundings unless it is consensual." You may be correct, but this
conclusion is a nonsequitur; it does not follow from the facts you present nor from
the study cited by Vanderbilt unless one assumes that the latter included acceptably
valid measures of all types of physician sexual misconduct rather than only sexual
relations agreed to by patients.

In your Sunday post, you wrote, "It's hard to come up with a more feasible
methodology." I assume you are referring to the self reports cited by Vanderbilt.
Again, victimization reports have been shown to provide more valid measures than
self reports for determining rates of victimization and risk to citizens.

You also write, "Criminal prosecutions are rare as they should be IMHO [I don't know
what you mean by IMHO]. Most states do not criminalize these transgressions and I
suspect that felony convictions are rare even in the states that do. These are civil
regulatory offenses for the most part." If you are writing about what you dubbed
"consensual" sex, then I have no quibble. If you are suggesting that the dearth of
prosecutions and convictions is an indicator that few criminal sexual violations
occur, then I must take exception. A number of writers to this blog, the example I
gave (and I have many more), and the recent allnurses reference are all examples
criminal statute violations in Missouri. Some, at the very least, violate Missouri's
invasion of privacy law (565.253) which reads, in part, "A person commits the crime
of invasion of privacy if he knowingly views, photographs or films another person,
without that person's knowledge and consent, while the person being viewed,
photographed or filmed is in a state of full or partial nudity and is in a place where
he would have a reasonable expectation of privacy" (MRS, 1995: 228). These laws do
not exempt healthcare providers. And, that they are not reported, prosecuted, or
lead to conviction do not make them any less a crime.

Finally, you write, "I'm not sure . . . that your assumption of misconduct is greater
when intimate exposure is present is correct . . . There is evidence that the
incidence of offenses is greatest in the field of psychiatry where there is no
exposure." Mine was not an "assumption" but a hypothesis grounded in opportunity
theory and differential association theory. In other words, I presented an empirical
question -- one that demands to be tested. Regarding the rate of offenses in
psychiatry, I think we are speaking primarily about what you call "consensual" sex,
which results from, I would propose, the exploitation by psychiatrists of patient
transference. I mean to include all forms of sexual misconduct in my hypothesis.
Findings resulting from a test of the hypothesis could be just as significant if the
hypothesis were rejected, confirmed, or found to be contingent on other variables.
c. ray b.
Monday, October 29, 2007 9:07:00 PM

Anonymous said...
I believe quite a few of us gathering here are beginning to ask ourselves, "What
does Plain Jane want?" Let me take a shot at answering this.

Jane believes she has a right to same-gender care beyond the provisions for it that
already exist. If she should ever find herself with a male doctor, nurse, or med tech,
chaperones of her sex are not sufficient protection as Jane needs to be shielded
from what's potentially going on inside the male mind. She views this is very logical
and calls thoughful comments by a male physician, "snide". Jane never pays any
attention to the fuller or more immediate issues. She never acknowledges anything
regarding the double-standard in patient modesty care stacked heavily against men
and could care less about the behaviour of female nurses who, in their
overwhelming numbers, are probably committing common battery against male
patients at the rate of a thousand-to-one over sexual "assaults" on females by male
doctors. She brings a myopic point of view here and is angered when told to put her
complaint into perspective with the bigger picture. Jane, the help you need with
this problem isn't going to be found here.
-- CHUCK McP
Monday, October 29, 2007 10:08:00 PM

amr said...
Dr. B – I do not believe it would be good to not publish anonymous entries –
although having a idea of how many people are contributing is of value.

JSmd – Oct 29 – On a few occasions now you have seemed to want to downplay the
possible scope of the problems. Because you haven’t heard about it in hospitals you
have been at, doesn’t mean that it doesn’t happen in those very hospitals. It could
merely be that you have not heard about it.

It was only because my wife’s 1st surgery failed that I even would be here today
talking about these issues on the web. It was never on my radar screen. Now it is,
and frankly, I could have easily lived the rest of my life not knowing what I know
now.

Voy: There was a point where I thought the voy blog entries were suspect. Now, I
believe they are, in a more “earthy” manner, representative of the modesty
conversation going on here and as represented in allnurses. BTW, the “stories”
although from nurses, show some very unprofessional behavior. I’m afraid that the
population that is attracted to nursing and the $$ paid for the work and
responsibility, is not the greatest.. I do not want to single out nurses however. I
believe the transgressions are made by a cross section of those in the medical field
caring for patients.

Here are some links. If memory serves, mention of this blog was made at some
point.

Voy 1

Voy 2


C Ray B –

IMHO = In my humble opinion (its blog short hand)

I’m referring to the piece you wrote that was published by Dr. Gott that you
mentioned in your blog entry of Friday October 26.

Filming: It might violate standards, then institutions such as UCLA have figured out
how to get a variance from those standards. The whole field of tele-presence and
using cameras in the OR suite to manage the case flow, where the feeds go to a
central location, or can be called up on the internet, are becoming prevalent. So
without the consent up front, the institution is refusing to treat. The consent is
hidden in the legal document a patient is required to sign on admittance to the
hospital. It is the same kind of justification for non-consensual pelvic exams – well
the patient signed the release, so it must be ok. As far as the bill or rights are
concerned, nowhere in the published bill of rights for UCLA does it say that a
patient may refuse being photographed or videoed. The reason being is that they
FORCE the patient to give up those rights as a condition of treatment. With the
new OR suites with internet and video streaming, there is more $$ incentive to
make sure the patients modesty rights are abrogated for the benefit of the
institutions bottom line. (By the way the UCLA release in my view would protect, or
bypass, the Missouri privacy law, as I suspect it bypasses the similar law in CA as it
pertains to filming, including in the OR, where we have clearly established that the
patient is as some point in a state of full or partial nudity. It should not however
protect the hospital against the behaviors we have been discussing.)

I agree with you about the film crews – if it happened to me or a member of my
family, I would sue.

Research paper: I am EXACTLY suggesting that this study be done by physician
researchers. I remember reading a book 30 years ago (?) about a surgeons 1st year
as a resident. In that book at some point, I remember him talking about comments
about patients breasts in the OR. This treatment of patients has gone on for quite a
long time, if not forever. The question I am asking is one that Dr. B has postulated
(and JSmd), how wide spread are these issues? How do we begin to asses this unless
we start somewhere, formally?

-amr
Monday, October 29, 2007 11:28:00 PM

Anonymous said...
JD here (just so I don't forget) The issue with filming, the one experience I had with
it, that I know of sheds a little light on an issue that goes throughout the medical
system. I was in for surgery, I was on the table, IV in, only in a gown, all the stuff
rolling and a nurse comes in with a clipboard full of consent forms, this is consent to
provide, etc. and matter of factly goes through the forms and hits on the is consent
to film...I froze up a little, the nurse noticed my hesitation and said its just a
formality they almost never do it, I signed it and have regretted it ever since. The
issue here is to wait until that point puts the patient in a position of making these
decisions in a state of elevated stress and anxiety, I was already stressing over the
procedure, over the prep, the stupid gown I was in....in business you can contest a
contract signed under duress...yet in medical care it is acceptable. This issue runs
parrell to the issue of who is primarily responsible for patient modesty and more
specifically, determining the level of concern. Everyone knows patients are
intimidated and have a problem stating their concerns, it has been stated numerous
times patients tend to suffer in silence...if providers know this, and choose to
ignore or not take positive steps to address it, even though they are in the position
of power in a relationship that is widely acknowledged as being unequal....is this
not a problem on the providers side? I think it is mainly an issue of convenience and
this is the way we always do it, providers don't want to create a situation they have
to deal with, so they just pretend it doesn't matter. JD
Tuesday, October 30, 2007 5:41:00 AM

Maurice Bernstein, M.D. said...
JD, I would never, never sign any document while lying on the table in the operating
room. All the papers are part of the informed consent and yes you are under duress.
And more than that..you actually may have already been given a pre-op sedative
medication and are under its effect. I am not a lawyer but in my opinion you can't
possibly meet any legal standard for informed consent under these circumstances.
Just don't sign it and request to speak with the hospital administrator.
..Maurice.
Tuesday, October 30, 2007 7:54:00 AM

gve said...
jsmd,

what I am saying is why do YOU not gather some evidence of your own? The fact
that you cannot change anything does not stop you gathering the evidence, you
could at least inform yourself with the reality of how people feel.

Publish what you find IN HERE, prove us all wrong, but at least ASK!
Tuesday, October 30, 2007 11:09:00 AM

js md said...
c ray b,
Thanks again for your thoughtful comments. I'm not sure we really disagree about
anything significant. I am using the term criminal in the narrow sense of one who
has been convicted of a crime that exposes the perpetrator to incarceration, which
usually means a felony. There are much more general uses of the term which I think
others are using.
amr, I of course know that my not being aware of an adverse event in the hospital
means it didn't happen. No hospital would want to publicize these events. Likewise
it doesn't mean it did happen, though there might well be enough talk about it that
I would have heard about the incident.
There are several much worse exchanges on voy from supposed nurses who abused
their trust and invited others in to see a patient or talked about them openly by
name. I have no way of knowing if they are real though I would say the posters did
seem knowledgeable about nursing in general.
Tuesday, October 30, 2007 12:51:00 PM

amr said...
Chuck McP – Oct 29

The issue of modesty is a continuum. And it is situational as I have mentioned
before. It is not just the nudity that is at issue, but it is also the issue of feeling
safe and cared for. It is difficult sometimes to separate the message from the
messenger. Plain Jane might appear very impassioned, in her point of view, but it
is on the continuum as far as the desire for modesty and same gender care. If she
has had an experience where she has been hurt by a male provider, I can see where
she would be coming from. Her issue is modesty as well as needing to feel safe.

It is the case that it is very hard to prosecute doctors for misbehavior, so I can see
her point that the system is rigged in the favor of the doctor not the patient. If that
is the case, then an oz of prevention is better than a pound of cure. But patient
abuse (modesty violations, etc) occurs by both male and female providers. So if it
were the case that society provided the method where all health care professionals
were quickly held accountable, then the threat of being disciplined would, by its
very nature, help to mitigate the situation, and the feeling of helpless on the part
of the patient would be lessened. When you do read stories in the paper about some
doctor being prosecuted, I have never read one where it is suspected that it was the
doctors first offence. If sorting out the “bad apples” were only easy…..

When I was at my low point with all of my modesty issues regarding my wife and
her illness, I was saying a lot a sweeping things about doctors in general. At one
point, my wife pulled me up short by reminding me that her father, brother and
sister-in-law were all doctors, and that medicine has kept her father, my farther,
her brother, her son – alive and it good health. I was being personally offensive –
though she understood where my heart was. So I can understand and appreciate how
“violations” can cause very strong emotions. I believe I had a form of PTSD, which is
hard to deal with.

Labeling all of some category is prima fascia wrong, and perhaps is the issue that
caused the strong comments against Plain Jane.

--- amr

ps. What’s wrong with me – I have no links to post…. ;-)
Tuesday, October 30, 2007 1:05:00 PM

Anonymous said...
amr -- Thanks for telling me what IMHO means; I think I figured out what PTSD
means; post-traumatic stress disorder. Right?

Dr. Gott's publication was on December 12, 1994.

I think I'm getting stupid or stupider; I'm having a difficult time visualizing what's
going on at UCLA. Are there cameras in the OR -- sort of like surveillance cameras -
- that capture all that goes on in the OR? If so, are the films made used only to
educate healthcare students or are they available to all on the Internet? And, if a
patient crosses out the consent to be filmed section of the legal document about
which you write, s/he will be denied OR service except in emergencies. Am I
correct? Will the patient also be denied service in other hospital departments if
s/he doesn't accept the invitation to be filmed?

My own experience is that hospitals use duplicity and guile rather than coercion to
ensure that patients sign away their rights. They train receptionists to tell the
patient that the document you are to sign "gives us permission to contact your
insurance company and gives the physician permission to treat." A cursory reading
of the document, especially in teaching hospitals, usually reveals that the patient is
signing away one or more rights as well.

The emergency room and emergency vehicle intrusions tend to be different from OR
intrusions. Unlike the latter, hospitals cannot obtain patient consent (nor loved
ones' consent) to film in emergency situations. Nevertheless, a day doesn't go by
that one cannot see patients on "Trauma: Life in the ER" being filmed without their
consent while they are stripped naked and catheterized. Group W. Productions, Inc.
got into some trouble when Ruth Shulman took exception to being displayed in front
of a camera person and ultimately on television without her consent. Personally, I
believe the emergency helicopter company should have been sued in addition to or
in lieu of the film company. At any rate, the CA Supreme Court decided that
Shulman had a reasonable expectation of privacy while in the emergency vehicle.
Ironically, the court also decided that what happened to Shulman was newsworthy,
so Group Productions did not violate her rights by airing her story without her
consent but did violate her right to privacy by filming her in an emergency vehicle
without her consent. The case was remanded back to a lower court with these
words, "Defendants . . . took calculated advantage of the patient's 'vulnerability and
confusion.' Arguably, the last thing an injured accident victim should have to worry
about while being pried from her wrecked car is that a television producer may be
recording everything she says to medical personnel for the possible edification and
entertainment of casual television viewers. [A nurse recored a conversation with
Shulman without her knowledge while she was pinned in an automobile.] For much
the same reason, a jury could reasonably regard entering and riding in an
ambulance -- whether on the ground or in the air -- with two seriously injured
patients [She was with her brother.] to be an egregious intrusion on a place of
expected seclusion."

Regarding nonconsensual filming of patients, I had an interesting exchange with
Johns Hopkins CEO Edward Miller and its president Ronald Peterson. Prior to the
airing of ABC's "Hopkins 24/7" the two of them posted the following on the Internet:
ABC film crews were "granted . . . unhindered access" to Johns Hopkins Hospital
"virtually around the clock, over a three month period." At the same time, Miller
and Peterson asserted that, "First and foremost, you should know that even though
we had no right of review of what ABC taped, we and ABC were exquisitely
sensitive to issues related to patient privacy and confidentiality. As you watch the
programs, keep in mind that we insisted upon and secured absolute protection of
our patients' privacy at all times. We required ABC to obtain written consent from
any patient appearing in the broadcast." Now, usually I don't attribute to malice
what can be explained by stupidity, but I'm not so sure in this case. It didn't add up
that ABC could be given "unfettered" access to "private corners" in the hospital for
three months and, at the same time, not intrude on patients' privacy. Somebody
was speaking with a fork in his tongue. So I wrote to both Miller and Peterson.
Miller wrote back, "You are correct that the patients did not give permission prior
to being filmed" in the emergency room episodes. And Peterson equivocated when
he wrote, "Even in the Emergency Room, consent was obtained in advance whenever
possible." Of course both bypassed my question about film crews viewing patients in
the emergency room who were not filmed. So much for being "exquisitely sensitive
to issues related to patient privacy and confidentiality."

Dr. B., I have a couple of questions for you. A preface first. You've frequently
mentioned your efforts to sensitize medical students to the dignity and privacy
needs of patients, a noble gesture which is greatly appreciated. Most nursing faculty
whom I know do the same. However, most of the people in the field with whom I
speak contend, in effect, that a resocialization process begins almost immediately
when they begin to practice. They, in short, internalize a set of beliefs, values, and
norms antithical to their academic instruction and ethical codes. Some of them
even pick up and use pejoratives they were taught to eschew while in school,
pejoratives such as GOMER, GOMERE, F.L.K., AMF, crispy critter, M.U.O., worm,
and the like. Use of these terms demonstrates the contempt they have for patients
and help sanitize subsequent dehumanization of patients. Do you anticipate this
resocialization and do anything you think might reduce its likelihood? Do you ever
casually or formally follow up with students to find out if your instructions have
stuck? c. ray b.
Tuesday, October 30, 2007 9:04:00 PM

Anonymous said...
In the last few days, a couple of incidents appeared among the postings here that I
feel need special re-focusing.

Thanks to c.ray b.(Oct. 26, 8:22 AM) for the first of these and AMR for the
latter(Oct. 29, 12:29 AM). I'm sure c. ray had one of his "very negative viceral
responses" when he encountered the first and AMR assures us that the second event
"turned his stomach". You can go back to the original posts and their links to review
what happened but I'd like to rework the scenarios with a simple gender swap to see
how they play out. (Thanks in advance to c. ray b. for letting me borrow
his passage for the experiment.)

"Several years ago, I gave a presentation to a nursing ethics class on the ethical
treatment of patients. The professor, who was very credible, reported that he and
several other male nurses were preparing an anesthetized woman for surgery when
one of the guys pulled on the woman's labia, stretched it out, and commented on it's
length and size. The class of males responded in the same way as the other male
nurses who were preping the patient; they broke out in laughter. I asked the
professor if he reported the incident. His response was 'no'. Following the class
period, several of the male nursing students, who had been practicing LPNs for
some years, approached me and defended the battery as being a legitimate
response to stress."

Now, a gender adjustment to an allnurse.com blog entry. It involves the experience
of a male nurse with two years on the job.

"A few nights ago, a young woman patient came to our MICU on a vent... since all
her clothes had been cut off by ER, she was exposed. Her vagina was quite large,
honestly. One person made a comment about... I thought that would be the end of
the situation. Nope. A few minutes later... about 8 male nurses aides, RTs, etc.,
came in to "see it". The male nurse taking care of the patient LET THEM LOOK!...
And, that wasn't even the end. A group of the guys, nurses/aides/RTs, were out in
the hallway talking about it and laughing... people were coming in and lifting up
her gown and stuff..."

So what kind of advice does this troubled male nurse get from at least one of his
fellow male nurses?

"Poor newbie. Don't go run around and tattle on your co-workers...the patient was
not harmed in any way. This type of behaviour has been common in every OR, ICU,
and ER I've worked in for the last 21 years."

I would like to suggest that if the genders of patient and nurses had been reversed
as I have just demonstrated, these two incidents would not have ended up as
internet blog fodder but as pieces of investigative journalism in some national
magazine. The double standard in all aspects of male patient modesty is quite
sickening. WJB
Tuesday, October 30, 2007 11:14:00 PM

Maurice Bernstein, M.D. said...
c.ray b., Ahh! You have touched on the issue that perplexes those of us who teach
first and second year medical students clinical medicine, humanistic behavior and
professionalism. The problems start in the third and fourth years and goes on thru
internship and residency and that is (as I have discussed on previous threads) the so-
called "hidden curriculum". In the first and second years, the students have no direct
responsibilities regarding the diagnosis and treatment of the patients they take a
history and perform a physical. They usually spend 1 1/2 to 2 hours with the
patient. However, as they move up in the medical education chain, things change.
They have far far less time to do a history and physical, they have more
responsibilites to their now many patients and they are guided in their training by
different "role models" than those physicians who taught them in the first two years.
These physicians are senior residents and attending physicians who may have lost
some of their ethics training or humanistic behavior (or never learned them) and
the students or interns are faced with following their guidance even though in
conflict with what we have taught them or being graded down or worse.

Fortunately, medical schools are aware of this hidden curriculum
but it would require substantial changes in the medical education system to remove
it. What we are doing as facilitators is to warn the students about the upcoming
potential of a hidden curriculum and trying to provide resources for the students to
turn to if they find they are being pressured into behaving wrongly because of their
poor role model superior's demands or examples. ..Maurice.
Tuesday, October 30, 2007 11:35:00 PM

js md said...
c ray b,
You have shocked me, and that's not easy to do. I have always assumed that all
these ER shows (which I've never watched) obtained specific permission before
filming. Hard to believe that they don't and can get away with it. Your tale about
Hopkins is frightening.
Unfortunately HIPAA is mostly about medical records and bills and doesn't
specifically address issues like this to my knowledge. It needs to be amended to give
more protection to direct patient encounters. At the very least permission to take
photos should be required to be obtained separately and not buried in a general
form. I may in fact write my congressmen about it. If I do I'd like to quote your
post. If you object let me know. You can do so thru Dr. B. if you prefer.
BTW (by the way) if you google any common abbreviations their meaning will pop
up quickly.
Wednesday, October 31, 2007 8:43:00 AM

amr said...
C Ray B – Yes you got ptsd…

WRT to cameras at UCLA, I attempted to cross out that section of the contract for
my wife’s 2nd surgery. We were told by the director of admissions that the contract
cannot be changed, and no lines could be crossed out. If we could not sign the
contract as is, then my wife would not be admitted. In calling our Dr. he assured us
that no filming or pictures (or camera feeds) would be done. The new hospital being
built at UCLA will have full AV in ALL of the operating rooms. This includes several
camera placed around the OR that can be remotely controlled.

Here are 3 representative links and articles

University Hospital in Alabama

One maker of OR suites and the AV equipment that makes this all happen

UCI New Release about new OR suites 2003

This process has been going on for about 7 years now – all new hospitals being built
will have this technology to remain competitive. In the ORTV site, you will see how
extensive the invasion of the OR has become. You will see pictures of auditoriums
full of people watching operations as well as a full discussion of how the operations
can be recorded and work can be posted on a web sharing site.

What isn’t said is that non-medical geek techs are now a part of the process. They
can dial in an OR to see what is going on. The cameras are not turned off – so a
patient when fully exposed will be visible to anyone dialed into the OR from
anywhere in the world. These streams can be captured on the receiving computer. If
you think it is bad that health care professionals make comments or inappropriately
touch patients, this is absolute remote voyeurism. Being in the computing business
all of my professional life, I guarantee you that this sort of thing is now going on
every day.

Although UCLA new hospital is not on-line, some of the OR’s in the current main
hospital have cameras that can be remotely accessed by a Dr. from anywhere in the
world. Thus, the techs that support that function also have the same access.

WJB: The abuse does in fact cut both ways. There is a voy entry that speaks to a
young college co-ed going to the university hospital for an appendectomy. She had
extra large vaginal lips that she was self conscious about. Apparently, her female
nurse would bring in male “people” into her hospital room to gawk at the girl.

So, this stuff goes on, and it probably is going to get worse with the ability to
remotely gawk at patients. What can be done to bring national attention to this
issue? The lobbyists are hard at work as we speak working on behalf of the medical
companies internationally. This is BIG BUSINESS.

-- amr
Wednesday, October 31, 2007 10:08:00 AM

Anonymous said...
amr -

Of course, the abuse cuts both ways. I'm just saying that the
number of incidents where the male is the victim is hundreds to one over the
incidents where the female is the battered party.

Your example is not the best one
to support "abuse cut(ting) both ways". Here we have a FEMALE nurse running the
show. I doubt it would have gotten started if she wasn't hawking the tickets to show
this girl's extra large vaginal lips.
-- WJB
Wednesday, October 31, 2007 12:53:00 PM

Anonymous said...
it is not important whether abuse or battery happens more to males or to females
the point is it shouldnt happen at all. This is disgusting and every person in the
room who knows this behaviour is going on should be prosecuted. Those who know
and do nothing are just as guilty as those doing it. Until medical staff stand up for
thier patients nothing will happen. Is it any wonder people like me are fast turning
against the medical proffession as a whole.RM
Wednesday, October 31, 2007 3:33:00 PM

Anonymous said...
It's absolutely important that we note that this disgusting behavior is happening
more to men than women because men have far less protection against it. The
vast majority of the nurses, med-techs, and admin staff, who are the backbone of
this patient battery, are female and the target is most often a man. The sisterhood
protects its own. WJB
Wednesday, October 31, 2007 4:01:00 PM

amr said...
WJB – I shortened the story, she was actually “viewed” by males first in the hospital
as a part of her acute phase and surgery. They spoke about it in the snack room,
then once she got to her hospital room, the hospital workers (nurse etc) started this
process. The male and female nurses were willing participants in the “fun”. In fact,
some may not have been nurses per se.

Girl Friend – Appendix

As far as your comment about males being abused over females more, a “violation”
can only occur if the male wants / requires modesty. Each patient should be
approached with that assumption. However, it is not true that all patients (male or
female) are concerned about modesty. If the concern is not there, then there can
not be a violation.

JSMd – Oct 31 – Now you are talking !!! (about the congressman) HIPAA has never
been about patient “bodily privacy”. And neither is the hospital and especially not
in the OR. Whenever I have spoken to Drs about this issue of “privacy”, I get blank
stares, and the reference is always made that the patients ID is always protected.

I do want to underline however that the basic technology changes happening in the
OR are really neat, and this is a huge train that has already left the station. There
is no question in my mind that the ability to train future docs, confer with
specialists, and having patient data available quickly, are all outcome benefits that
cannot be denied . But it is equally true that camera and video feeds are simply
trampling upon patient privacy and modesty rights. If the patient were awake in the
OR, medicine would never be able to take advantage in this way. Further, without
outside limits being placed upon medicine, this trampling of our rights shall
continue.

JSMD, I think that you will find that the lobbyists are already hard at work to make
sure the interests of the hospital comes before the privacy / modesty issues of the
patient.

If….. the patient was truly given a choice to opt out, by an explicit informed
consent that they could sign “NO” and still get treated, AND the hospital respects
the “NO”, then I would have absolutely no problem. However, as you can see by the
U of Alabama link, there is a room full of video feeds being monitored, with people
just walking on by a huge window into the monitor room. There was no attempt
made obviously to even make the monitor room private. The rational is that the
room is already in a private part of the facility so within that part of the hospital,
it can be “public”. Well, what business is it of those that are just walking by for any
given case to be on display for them to see, even casually.

I have another link of a study where the monitors are placed in the doctors lounge,
where all sorts of people gather, including medical sales reps.

With the monitor room on “public” display in both examples, it is simply a concrete
example of how these hospitals simply give no consideration to patient modesty
within the OR suite. Simply put, the purpose of the monitor room is to increase OR
through put (get more surgeries done) because the OR is a big profit center.

So taking the U of Alabama as an example, if a patient refused to have cameras on,
what procedure could be put in place so that the patient’s rights are protected.
Being very cynical here, there is no way a patient, even if they opted out, could in
fact be assured that their wishes were met. The more these systems are put into
place, the more institutionalized the problem is going to become.

So, JSMD, I would submit that if the hospital has no problems putting these systems
in, where the patient is monitored anyway, then having an outside camera crew
come in (for the hospital to make more money) is already on the slippery slope, so
why not; come on down folks, have a look at our sick and dying patients, after all,
we do protect their “privacy”.

Ahhh – that felt good…. ;-)


-- amr
Wednesday, October 31, 2007 4:13:00 PM

Plain Jane said...
WJB

You said that males are victims of medical abuse hundreds to one as compared to
women. Would you clarify more what you mean please?

Unfortunately abuse of both genders happen. This abuse is unacceptable for anyone,
regardless of gender. One of the reasons that male abuse is not as recognized as
medical abuse towards women is that men are more reluctant to share "those" kinds
of stories with others. It is becoming more recognized and that is a good thing. My
husband has agreed to only have male caretakers when he needs any kind of medical
treatment. Of course, this could mean that we have to be a bit more creative in
getting adequate care for him. This pact with my was before I became active on
this blog.

Plain Jane
Wednesday, October 31, 2007 8:30:00 PM

Anonymous said...
I hear you loud and clear, RM. And, I agree with you but, at the same time, I also
disagree with you that "it is not important whether abuse or battery happens more
to males or to females." Patient abuse and battery by those in the "helping
profession" have moral/ethical, legal, social, political, and economic ramifications.
Morally/ethically/legally, few would quibble with your assertion, "the point is it
shouldn't happen at all." However, that males are at greater risk (assuming that is
true) may be important socially, politically, and economically. To illustrate, I plan
to allert my cousin's husband to what has been communicated on this and other
blogs and to the research that has been done on the subject. He is an investigative
reporter responsible for uncovering, among other deviancies, the sexual abuse of
women at the airforce academy in Colorado. At one time, he was a member of the
team on "West 57th Street" a CBS program long since taken off the air modeled
along the same lines as "60 Minutes." He is, unquestionably, a no-nonsense type of
guy. Were he and/or other investigative reporters to know that males are at
greater risk than females, he would also know where to focus his investigation in
order to maximize the likelihood of uncovering provider miscreance. Similarly,
were he to know in what hospitals abuse and battery were most likley to occur, he
could focus his attention on those hospitals rather than taking shots in the dark.
The more information one has about a phenomenon, the more likely that person
will be able to measure it, observe it, establish its causes, and act to ameliorate
the problem.

My sister runs a domestic abuse shelter. I'm sure she would agree that it's not
important whether abuse happens more to females than to males, the point is it
shouldn't happen at all. However, knowing that it is much more likely to happen to
females than males has led her to organize the facility she runs more for females
than for males, although she also provides accommodations for the few males that
seek the program's help.

Thank you amr -- a disturbing report, indeed. I will phone the quality control officer
at UCLA and an authority at the Joint Commission to find out what they have to say
about the matter, if anything. Depending what I find out, I will alert my cousin's
husband to the matter as well. Your state representative might also be interested in
your experience and what's going on. Our political leaders often obtusely cover their
eyes, ears, and mouths unless they perceive themselves or their families as possible
victims of norm violations. For example, apparently Missouri Senator Sam Gaskill
was humiliated because he was compelled to wear the ubiquitous gossemer-like
hospital gown. So he introduced a "Dignity Gown" bill (HB 128) designed to require
hospitals to give patients the option of a more substantial gown. Of course, the
lobby efforts of the Missouri Hospital Association kept the bill from going anywhere,
but at least he got the attention of hospitals some of which now provide gowns that
allow patients a modicum of dignity.

js md - You don't need my permission to quote me but you have it anyway.

I studied HIPAA standards right after they were implemented. That was a few years
back and I've forgotten most of what I read. But, I do recall at the time that I too
got the impression HIPAA focuses on privacy of records although some of what was
written I thought could be construed as referring to personal privacy. My impression
was that to deliberately communicate to members of film crews (or anyone else not
involved in patients' care and treatment) information in patients' records without
patients' consent violated HIPAA standards. It was also my impression that exposing
members of film crews to patients' naked bodies without their consent could be
construed as being an illegitimate communication of private information about the
patient. A document that promises patients privacy but does not encompass the
latter in its conceptualization of privacy would be a strange document indeed.

There is no question in my mind that patients who are unconscious or DOA do not
give their consent before being filmed. There is no question in my mind that film
crews in the ER sometimes film people who don't give their consent to broadcast.
There's no question in my mind that members of film crews, by virtue of their mere
presence in the ER, sometimes observe patients, without their consent, in various
stages of undress but never film them. In their e-mails to me, Miller and Peterson
conflated consent to film and consent to broadcast, justifying the former by pointing
to the latter. If one assumes that to film someone without prior consent is as
privacy right breach, then Peterson and Miller were suggesting that it is acceptable
to violate people's right to privacy if after you have done so, you ask them if it was
alright that you did so and they respond affirmatively. Of course, if ER patients are
asked to consent to being filmed by someone with authority, it would be
reasonable, if not advisable, for them to do so whether they want to or not.
Ironically, physicinas on the Hopkins program made my case for me. One observed,
"We see patients in their most desperate situations." Another proclaimed the
following about ER patients: "They're scared. . . They're willing to do just about
anything we ask them to do. . . They're afraid they're going to die."

I should add that the Hopkins program premiered August 30, 2000 and ran until
September 27; that was before HIPAA was implemented I think. I e-mailed Miller or
Peterson (I can't remember which) after HIPAA was implemented about his opinion
of the Hopkins program in light of the new HIPAA standards, but I never received a
resonse.

At a risk of being ad hominem, my impression of both Miller and Peterson is that
they would have prospered as Nazi concentration camp wardens. Their statement on
the Web and communication with me was full of self-serving platitudes and revealed
how oblivious they were to the inherent contradictions and convolutions in their
reasoning. Peterson revealed a chilling perverseness by commending parents for
putting their child -- a victim of sexual abuse -- on public display. What kind of
parents would display their abused children to public scrutiny and what kind of
people would commend them for doing so? Were these parents to have voluntarily
spread the news of their child's abuse outside of a hospital's sanitizing milieu -- had
they spread the news in their community, for example -- people of principle would
have probably viewed their actions as barbaric and contemptuous. And, Miller
defended Johns Hopkins following the death of Helen Roche in that facility. Roche, a
24- year-old healthy college student, had accepted $365 to participate in an
experiment on the effects of irritants on healthy lungs. Following Roche's exposure
to the irritant hexamethonium, she began to cough and experienced shortness of
breath. She was dead within weeks after her lungs failed and her kidneys ceased
functioning. The Office for Human Research Protection (OHRP) temporarily
suspended all human-subject research at Johns Hopkins Medical Center for failing to
follow proper ethical guidelines. The OHRP found that Hopkins' physicians had not
obtained readily available information about the relationship between
hexamethonium and lung toxicity and had ignored the warning that it was for
laborastory use only. Furthermore, the consent form signed by Roche incorrectly
described hexamethonium as being a "medication," failed to indicate that
hexamethonium was not approved by the FDA, and did not warn participants about
the connection between hexamethonium and lung toxicity (Begley, Sharon and
Donna Foote. 2001. "Trials and Errors." Newsweek. (August 6): 38-42.) In response
to OHRP -- rather than admitting to, apologizing for, and expressing remorse over
Hopkins' mistakes -- Miller cavalierly dismissed Roche's death with these words:
"Hopkins has had over 100 years of doing clinical trials. . . We have had one death
in all of those years" (Begly, Sharon. 2001. "Dying for Science." Newsweek. (July
30): 36)) I must confess, although I am a peaceable man, I shudder to think what I
would do were Roche my child.

WJB -- You may very well be correct. The people with whom I've casually spoken to
about the matter agree with you. So I thought I'd test out the hypothesis that people
would judge male healthcare providers who behaved inappropriately more harshly
than female providers who did so. I created a scenario of abuse, held everything
constant except the sex of the provider, and randomly assigned the two
experimental conditions to 28 students. Surprisingly, there was no significant
difference in the harshness of students' judgements of the male and female
offenders. However, I did have an open-ended question which revealed that students
appeared more suspicious of the male provider's motives than the female provider's
motives.

Although experimental in nature, this was a quick and dirty study which amounted
to no more than an appetite wetter. Given the time and inclination, I'd like to do a
more thorough study with a larger sample from the community instead of limiting it
to students at the university, increasing the number of scenarios organizing them by
seriousness of infraction, and establishing the levels of validity and reliability of the
instruments used. -- c. ray b.
Wednesday, October 31, 2007 10:37:00 PM

Maurice Bernstein, M.D. said...
c.ray b, I am very pleased that you have available contacts that can help obtain
information and perhaps unpublicized details regarding the various aspects of the
patient modesty especially in the hospital environment. In addition, that through
your actions you may be able to initiate investigation into aspects of hospital
and/or employee behavior that has been of concern here. Your presence on this blog
may change simply gripes into something more constructive and hopefully more
effective to solve these concerns.

By the way, I found an interesting article in which hospital video/audio study
apparently utilized with the specific permission of women in labor demonstrated the
lack of concern for the woman's modesty in addition to other poor practices
associated with the repeated vaginal exams clinically indicated during the labor
process. The article,"An observational study using audio-video recording to assess
care given to vaginal examinations during labour" by Hayward, Harris and Greene
was published in the Journal of Obstetrics and Gynaecology v.23 issue 2 Supplement
March 1 2003.
The Abstract follows:

Vaginal examinations are intimate and potentially embarrassing experiences,
particularly so during childbirth, where they are a common procedure. Few
investigations of vaginal examination procedures in labour have been undertaken,
yet it carries risk of emotional trauma and infection, a potentially avoidable cause
of perinatal mortality. As part of our ongoing investigation of care in labour we
undertook a detailed analysis of vaginal examinations during labour. Informed
consent was obtained for observation of direct care of 20 mothers in labour by
audio-video recording, within a single delivery room. A protocol was developed
from professional guidelines to assess quality of care during vaginal examinations
with emphasis on dignity, hygiene, contamination and communication. Experienced
clinicians performed the examinations. On average a vaginal examination was
undertaken every 2 hours with a total of 59 examinations (minimum one to
maximum eight) during 123 hours of labour. Table I summarises the findings. No
vaginal examination conformed to the 'ideal' model. Mothers were exposed
unnecessarily during the procedure, with only 11 examiners using simple measures
to maintain the mother's dignity. There was a lack of basic hygiene standards, with
contamination of the room post-examination. Points will be illustrated with video
clips. ..Maurice.
Wednesday, October 31, 2007 11:08:00 PM

Anonymous said...
I have worked in reality TV in both production and post-production and can assure
you that concerns for patient modesty and privacy take a back seat. Medical reality
shows are basically relentless camera affairs. Enormous amounts of footage are shot
by freelance camera crews who are expert at hanging tight with a developing
situation to capture the tense moments. What allows these shows to be different
from the medical TV documentaries of the late- seventies and early-eighties is the
fact that digital recording has totally replaced film. In the early days, when film was
a great expense to the production, the camera was never just left on. More pre-
production control and approval was required to make the cost of production
feasible. Now digital tape cost 1/20th what 16mm film did and the camera is
always on. The process of securing releases almost never begins until subjects are
recorded. Then production assistants go rushing to the subjects to try and obtain
signatures on standard forms. If they refuse, identity is sought and a follow-up is
made by a higher-up in the production staff with an inducement of money. If the
footage is unique enough, further concessions will be made to blur faces, etc. While
this is going on the video dailies are being loaded to electronic systems, viewed,
and edited. Obviously, these videos often include nudity and graphic medical
situations. Even if permission is not secured, footage of subjects with blurred faces
who can not be identified by
voice, often find there way into a cut acceptable to broadcast because the subjects
identity is deemed protected. Of course, behind the scenes, dozens of production
and post-production staff have all the footage to view. Occasionally, you'll hear
something like, "Hey, I think I know that guy. He lives in my neighborhood." Anyone
on the post
editorial team with a USB memory stick can walk away from an Avid or FinalCutPro
system with some juicy moments in a minute. While this usually doesn't happen, the
fact that a patient will be exposed to perhaps a dozen or more program workers is
always a given. If you find yourself in an emergency situation with a camera crew
intruding, the best thing to do is immediately shout your obvious annoyance. The
bigger the scene the better. All reality show producers have delicate arrangements
with hospital facilities. There primary business can not be compromised. If there is
tension,
the hospital administrator who is always assigned to the crew will have to get them
away from patients. Of course, if the patient is in no shape to protest, this is a
mute point.
If you are ever witness to a gross invasion of someone else privacy, the best thing to
do is become very vocal. Block the camera's field of view with your protest. Hospital
security is usually tailing the crew. Disregard their efforts to bring you into line
despite threats. They too know that the hospital must come off well in the show and
that primary medical business comes first. So you will almost always disrupt the
immediate proceeding and cause the attending invasive footage to become
unuseable in the storyline being developed. Also, beware of indy reality shows that
use crews wearing legitimate news network jackets. I know a producer who used
this ploy as news crews are usually more respected. It actually backfired a few times
when the logos came into shots and had to be obscured. Sorry, I can't mention
particular shows here. It's a small business and there are some previous medical
postings that I have made in this blog that could serve to give me away. DIRTY
REALITY
Wednesday, October 31, 2007 11:29:00 PM

amr said...
Dr. B –

I believe USC is ahead of UCLA on this whole issue of AV in the OR. Is there any way
you can find out how USC handles these issues.

1. Where is the monitor room?
2. Where do the feeds go from the OR?
3. What internet / intranet security is in place?
4. How is the recorded surgeries stored?
5. How much of the before / after surgery is caught on tape?
6. How is consent obtained from the pt?
7. What are the opinions of the technology from the docs?
8. What thoughts about “privacy” / “modesty” of the patients are considered by the
docs?
9. Can the pt opt out of cameras in the OR (or anywhere else)?

Law frequently lags behind technology. However with this advent of tele-medicine,
the industry lobbyists have learned and are hard at work to make sure that the law
is changed or not made to allow the technology to be deployed. The net is full of
articles about this.

For what it is worth, the LA Times article I mentioned earlier shows the OR at the
new hospital at UCLA is using STORZ OR systems. Anyone who wishes of course can
go search on “STORZ OR1”. I thought that talking about these things was useful, but
I am learning that it is true that pictures are worth a 1000 words. So seeing what is
going on (right in front of our eyes) gives weight (maybe) to the situation.

The links below: The first is a rendition of what the OR suites will look like as part
of a PR effort for the new hospital. The next two are examples of on line articles
put out by one of many industry magazines (now on-line). This one is called “Virtual
Medical Worlds” – a monthly new service for the Virtual medical community. These
are examples from 2003. These articles spell out how the technology is being used
as of 2003. In the first VMW link it says in part: “The surgical staff at St. Michael's
hospital has already put these capabilities to good use with a live broadcast from
the OR1 facility last month of a laparoscopic splenectomy and a laparoscopic colon
resection. Over 190 surgeons and residents from across America and Canada
participated in the broadcast, which incorporated a daylong training course.”

You have to know that there were a lot more people involved in the set up and
monitoring of the technology than just the 190 medical personnel observing for the
day.

I sure hope that the patients were given an opportunity to give true informed
consent. In any event, this is just one example of why I state that the OR is
becoming a public (NOT PRIVATE) room. Is it “reasonable” to state that it is still
private because the feed was to medical personnel? This is a modern day extension
of medical presentations given to large medical conventions. Are those conventions
public or private? What about the staff supporting the St. Michael’s hospital day
long demonstration. I do not define privacy as the type of person watching as being
the determining factor.

UCLA Rendition

VMW 1

VMW 2

These are no longer isolated occurrences or demonstrations.

On the website: WebSurg , you can find links to permanent auditoriums that are
set up for doc training – in Europe. I’m sure it is also being done in the US. In the
surgeries saved on this site, there are several examples where patients are shown
undraped as part of the discourse on patient positioning. There are other cases
where draping is done for sterile field, but does not cover the pt breasts that are
not involved in the surgery.

And finally: England 1800’s

The tradition of observing operations is well engrained in the lexicon of medicine.
From the beginning it is clear that doctors’ took advantage of patients for the
benefit of the advancement of medicine. So the issues here are not new, it is
merely the scope of the invasion of privacy because of the capabilities of the
internet that I suppose is noteworthy.

I still don’t have to like it. And what is so interesting to me is that, as stated
before, I’m not personally modest. But as a matter of principle, if I’m not given the
right to opt out, I’m opposed to the forced invasion of privacy. (My definition of
privacy – not the medical worlds definition of privacy.)

- amr
Thursday, November 01, 2007 10:25:00 AM

Anonymous said...
Just as an aside, HIPPA does address, both directly & indirectly, a hospitals
responsibility for confidentiality of photographic or video images of a patient in
160.103 and 164.514.

JCAHO also strongly recommends a clear informed consent before any patient
photography or video is done, and for those facilities that include it in their general
"consent to treat" document, they recommend a separate explanation of the specific
provisions.

The AMA policy on patient's rights clearly recognizes a patient's right to refuse any
treatment or procedure without prejudice to any other treatment they may need -
in other words, you can't use the threat to cut off or refuse all treatment to coerce
them to consent to a specific treatment or procedure they don't want.

My recommendation is that if you go to a facility, READ the admission forms and
cross off & initial anything you don't agree with. If the admitting clerk objects,
don't argue with them - they're just doing what they're told & aren't high enough on
the food chain to make those decisions. Instead, ask that they summon a hospital
administrator and their HIPPA compliance administrator. Calmly and rationally
explain your concerns, and if they refuse to budge, ask them this: "I just want to
make sure I'm clear on this. Are you refusing to provide me needed medical care
because I refuse to consent to an unnecessary and unrelated procedure?" If you don't
get a satisfactory response, follow up with: "My research indicates that your refusal
would be in direct conflict with both AMA and JCAHO policies, and a possible
violation of my privacy rights under HIPPA. I just want to make sure that's your final
position before I contact the appropriate agencies to register a complaint and follow
up with the local news media."

Hospitals hate bad publicity of any kind & the media feeds on it (if it bleeds, it
leads, and corruption & human rights violations are a close second). Who could
resist a nice juicy headline like "Hospital refuses patient needed medical care
because patient wouldn't agree to let them take pictures/video of their naked body"
or "Hospital policy violates patients' right to privacy".

The bottom line is that the patient should have the right to refuse any procedure
without prejudice to obtaining other needed medical care. IMHO, except in very
rare instances, a health care facility would have a very tough time justifying that
photographs/video of a patient's procedure were necessary. Just my $0.02....

TT
Thursday, November 01, 2007 10:37:00 AM

js md said...
I have begun to review HIPAA regulations online. I cannot find any specific
references to photos or videos being taken. Anything applicable would be couched in
terms of identity protection. I still believe that HIPAA laws were not promulgated
with the intent of protecting specific patient encounters, but only to protect the
information generated. If anyone knows differently please let me know as it would
make a huge difference. Anyone know offhand what congressmen were instrumental
in drafting HIPAA? Kennedy perhaps?
Further does anyone have any idea what percentage of hospitals routinely film in
the OR? I think it is uncommon. My hospital has a separate permission form for
photography, but I do not know of any state or federal regulation that requires it.
Any input would be greatly appreciated to help in pursuing this.
As an aside, let’s keep straight that modesty is a much narrower issue than privacy
which is a much more general and all inclusive topic.
Thursday, November 01, 2007 11:45:00 AM

Anonymous said...
TT

I like your added 2 cents. But I agree with jsmd that we need to find the actual
wording in AMA and HIPPA and collect everything that supports this point on one
posting -- sorted out, set in caps, and written as a type of declaration a patient can
present at the moment they hand back their consent forms with crossed- out
sections. Of course, you also have to be able to cancel the prodedure while their
legal reviews it. How often will that be possible? Your own HMO is going to come
down on you regarding possible charges the hospital decides to bill for on your
choice to cancel at the last moment, etc. They may refuse to pay, twice. The
medical community always uses these moments to enforce their vested policies.
KYLE
Thursday, November 01, 2007 1:22:00 PM

Maurice Bernstein, M.D. said...
The AMA Code of Medical Ethics with regard to filming with intent for public
viewing is as follows:

E-5.045 Filming Patients in Health Care Settings

The use of any medium to film, videotape, or otherwise record (hereafter film)
patient interactions with their health care providers requires the utmost respect for
the privacy and confidentiality of the patient. The following guidelines are offered
to assure that the rights of the patient are protected. These guidelines specifically
address filming with the intent of broadcast for public viewing, and do not address
other uses such as in medical education, forensic or diagnostic filming, or the use
of security cameras.

(1) Educating the public about the health care system should be encouraged, and
filming of patients may be one way to accomplish this. This educational objective is
not severely compromised by filming only patients who can consent; when patients
cannot consent, dramatic reenactments utilizing actors should be considered instead
of violating patient privacy.

(2) Filming patients without consent is a violation of the patient’s privacy. Consent
is therefore an ethical requirement for both initial filming and subsequent
broadcast for public viewing. Because filming cannot benefit a patient medically,
and moreover has the potential of causing harm to the patient, it is appropriate to
limit filming to instances where the party being filmed can explicitly consent.
Consent by a surrogate decision-maker is not an ethically appropriate substitute for
consent by the patient because the role of surrogates is to make medically
necessary decisions in the best interest of the patient. A possible exception exists
when the person in question is permanently or indefinitely incompetent (eg,
persistent vegetative state or minor child). In such circumstances, if a parent or
legal guardian provides consent, filming may occur.
(a) Patients should have the right to have filming stopped upon request at any time
and the film crew removed from the area. Also, persons involved in the direct
medical care of the patient who feel that the filming may jeopardize patient care
should request that the film crew be removed from the patient care area.
(b) The initial granting of consent does not preclude the patient from withdrawing
consent at a later time. After filming has occurred, patients who have been filmed
should have the opportunity to rescind their consent up until a reasonable time
period before broadcast for public viewing. The consent process should include a
full disclosure of whether the tape will be destroyed if consent is rescinded, and
the degree to which the patient is allowed to view and edit the final footage
before broadcast for public viewing.
(c) Due to the potential conflict of interest, informed consent should be obtained
by a disinterested third party, and not a member of the film crew or production
team.

(3) Information obtained in the course of filming medical encounters between
patients and physicians is confidential. Persons who are not members of the health
care team, but who may be present for filming purposes, must demonstrate that
they understand the confidential nature of the information and are committed to
respecting it. Where possible, it is desirable for stationary cameras or health care
professionals to perform the filming.

Physicians, as advocates for their patients, should not allow financial or
promotional benefit to the health care institution to influence their advice to
patients regarding participation in filming. Because physician compensation for
participation in filming may cause an undue influence to recruit patients,
physicians should not be compensated directly. To protect the best interests of
patients, physicians should participate in institutional review of requests to film.
(I, IV, VII, VIII)

Issued December 2001 based on the report "Filming Patients in Health Care
Settings," adopted June 2001.

Last updated: Jan 07, 2005

..Maurice.
Thursday, November 01, 2007 2:19:00 PM

js md said...
Well the AMA got it right. There's nothing even remotely like this in the HIPAA regs
I've seen. They mention pictures only to include them in the long list of protected
information that can reveal identity. I looked up TT's reference, but one is
definitions, the second is about accounting. If I missed something, please post a
link.
Unfortunately the AMA policy is not binding on anyone. If it was institutions couldn't
get away with filming before asking for permission. Hopefully the latter is
uncommon especially in ERs. Most of us will never encounter it.
But I do believe the only real cure would be to get HIPAA amended to cover these
situations explicitly. I think I will try, but it will take much more than me to
accomplish even a review.
Thursday, November 01, 2007 4:59:00 PM

Anonymous said...
Dr. B., thanks so much for the reference to the Hayward, et al. study -- very
informative as is your post about the AMA's code. I wonder if the American
Osteopathic Association takes a similar stance.

The AMA Code regarding filming is well written but it seems not to consider the
possiblity that a film crew may intrude on the privacy of patients not being filmed
in the process of filming those who have given their consent to be filmed.

Js md -- What are you going to do to try to get HIPAA amended to cover these
situations? If you plan to begin with a letter, maybe some of us who have
participated on this site can do the same. And maybe we can share any
correspondence we have with HIPAA on the matter.

I phoned JCAHO in the late '90s and spoke to a rep. about the organization's position
on filming without consent. The rep. told me that JCAHO expects only that the
public be notified via the media or signs placed at choice spots in the hospital.
When patients come to the hospital that has communicated its intent to film, it is
assumed that they are, ipso facto, giving their consent to be filmed. I was also told
by the rep. that they had received many complaints about filming without consent
but had not acted on the complaints. c. ray b.

DIRTY REALITY -- A nicely detailed description. I didn't know there was so much
involved in the filming and editing of episodes or that money so readily changed
hands.
Thursday, November 01, 2007 7:06:00 PM

Maurice Bernstein, M.D. said...
I hope that everyone has recognized the change that has occurred thoughout the
now 600 comments on this thread. There has been a more recent migration from
disclosure of the visitor's own personal modesty experiences and reactions to a more
general discussion of the modesty issue itself in terms of the ethics and laws, the
epidemiology of what appears to be a disorder of the healthcare system and
currently there is discussion on how to treat and try to prevent it both from an
individual and a group action.

Personal modesty concerns and its relationship to how medicine is practiced, like a
disease (cancer, diabetes or rheumatoid arthritis as examples) does not necessarily
directly affect every person in society but as many diseases, there is some impact
on us all in other terms. For example, the example diseases noted above may affect
the allocation of healthcare dollars, the effect on the maintainence of a professional
or work force and ripple effects on the management of other conditions. Similarly,
how the institutions and government react to the modesty views of some might be
an indication or indeed affect their responses to other issues that these and other
patients may have.

The telling of individual stories is important to characterize the problem. The
discussion of the broader issues is even more important to fix the problem.

I just wondered if you noticed. ..Maurice.
Thursday, November 01, 2007 7:47:00 PM
Anonymous said...
Yes, Dr. Bernstein. I've been noticing. On Sept. 12th, 2007, I posted here that you
had 419 entries since opening in May of 2006. That was an average of 1.16 per day.
I mentioned this because on the previous day there were 11 postings. Now, in the
seven weeks since, the total number has risen by an unbelieveable 45% to 600!

In the last couple of months, I've seen this blog mentioned on a half-dozen different
sites from voy to allnurse.com. The quality and focus of what's being posted here is
far ahead of any other
blog and the influence is strong and exceptionally devoted. It only took one posting
to bring a dozen strong responses to Dr. Keagirl a couple of weeks back.

Less than two months ago, you were suggesting a blog of registered posters needed
to be formed for a head count. Forget about it. This blog has broken so far out in
front that it would be impossible to catch up to what you've accomplished here. And
there's no need to count heads. The numbers, in the hundreds or even thousands,
would represent nothing against total population and they don't have to. The posters
here represent probably less than a dozen "types" with slightly different key agenda
related to patient modesty. Human nature is not so varied that these "types" don't
cover a great portion of the general population's feelings. The woman's movement
started with a few activists who actually spoke for millions from day-one but simply
lacked a forum to begin their push for change. I feel something of the kind may be
taking form here.

If a blog can expand 45% in under two months, it will soon be totally out of hand.
Like it or not, all eyes are focusing here. There are somethings that need to be
done ASAP to increase the organizational effectiveness of this site and to correctly
handle the rising volume. I believe (blog technology permitting) that you need to
set-up a home page on the current URL with "links" to at least a half-dozen sub-
heading
threads. They would cover: Modesty and the OR, Modesty in the ER, Modesty and
Videotaping, Modesty and Gender Sensitive Care
in Exams and Testing.... I know you could come up with a good breakdown. Your
spinning-off of the "Sexism" thread shows that your recognize this need. I do want
to stress that the sub-headings need to be covered by a home page on which all are
listed.

One of the problems this blog is now facing is the competition between thread lines
of thought. As volume grows, this becomes maddening. It's also important that all
that has been previously posted (the thousand or so entries of "Naked" and "Patient
Modesty") be sorted between the new sub-headings. I know it's a massive job but
these early entries have much that needs to be retained. When this job is
completely sorted (and previous redundant posting deleted), I envision hard-hitting
and focused threads of 150-250 entries... and growing. Anyone needing to bring the
argument to the attention of a medical provider might push a "print" button and
have a lot of good response ready to go on any particular view of the subject.

I, for one, would be willing, (after you designate sub-headings) to help with the
sorting of the previous postings. I know there are others here who would also help
with that task. What do you say? Can it be done? How could your readers help?
-- WJB
Thursday, November 01, 2007 11:23:00 PM

Anonymous said...
This is the applicable section of 45CFR160.103:
from HIPPA 160.103 (definitions)
Protected health information means individually
identifiable health information:
(1) Except as provided in paragraph (2) of this
definition, that is:
(i) Transmitted by electronic media;
(ii) Maintained in electronic media; or
(iii) Transmitted or maintained in any other form
or medium.
(2) Protected health information excludes
individually identifiable health information in:
(i) Education records covered by the Family
Educational Rights and Privacy Act, as amended, 20
U.S.C. 1232g;
(ii) Records described at 20 U.S.C.
1232g(a)(4)(B)(iv); and
(iii) Employment records held by a covered entity
in its role as employer.

It defines what is protected health care information and specifically refers to
information that is transmitted by or maintained in electronic or any other form of
media. This would include any photographic or video information.

Basically what it means is all information transmitted by or maintained in any form
is protected under HIPPA.

Sections 164.5xx specify under what conditions, how much and for what purpose
protected health care information may be disclosed and and what permissions or
consent is required. It is very long and convoluted (hey, it's a government document
- no big surprise there.)
As I get a chance to go through it, I'll pull out the relevant sections & post them
here.....

And yes Dr. Bernstein, I did notice the change in direction of the discussion and
welcome it. In the engineering world we call the process root cause failure analysis
- the short description is finding and fixing the cause of a problem as opposed to
simply treating the symptoms. Part of that process is taking interim steps to
minimize the adverse effects until the long term solution can be implemented.

Interesting concept. eh? Sounds a whole lot like what a good physician is supposed
to do.....

TT
Friday, November 02, 2007 12:09:00 AM

Maurice Bernstein, M.D. said...
First I want to thank WJB for the supportive comments about this blog and thread. I
also would thank those other visitors who agree with WJB.

But I have to make it clear to all now that I don't want to turn the blog or the
threads into an activist blog or thread to take on one view and the purpose would
then be to promote it in a biased fashion and attacking other conflicting views.
That is not what I intended for a bioethics discussion blog. For your information,
the majority of my blog visitors are going to other threads and multiple important
bioethical issues even back to 2004 postings and that tells me that I don't want this
bioethics discussion blog to be looked upon as mainly a "patient modesty blog"
because it isn't.

I really should explain why I take this stance. I have been chairman of a community
hospital ethics committee for a total of two hospitals since 1986 right up to the
present. A common denominator for virtually all ethics committees dealing with
conflict resolution, which is one of our tasks, is to do so by mediation of the conflict
between the stakeholders and not to make decisions for them. We do this through
methods which include educating the parties regarding ethical principles and
consensus and the law. We listen to the views of both sides but keep our mind open
to their responses and never force our views on others.
So you see I have been fully immersed in bioethics for all these years and I come
away with the approach of open discussion and education but not to take sides. This
applies to the issue of patient modesty. In fact, I would have liked to find visitors
contributing comments who represent opposing views to the majority writing here
and to present evidence why they find that it would be impractical or otherwise to
mitigate some of the personal modesty concerns through approaches already
presented.

Of course, my visitors might observe that there appears to be some ethical issues
which could be interpreted that I am showing some slant. Yes, I am against torture,
for any rationale and I am against physician involvement in assisted suicide or in
euthanasia if ever legalized. Let society assign others but not physicians. But with
regard to patient modesty, I accept it as an issue, which I was previously not fully
aware of the magnitude of concern but about which I am learning from this blog. I
also see it as a developing conflict which is of importance. But I look to this blog to
be a place of rational and civil discussion and not one of activism toward one view.

Finally, I want to say that I am in full agreement with the concept of an activist
blog since as I said previously this is one way to enhance getting change in our
society. I would advise WJB and others to form their own activist blog and I am sure
that with a little publicity it could develop into a worthy tool for expressing
modesty concerns and mitigation approaches.

I hope you all understand my view. Please continue to participate on this blog.
..Maurice.
Friday, November 02, 2007 8:43:00 AM

amr said...
JCAHO and AMA do not carry any weight of law and the issues of cameras et al are
carefully worded in each to avoid “problems”. HIPPA from what I can see is moot on
the whole issue save for what must happen if the images / videos are retained. And
it does not cover feeds. I think we will also have a States rights vs Federal govmt
issue as we move forward as to who has jurisdiction over the regulation of the
hospitals and doctors.

Photographic releases (and video) are well established in our society. The health
care industry has burried these releases in the standard Terms and Conditions of
Service that must be signed by a patient prior to treatment. We have now seen this
particular form not only at the Main hospital at UCLA but also at their Oncology
center (a docs office suite). To be fair, the Plastic surgery center has you sign a
more detailed photo release which lists the places / purpose they may or may not
use your images they take in their office.

Here is the paragraph. You will find similar verbiage in most hospital institutions.

2. MEDICAL CONSENT: I consent to any medical treatments or procedures (except
for complex procedures which require special consent), X-ray examinations,
drawing blood for tests, medications (except for those which require special
consent), injections, taking of medical photographs, videotaping, laboratory
procedures, and hospital services rendered to me under the general and special
instructions of the attending physicians or other physicians of the UCLAHC assisting
in my care. I also consent to my admission to the UCLA Medical Center if this is
deemed necessary for my care. All of the terms and conditions of this agreement
shall also apply to such admission.

From what I can see so far, by signing this, it takes care of JCAHO / AMA / other
applicable law in regards to photographs.

But who really ever reads this stuff --- well I do….

Also, for the issue of non-consensual pelvic exams, I submit the following part of the
T&C’s for UCLA. Now as I understand it, a separate release must now be signed
because of the law enacted in 2004. However, it is this very following verbiage that
other states / hospitals rely upon and docs have sited as reasons that patients have
given consent to be practiced upon so that no further informed consents need be
obtained. This below also allows UCLA to make money from your specimens taken
from your body. This also gives them leave to have whomever they want “observe”
you in the OR. If you couple paragraph 2 and 4 together, this is their cover to allow
the new internet technology to be used in the OR. They even have a reference to
“other trainees”, which could really be anyone UCLA says is ok to observe to do so.
It says they may “examine” at the direction of the attending (this is the go-ahead
for non-consensual exams)

4. TEACHING, RESEARCH AND HEALTHCARE INSTITUTION: The University of
California including UCLAHC, is a teaching, research and healthcare institution. I
understand that residents, interns, medical students, students of ancillary health
care professions (e.g. nursing, x-ray, rehabilitation therapy), post-graduate
fellows, and other trainees may observe, examine, treat and participate at the
request and under the supervision of the attending physician in my care as part
of the University’s medical education programs. I understand that my health
information may be used and shared with researchers who engage in research
related to my treatment, health condition, or medical or physical status. I further
understand that the University of California, including UCLAHC, may use my
medical information and specimens for teaching, study and research purposes,
including the development of potentially commercially useful products. Any use of
these materials and information by UCLAHC or other institutions will be in
accordance with state and federal law, including all laws and regulations governing
confidentiality of patient records.

I’m sure that USC and all other teaching hospitals (of any stripe) have similar
verbiage.

There is a long standing tradition here that has been lobbied for in Congress. But
we have to start somewhere.

--amr
Friday, November 02, 2007 10:15:00 AM

Maurice Bernstein, M.D. said...
When I recntly put the issue of patient modesty on a moderated bioethics listserv to
which I subscribe, a physician ethicist, Dr Erich H. Loewy wrote the following
commentary which he has permitted me to reproduce here. Much of what Erich
describes, I too have experienced. Particularly discouraging in his commentary is
about the hesitancy now of teachers to even touch their students or "father's who do
no longer take their daughters on their lap and avoid body contact" presumably out
of concern others will ascribe unmoral behavior. Read what Erich says because he
comes out of the same social period as I did and we now see the differences.
..Maurice.



It has been more than 25 years since I have limited myself to Bioethics but on the
other hand in doing health-care ethics one is never out of the loop. I fear that
things have become a lot worse for that certainly shows the way that the patient-
physician relationship (and by no means only that has been damaged. When I was in
practice I rarely had another person present when I examined a patient. Sometimes
when, for example, I did a Pap smear I would ask my assistant to come in but even
that was rare. I did not subscribe to the"peekabu" approach. No one ever
complained or hesitated and I would continue a normal conversation while
examining the patient. I also did not drape them for the pelvic--when I was in the
service a new nurse draped the patient and (since I am very short drapes prevent me
from seeing facial expressions) so I went along with the drape, promptly got
tangled up in the drapes when reaching for some instrument and landed with my
head smack in the perineum. We both laughed and that ended the matter. There
are intangible ways people interact and--short of saying that blaspheming the
patient isn't quite proper--each relationship (if it can be called one) is unique.
There were some (few) patients with which my assistant was always present--but
these were few and far between.

Really the physician-patient relationship is only one out of a host of them. Teachers
no longer touch or embrace their students, let alone have one on his lap while
drying their tears. There are many father's who do no longer take their daughters
on their lap and avoid body contact. This is not a minor affair--it is underwritten by
mistrust, when trust is so essential in our various relationships. It does not bode
well for our future when we isolate ourselves in this way. There is no question that
this is a serious problem but it is trivialized when every personal contact is
eschewed. We have two sculptures on the lawn of our hospital: one shows two dogs
romping with one another, the other a young lady with a short skirt swinging her
little child over her head. Both have been complained about as being suggestive.

In Bioethics for the last 20+ years I have never hesitated to put my arm around the
shoulders of a grieving person or someone anxiously waiting in the ICU. One knows
soon enough if the patient is uncomfortable with this--but frankly I have never
encountered one.

Ending up by relating with patients according to some law is, in my view, artificial
and destructive. At a time when human beings have become so isolated from one
another it is time we rethought the matter. No doubt--there are instances when
teachers, physicians, social workers or clergy-persons have misused their
relationships--but these are really rare rather than being prevalent.

On the one hand, we preach that a patient/physician relationship should be warm
and that one should seek to know their patients as persons. On the other, we
recommend approaching every patient as a human being who is in need of comfort.
Often the same can be said of our students and especially of teachers in the lower
grades were children may be in great need of a personal relationship. I do not
believe that laws can dictate personal relationships, practice medicine or teach.
What is going on speaks for a sick society.
Friday, November 02, 2007 11:51:00 AM

Anonymous said...
amr,

A video feed is a transmission of data, and Hippa does directly address this - see my
post of earlier today.....

TT
Friday, November 02, 2007 12:21:00 PM

Anonymous said...
Dr. Erich Loewy's position is meaningful but it's hard to balance it against the
demands of a UCLA, which will refuse to treat you if you don't accept their fine
print abuse of your modesty, or a profession which will protect woman from PTSD
but laughs at the same need in men because it is convenient and protects the status
quo of the female gender in their employment practices. 25 years ago, people
weren't finding themselves being filmed by cheap thrill reality TV crews when they
entered an ER. If Dr. Erich wants to cuddle his patients he should start by making
the atmosphere around modern medicine more warm, fuzzy, and considerate.
- CHUCK McP
Friday, November 02, 2007 1:36:00 PM

Anonymous said...
"No one ever complained or hesitated and I would continue a normal conversation
while examining the patient. I also did not drape them for the pelvic.."

From SEXUAL BOUNDARY VIOLATIONS IN THE PHYSICIAN-PATIENT RELATIONSHIP
Medicine and Health Rhode Island, Aug 2004 by Crausman, Robert S,: "There is,
however, a wider range of sexually exploitative behaviors that are less well
recognized....Disrobing or draping practices that fail to respect patient
privacy...are also violations."

Sounds like Dr. Loewy is nostalgic for the days when patients didn't complain about
practices that today are considered misconduct.

CLW
Friday, November 02, 2007 3:23:00 PM

Maurice Bernstein, M.D. said...
CLW,it is easy for an outsider and one not involved in the mechanics of the process
involved in examination and treatment of patients to say that any activity of a
physician attending to a patient may be a "sexually exploitative behavior". But
errors occuring in disrobing or draping procedures, whether the assumption is made
by others that patient privacy is being disrepected or is not, need not be arbitrarily
considered sexually exploitative. For a physician to be exploitative means the
physician must have an intent to sexually take advantage of the patient. To the
outsider, that may be the assumption but the physician's intent may be motivated
by time, available gowns or drapes, or many other factors including just plain
ignorance of the patient's feelings but nothing that has to do with sexuality.

I go along with the need for more professional attention to patients' needs for
privacy and their personal modesty. I am totally against many proceedural activities
within the process of patient care being characterized as sexually exploitative or
misconduct without knowing the physician's intent regarding the act.

OK, as you have read from my previous comment, I was concerned about the
physician fondling the cephalic hair of a female patient on repeated occasions when
this was not in the context of examination of the head, scalp or the hair itself. But
even that behavior, as I told the visitor, should be brought to the doctor's attention
first before assuming a sexual motivation. Intent may be difficult to ascetain but
certainly some attempt should first be made to establish intent. Clearly draping
practices may be a system issue and have no sexual intent or motivation. Anyway,
this is my opinion. ..Maurice.
Friday, November 02, 2007 5:01:00 PM

js md said...
TT, thanks for your research. Yes I agree that pictures and videos are covered as
protected information but in such a convoluted way that it takes legal clarification.
And obviously institutions ignore it or interpret it differently. Remember that one
cannot sue under HIPAA, complaints have to be filed with the feds and only they can
enforce it and levy penalties. That would be one way to push compliance, that is to
file a complaint with US Department of Health and Human Services, Office for Civil
Rights, HIPAA Link. To do this one would need hard facts and names. Anonymous
posts won't do.
The other way is to get the HIPAA laws amended to cover these situations
specifically. I intend to write my congressmen and maybe a few other legislators
who are active in health issues (anyone know who they are?). I'll also write the
above agency though I don't really know how much power they have to interpret the
laws. Bear in mind that I don’t have the time, knowledge or resources to be an
effective lobbyist. Any help from any of you would be appreciated. I thank c ray b
for the offer.

Obviously Dr B. does not want activism continued on this web site. Are others
interested in pursuing this and related topics on a separate site?
Friday, November 02, 2007 8:59:00 PM

Anonymous said...
Dr. B., I understand your view regarding activism. I've never created a blog so if
someone would like to go in that direction, I'd like to be drawn into it.

I don't know if you mean for "rational and civil discussion" to be necessarily
inconsistent with "activism toward one view," but your sentence seems to so imply.
Since I've come on board, the discussion has been surprisingly rational and civil,
even as it moved toward activism. On a scale of 0 to 10, I'd say rationality and
civility ranged from 7 to 10. I've taken some exception to what others have written
and they either did not reply or replied graciously. I hope that any activism blog
would do as well or better. And, I must commend all the contributors, as dull as I
am, I've learned a great deal, although I may forget it all by tomorrow.

Like you, Dr. B., I am uncomfortable with Crausman classifying failure to drape as
sexual exploitation. On the other hand, he may be coming from the viewpoint of a
post-modernist among whom are social psychologists who refer to themselves as
social constructionists. They classify health into three categories: Disease -- the
physician's construction of reality. The focus is on the efficient and dispassionate
"treatment" of disease, an approach which leads to the dehumanization of the
patient. Unnecessary exposure of the patient's genitalia carries no sexual meaning.
Draping becomes an unnecessary action in such a milieu. If the patient's definition
of the situation parallels the physician's, tension between patient and physician does
not occur.

Illness -- the patient's construction of reality. The focus is on improving one's health
without relinquishing one's self image as a sexual but modest being. Physicians who
threaten this image by behaving in a way that undermines the patient's modesty
(e.g., not draping the patient) feel sexually exploited whether or not this is the
physician's intent.

A nurse sociologist by the name of Joan Emerson published an article in 1970
entitled "Behavior in Private Places: Sustaining Definitions of Reality in
Gynecological Examinations" (a must read for all healthcare providers and students).
Today, the publication is considered a classic. In it, she describes how the skilled
male physician recognizes and preserves the humanity of the gynecological patient
while, at the same time, ensuring that the patient does not define his actions as
sexual. John Macionis (Society, 2007. p. 441) does a good job summarizing
Emerson's piece after which he adds: "Managing situational definitions is rarely
taught in medical schools. This oversight is unfortuante, because as Emerson's
analysis shows, understanding how medical personnel construct reality in the
examinaiton room is as important as mastering the medical skills needed for
treatment."

As a social constructionist, Emerson would propably suggest that categorically
dismissing the failure to drape as being sexually exploitative is characteristic of
those who adopt the disease model while those who recognize it as sexually
exploitative adopt the illness model. They might also hypothesize that gynecological
patients today who are most likely to stick with physicians who have the view of
reality that Dr. Loewy has (assuming that patients with other views are not bereft
of other options), tend to be those who view reality as he does.

"Sickness" -- This is the definition that people in the patient's environment have of
the patient and her illness. It's not apropos to this discussion.

I told the following true story to students. A young man was in a private hospital
room with his leg in traction. A nurse came in with a bowl of warm soapy water and
without saying a word whipped off his sheet, exposing him completely. She then
began to wash his genitalia, although he was completely able to do it himself. Her
only explanation was that she thought it important that she ensure his cleanliness in
that area so he wouldn't develop a rash. "I was so humiliated and mortified that I
turned red from head to foot," he proclaimed. "Was there anything sexual about the
nurse's behavior," I asked the students. Most students didn't think so; they adopted
the disease model and attributed her behavior to insensitivity. Others constructed
the situation using the illness model and responded affirmatively. They quibbled
back and forth for awhile until I said, "Oh, I forgot to tell you. While the nurse was
working on the boy, she said, 'Most young men I do this to show their appreciation,
if you know what I mean.'"

Therein lies the dilemma in establishing mens rea; one's behavior does not always
give away intent and we can't read people's minds. But, for the young man the harm
was done, and it was aggravated when the actions of the first nurse were, within a
two day period, repeated by two more nurses but without the verbal giveaway. Did
the intent of the nurses matter to the young man? Not at all; the consequences
would have been the same, no matter what the intent. His sense of self was so
completely obliterated that he fell into a deep depression. Nobody could figure out
why a young man who had been bright, vivacious, and athletic could change
overnight and he was too ashamed to do anything but stay mum. To this day, the
young man, now an adult, will not allow female nurses anywhere near him. To
suggest he get counseling would send the message that his concerns are illegitimate
-- Like the man who was hospitalized for paranoia because he had hallucinations,
beliving that hitmen sent by La Cosa Nostra were trying to murder him. After years
of therapy, he walked out the hospital doors and was shot down in a gang-land
shooting. c. ray b.
Friday, November 02, 2007 11:14:00 PM

Anonymous said...
While the AMA & JCAHO do not have the weight of law, they do have input.

The AMA, for example, is the recognized "gold standard" when it comes to medical
ethics. It would be very difficult for a health care facility to justify to a "reasonable
person" that a policy (such as photo or video) which directly contradicts AMA
recommendations with respect to patient privacy and confidentiality, while
providing little or no direct benefit to the patient, has merit. Even if it potentially
could provide some benefit to the patient, the patient should have the right of truly
informed consent, and be able to decline as they can with any other procedure or
treatment, without prejudice.

Likewise, JCAHO is an accreditation organization and pressure could be brought to
bear from that quarter as well.

The following link to the AMA website has some documents you may find of interest.

http://www.ama-assn.org/ama/pub/category/3840.html

Specifically 2-A-07, 2-I-05, 4-A-05, 3-A-05, 12-A-03, 2-I01, 3-A-01, 2-I-00 & 6-A-99
contain information relevant to the discussion here. Peruse them and see what you
think (they are all copyrighted, so please don't copy & paste them....). Some cite
references to policies from other organizations, such as JCAHO, that may also be
relevant.

TT
Friday, November 02, 2007 11:24:00 PM

Anonymous said...
Sorry, Dr. Bernstein. I've only been around your "Patient Modesty" blog for a couple
of months and didn't realize it wasn't an activist site. Glad you explained it's neither
a sheep nor a wolf. It looked, smelled, and snarled like a wolf,
so I though I had found the right animal. I still think your blog needs to be divided
into a half dozen or more threads. Would you permit someone else to take all the
posting here, set them up that way, remove your comments
and name to keep you free of any activism? jsmd, are you thinking of moderating
such a blog? I think it needs to be a doctor or a recognized patient advocate. I'd be
willing to participate financially with the set-up?. I think others posting here would,
too. -- WJB
Friday, November 02, 2007 11:28:00 PM

Anonymous said...
What Dr. Erich leaves out of his approach is how the patient feels. He applies the
theory of a warm relationship stictly from his perspective. It is a lot easier to feel
at ease in these situations (relationship) when you are the one in your natural
environment fully clothed. This I think is the crux of a vast majority of the issue,
not that providers are sexually explotive, they are convientietly insensitive. In other
words it is easier to plead "no contest" than to deal with any issue a patient might
have. The don't ask, don't acknowledge, so you don't have to deal seems to be pretty
wide spread in medicine. Contrary to the rest of medicine which is so
compassionate, the issue of modesty seems to be its all about me, with me being
providers. The power embalance is so overwhelming at this point it controls the
whole relationship...when he said no one complained, did he ever ask? How many
kids tell the prinicple, I don't like the way you conduct yourself?

The second issue, I completely understand Dr. Bernstein's not wanting to be the
vehicle for activism on this, it wasn't the intent and with all the work this and the
other blogs take, along with teaching, even if he wanted time would be an issue.
The question becomes, how do we transition to a forum where it can start.
Personally I am so e-impaired I am lucky to have found this blog. A website with
tabs on issues has been suggested, while I think it is a great idea, and would be
willing to support it financially, I would have no idea where to start. Also as some of
the other attempts (plain Jane's effort for example) have exerienced it makes one
wonder, what it takes for one to run like this compared to having few or no hits or
responses? Dr. Berntein is obviously skilled at putting the sites out here and
moderating them. This is a very professional and helpful site as compared to say the
voy site where sensastionalism is mixed with real posts. If someone has an idea or
would be willing to spearhead that, I could help financially but am limited in my e-
ability....I don't know if Dr. Bernstein would be willing to allow a link in this
posting section for an activist site or even if it could be done, but Dr. Bernstein has
taken the ball this far and I can not thank him enough, it has empowered me in
many ways, but how do we leverage this...JD
Saturday, November 03, 2007 6:31:00 AM

Maurice Bernstein, M.D. said...
First of all, I want to say that I have never concluded that the comments written to
this particular thread were anything but civil and represented true personal
experiences and rational discussion of the issue of patient modesty. I have been
particularly pleased by all of the documented arguments that have been presented
recently. That's how a discussion, when there is no complete consensus amongst the
participants, should go. By the way, if you want to see truely uncivil
communication, just go to my thread on male infant circumcision and read how
comments were written till I put a stop to it finally by use of the moderation
function of the blog system and deleting posts.

My concerns about activist blogs is that of there is a potential for much less in the
way of "rational and civil" discussion than here since the goal of the blog would be
to support and maintain a point of view as part of demonstrating unanimity of the
activist group. I said "potential", not that it definitely would occur. However, I find
nothing unethical in forming a
group blog with a goal to change the medical practice system through group clout.

I want you also to know that there is nothing too technical about starting and
running a blog, for example here on blogger.com. I admit, that I was slow on
recognizing the full moderation potential I had avaiable until things got out of hand
on the circumcision thread. I am still not familiar with every function such as
organizing archives. Also I am not familiar with other free blog sites. I would
suggest some of my visitors who are interested in an activist blog simply go to
http://www.blogger.com,register and click on starting a new blog. It is all very
easy, just follow the simple directions, and if you are unsatisfied you can delete the
blog.

With regard to the use of comments from my blog transferred to the new activist
blog, I think individuals who had written a comment here can copy their own
comment and put it on another blog. Or the blog owner could do it with specific
permission by the writer. I think, however, it would not be fair (ethically just) for
others to transfer comments by an individual without specific permission by the
individual particularly to an activist blog..if you undertand what I am getting at.
Remember, when you are transferring other's comments from portions of a thread,
you are taking the words possibly out of the context to which they were initially
written--that is also unfair.

I would not want my blog otherwise or myself to be documented there as a
participant. Obviously, the activist blog could have links to my blog as a resource as
needed.

As I have repeated, I am all in favor for the development of such a blog as a step for
change and though I don't want my blog or myself to participate, I do want those
who would want to communicate with me for one reason or another to feel free to
do so,however do it by e-mail (DoktorMo@aol.com) rather than communicating by
posting to this blog. ..Maurice.
Saturday, November 03, 2007 9:07:00 AM

js md said...
I am seriously considering starting a blog on medical privacy and related issues.
Bear in mind that I think others are better qualified for this. As a physician in
private practice, I have no academic credentials or experience. All I have is the
interest.
I don't think the blog can be very effective anonymously. I see no reason to hide my
name, but others may have special concerns.
Those of you who are interested can email me at joel.sherman@gmail.com . Please
let me know if I can post your responses on this blog. Based on the response I will
make a decision.
Thanks.
Saturday, November 03, 2007 10:31:00 AM

Anonymous said...
Dr. B. -- Thanks for the information re. starting a blog.

I meant my paragraph to be complimentary to you and others who have contributed
to this blog, but maybe it didn't read that way. The discussion has been at a level
that I did not expect and I have appreciated it; my ignorance has been informed
repeatedly. And, I can see from where you are coming. It's easy for me to imagine,
as you have experienced, an activist site full of recriminations and personal attacks.
I've never experienced such a thing where I work, in spite of the fact that I and my
colleagues seem seldom to fully agree with each other on anything. c. ray b.
Saturday, November 03, 2007 3:10:00 PM

amr said...
TT: Thanks for your post about the AMA and the links. Although I have not yet read
through them, I wish to point out that UCLA was named one of the top hospitals in
the US and they advertise it by a seal and logo all over the facility. To say that they
get JCHAO certification is a given. Therefore, they have clearly figured out what to
do to bypass whatever organization or law they need to, to achieve their goal. It
might not be “legal” but “legal” is only what is adjudicated.

Also law and regulations are often times not followed. Look at the immigration
issue. (Regardless of the side you are on is not the point.)

Learning that you can not sue under HIPPA is of great concern, given the lobbyists
that are hard at work to insure that this technology gets put into place.

I think I have presented ample evidence, and there is more on the net, that the OR
of future is here to stay. Even if a patient is aware of how they might be exposed in
the OR, most will not have the time or money, or choice due to the need for an
operation to do much about it.

Modesty issues: With a great deal of appreciation, I do need to note that the
draping techniques employed with my wife during this process has been generally
caring. On her visit to the oncologist, the doc (a female in her late 30’s) was
careful to only expose that part of her body she was examining. And during the
breast exam, she was careful to only expose one side of her chest at a time. So,
maybe…… this latest generation of docs have been given a better set of patient
sensitivity tools than the last. I think that at the end of the day, it is all about trust
and making the patient feel safe.

Also, except for her plastic surgeon who is male and very sensitive to modesty
issues, all of her docs are female. There is more of a dialog and connection that
seems to take place.

-- amr
Saturday, November 03, 2007 5:27:00 PM

Anonymous said...
Jsmd, I think you should do it.
I plan to gather my thoughts and sent them to you in an email in the near future. It
should not be done as an overnight opening but a home page first with indication
that the site is "under construction", etc. It might take several months at that level
before it opens. Much needs to be lifted and sorted from this blog. It promises to be
a massive cut-and-paste.

UCLA, like G. Washington University, and a half-dozen other vocal defenders of the
unauthorized pelic exam,(UCLA actually threatened online activists with law suits if
they didn't close their sites) has never been open to patient modesty
issues and the need for approval.
They may not realize it but the operating room of the future may pull in many a
tort suit's needed documentation... and if digital images get out on the net(which
they will) they'll be in more legal hot water. Perhaps they're really setting-up to pull
the roof down on their own heads.
I would like to see their plans implode. It's not that space age medical needs aren't
valid, it's just that they view the patient as a mere speciment in all these decisions.
WJB
Saturday, November 03, 2007 8:59:00 PM

Maurice Bernstein, M.D. said...
c.ray b., it appears that it was my posting that would be interpreted ambiguously,
not yours.
I was trying to contrast what has been going on with this thread as compared with
what I feared would be a potential behavior of expression on a frankly activist blog.
I really want to commend you and the other recent active writers for the well
thought out, documented and expressed views on the subject. When one stands back
and looks at the commentary here, it really looks like what one might find in an
academic colloquial setting. Again, thanks to all and keep it up. I think there still
are some points of clarification regarding institutional or regulatory rules or laws
dealing with audio/video transmission of actual patient images. ..Maurice.
Saturday, November 03, 2007 9:37:00 PM

Maurice Bernstein, M.D. said...
If you want to read what conversations are going on in her operating room as
reported by a female plastic surgeon, go to her Suture for a Living blog.
Interesting. ..Maurice.
Saturday, November 03, 2007 10:54:00 PM

js md said...
Hope to hear from you WJB. I'm not in a rush to do this. And yes, liability concerns
have already crossed my mind.
-Joel
Sunday, November 04, 2007 6:38:00 AM

amr said...
JSMD – I’m in. I will email you off-line. I feel VERY strongly that a MD – someone on
the inside must be actively involved with this process. A lot of this change is
“cultural” and is going to take change from the inside. Unfortunately, MD are not
the only stake holders within the medical $$ complex.

WJB – I have heard of other institutions going after web sites at the start of the
non-consensual public airing, but I did not hear that UCLA also did this. Could you
provide some link that names UCLA being aggressive in this area? It would also be
very interesting to see if this was pre or post the CA law.

-- amr
Sunday, November 04, 2007 11:10:00 AM

Maurice Bernstein, M.D. said...
Out of fairness in the presentation of views, I must stress an invitation to any
representative of UCLA or any of the other institutions mentioned on this blog to
post their own views, explanations or facts. Obviously this also applies to anyone
else who wishes to comment with contrasting views to those already presented. I
would agree with amr's request to WJB regarding documentation. ..Maurice.
Sunday, November 04, 2007 1:01:00 PM

Anonymous said...
It appears that the only opposition Dr. Berstein is going to attract is from Dr.
Loewy, and he did not contribute directly to this blog. What he has written provides
as challenge to the ideas introduced by some other contributors to this blog. If I
understand his words, I have heard them said many times before and they demand a
reply. However, Dr. Loewy's peice seems to have been written in haste with
frequent convolutions. I won't detail these limitations, but they did interfere with
my efforts to decipher what Dr. Loewy was trying to communicate. It would
certainly be desirable for him to participate in this blog so he could clarify and
respond to our critical assessments. Short of that, maybe Dr. Bernstein can respond
for him.

Here's my understanding of Dr. Loewy's piece. In the first paragraph, he suggests
that patient-physician relationships have been damaged. The evidence he gives is
that when he practiced he seldom used chaperones and seldom draped patients and
they didn't make a stink about it. Of course the latter is not evidence that patient-
physician relationships have been damaged. So, maybe what Dr. Loewy means is
that physicinas in the past usually felt comfortable not using chaperones and drapes
and patients tended to feel comfortable with physicians not using chaperones and
drapes. Today, neither is true.

In the second to last paragraph and the last sentence of the last paragraph, Dr.
Loewy seems to suggest that laws governing physician-patient interactions are
responsible for damaging patient-physician relationships by making interactions
artificial in the sense that physicians now interact with patients according to the
laws rather than naturally (and the same is true for teacher-pupil relationships).
When laws "dictate personal relationships" in medicine and education, we have
ourselves "a sick society." These laws are not needed or should not be employed
because physicians and other professionals rarely misuse their relationships with
subordinates.

Dr. Loewy, in the second paragraph, suggests that teacher-pupil and father-child
relationships have also been sullied as evidenced by teachers not touching or
embracing their students and fathers not touching or embracing their daughters.
Isolating ourselves from others in this way reflects distrust. Isolation and distrust
are serious problems that are trivialized when people complain about little things
such as the suggestiveness of sculptures depicting romping dogs and swinging
children.

In the third paragraph, Dr. Loewy notes that he defies the new convention whenever
the opportunity arises by continuing to touch and embrace patients.

I have trouble with the first part of Dr. Loewy's last paragraph. His intent appears to
be to introduce a dilemma. He writes, "On the one hand, we preach that a
patient/physician relationship should be warm and that one should seek to know
their patients as persons. On the other, we recommend approaching every patient
as a human being who is in need of comfort." Implicit in his use of "on the other
[hand]" is that warmth between physician and patient and knowing patients as
persons are on one end of a continuum while "approaching every patient as a human
being who is in need of comfort" is on the other end of the same continuum. It
would have made more sense had he written, "On the other [hand], we recommed
approaching patients scientifically and dispassionately." Whatever he means here, I
don't think this part of the piece is pivotal for understanding Dr. Loewy's messages
so does not need to be considered in any analysis of what he has written.

Maybe Dr. Loewy or Dr. Bernstein can tell me if I pretty much captured what Dr.
Loewy is saying in his piece or if I've gone astray anywhere and if the latter, maybe
they can set me straight. Once that is done, I'll feel more comfortable responding to
the substance of what Dr. Loewy has written. c. ray b.
Tuesday, November 06, 2007 10:49:00 AM

Maurice Bernstein, M.D. said...
c.ray b., I can't answer for Dr. Loewy but I will e-mail him a copy of your comment
and suggst that he respond directly to the blog but, if not, I will be pleased to copy
here a response he sends me by e-mail. Sorry, for not posting your comment and my
response sooner but I was away for most of the day. ..Maurice.
Tuesday, November 06, 2007 5:43:00 PM

js md said...
For anyone wondering, I am setting up a website on privacy concerns.
Just trying to get the layout right.
Please email any suggestions anyone has to my prior email address.
Tuesday, November 06, 2007 7:49:00 PM

Maurice Bernstein, M.D. said...
Dr. Loewy responded by e-mail to c.ray b.'s most recent posting with the following:

In a submission to Dr. Bernsteins magnificent blog an anonymous (I love anonymity;
it is always disquieting when a person will not stand openly for what he/she stands)
a respondent attempts to tear apart an article I wrote for the mcw discussion list. I
do not generalize from my experience, I merely use it to illustrate a point. And
that point. writ large, is that since the 60's there has been a to me very
unfortunate separation and trust between physicians and patients. The difference is
stark, the separation of patient from physician (a clerk decides if an individual will
be a patient--if no insurance or cash he/she will be asked to leave (except in
critical emergencies)so that the physician never needs to feel guilty about not
seeing poor patients. As physicians we are enjoined to help all those in distress
regardless of their being friend or foe, race, colour, creed or economic standing.
This under managed care is not the case. The physician is an employee who is doing
as good a job as he can (now he/she is a "provider") give good care to his patients
(now consumers). The change in language is obviously related to changes in feeling
one to another.

I am not quite certain what "anonimouslys" objections are. Patients (and with good
reason) do not trust their physicians as they did before since they are perfectly
aware of how the "system" is constructed. To get a test which a physician feels
necessary & which the insurance company refuses because it doesn't quite meet
"criteria" can be handled in two ways: #1 Invent the necessary criteria or coerce the
patient in doing so (blood in the stool is a favourite) or # 2 fail to get whatever is
felt needed.

Lying about it (if one wants to protect one's patients) will occur if the physician's
priority is the patient's good. This puts the physician (and the patient knows it) into
a position of lying--not a habit I think should be encouraged but if this happens
again and again it will be.

The "modesty" issue is merely an example of lost trust in one another. It seems true
that one cannot (or with great difficulty) practice ethical medicine in an unethical
institution nor build a just health care system in a basically unjust society.


Actually, in my own opinion, the issue of trust may well be at the basis of patient
modesty rather than some genetic formation or some psychologic aberration or
psychopathology. Trust means that the patient trusts the physician from
intentionally harming, making premature judgments of the patient's mind or
appearance or even intruding into the patient's own control or desires. Trust also
means the patient trusts himself or herself from not inappropriately submitting to
the directions or actions of the physician. Let's talk about your views of trust and
how it might be related to personal modesty. ..Maurice.
Wednesday, November 07, 2007 8:15:00 AM

js md said...
Here is my blog: Medical Privacy, A Patient Oriented Discussion

Please check it out and make any suggestions, especially for new topics. Those of
you who volunteered, please transfer your posts from here to the appropriate
discussion. All are invited to participate.
Wednesday, November 07, 2007 9:41:00 AM

Anonymous said...
"Methinks" Dr. Loewy "doth protest too much." He writes, "In a submission to Dr.
Bernsteins magnificent blog an anonymous (I love anonymity; it is always
disquieting when a person will not stand openly for what he/she stands) a
respondent attempts to tear apart an article I wrote for the mcw discussion list." In
response to Dr. Loewy's first innuendo, I will refer him to Dr. Berstein's following
request: "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." (capital letters are mine) I was only
doing what the good doctor ordered, as did everyone else who directly contributed
to this blog. Thus did we all avoid being noncompliant. If Dr. Bernstein would like
to change his orders and allow me to reveal my name, I'd be happy to do so. ;)

I reread what I had written and must wonder where Dr. Loewy got the idea that I
was tearing apart his article. In order for two people to engage in reasoned
discourse, each must understand what the other is trying to communicate. With
that in mind, I sought to communicate my understanding of the points Dr. Loewy
was trying to make in his piece. It is no wonder he's "not quite certain what
'anonimouslys' [that is I] objections are," since I made no objections. My
contribution to his contribution to this blog was not a critical analysis of his
contribution but an attempt to find agreement as to what points he was tring to
make in his contribution. Thus, I began my efforts with, "Here's my understanding
of Dr. Loewy's piece," and ended it with, "Maybe Dr. Loewy or Dr. Bernstein can tell
me if I pretty much captured what Dr. Loewy is saying in his piece or if I've gone
astray anywhere and if the latter, maybe they can set me straight." Dr. Loewy's
response to my request was less than forthcoming. I expected something such as,
"Yes, you hit it on the nose here"; "No, you're way off here, you dope -- This is what
I mean. . ."; "Yea, you sort of got it here, but let me elaborate." But, that's ok,
maybe what I was trying to accomplish in my piece was as ambiguous to Dr. Loewy
as what he was trying to accomplish in his piece was ambigouous to me. Either
way, it appears I failed in my mission.

Since Dr. Loewy does not debate my interpretation of what he wrote in his first
piece (and, indeed, seems to confirm some of it), I'll proceed as though my
interpretation is correct. I'll have to do that later, though, since the work day is
over and I'm heading home. c. ray b.
Wednesday, November 07, 2007 2:31:00 PM

js md said...
P.S.
I meant to thank Dr Bernstein for major advice in setting up the blog.
I hope you all realize how lucky you are to have his advice and blogs available.
Wednesday, November 07, 2007 3:42:00 PM

Maurice Bernstein, M.D. said...
At Wednesday, November 07, 2007 2:56:00 PM, Maurice Bernstein, M.D. said...
c.ray b., I still can't speak for Dr. Loewy's wording but I definitely should speak up
about mine. I apologize if my words "no names please" was ambiguous in the
context from which I wrote it. I did NOT mean that the writer should ALSO remain
anonymous (certainly whether or not to remain anonymous is up to the writer) BUT
I did want to emphasize that as the patient was relating his or her experience story
to us, the names of the physician or others involved should not be disclosed. I want
this blog to be fair and also not unnecssarily exposed to the risk of accusation of
libel. In this regard I have had concerns about UCLA being specifically identified in
some of the posts but that is why I look forward for a UCLA representative to reply.

I hope this explains my words and my intent. However, I might add, just as I am not
running this blog with some pseudonym and whatever I write I want to be personally
responsible for, it is my own opinion (and perhaps that of Dr. Loewy) that others
should take the same responsibility and declare who they are. Of course, I can
understand special circumstances where a visitor might not want to do that but that
is why I will accept pseudonyms. ..Maurice.
Wednesday, November 07, 2007 5:45:00 PM

Anonymous said...
I see. Thanks, Dr. Bernstein for the clarification. I am a neophyte at this blogging
stuff and in all the blogs I read, contributors used first names or pseudonyms. If Dr.
Lowewy is genuinely interested, you can tell him I am Dr. Ray Barrow.

As to the substance of what Dr. Loewy writes, as I understand it, I'll concede to his
contention that patient-physician relationships and teacher-pupil relationships have
changed. I'll not concede to his assertion, "There are many father's who do no longer
take their daughters on their lap and avoid body contact." I am inclined at the
moment to consider this statement as existing somewhere between hyperbole and
preposterous. My mind can be changed, but, given I'm from Missouri, you'll have to
show me, partner.

I'll also not fully concede to Dr. Loewy's suggestion that patient-physician
relationships have necessarily suffered and that "there is no question that this is a
serious problem." They have suffered, he suggests, in the sense that, unlike in the
past, they are "underwritten by distrust" and "isolation." I could be persuaded to
partially concede if Dr. Loewy is referring to the loss of trust physicinas have for
patients once he gives me the evidence. However, I don't agree that patients' loss of
trust in physicians is a serious problem and here's why. Right now I have in front of
me several years of Gallup Polls that measure the level of trust the public has of
people in various occupations. The most recent is a 2005 Gallup Poll that places
medical doctors third out of 21 occupations behind nurses and pharmacists. Another
places medical doctors fourth out of 45 occupations behind nurses, pharmacists, and
veterinarians. Second, if physician/patient relationships have been sullied by laws,
as Dr. Loewy seems to suggest, one would expect that younger physicians would be
most affected by this change. Yet, comments on this and other blogs -- if not
scientific evidence -- suggest that young physicians are lauded for their superior
bedside manners. Could it be that physicians can develop warm and trusting
relationships with their patients in ways other than the use of touching and hugging
which Dr. Loewy seems to imply is missing in today's patient-physician
relationships?

To me, a question more interesting than "Why have people lost trust in physicians
(and other healthcare providers)?" is "Why do people have so much trust in
physicians (and other healthcare providrs)?" After all, healthcare providers have
been responsible for some of the most outrageous acts of inhumanity this world has
ever known, from leading the pack against witches in Salem and in other Eastern
Seaboard communities (see, e.g. comments by John and Sonja McKinlay, "The
Questionable Contribution of Medical Measures to the Decline of Mortality in the
United States"); to leadership in the American eugenics movement from which
Hitler borrowed his ideas and justified his programs (Edwin Black, "War Against the
Weak"); to leaders in the Holocaust (Robert Lifton, "The Nazi Doctors"; Posner and
Ware, "Mengele"); to experimentation on the powerless in the U.S., the most
notorious of which was the Tuskegee syphilis experiment (James Jones, "Bad Blood:
The Tuskegee Syphilis Experiment"); to, more recently, complicity with torturers
and abusers in Iraqi pisons, including Abu Ghraib (Steven Miles, "Betrayed: Torture,
Medical Complicity and the War on Terror"). And, one would be hard pressed to find
a week gone by without one or more media sources reporting on misconduct by
healthcare providers. Thankfully, those at the forefront opposing these outrages and
misconduct were and are physicians and nurses some of whom have been treated as
pariahs and heretics by their peers (see, e.g., John and Sonja McKinlay). In spite of
the rarity of these outrages and misconduct, laws and ethical standards at the
international, national, and state levels have been passed to try to curb the
likelihood they will ever occur again.

Speaking of the rarity issue, Dr. Loewy does address it. The implications of his
words are chilling. He writes, "Ending up by relating with patients according to
some law is, in my view, artificial and destructive. . . No doubt there are instances
when teachers, physicians, social workers or clergy-persons have misused their
relationship -- but these are really rare rather than being prevalent." Dr. Loewy
seems to be suggesting that since laws governing relationships are destructive to
those relationships, and since so few people in the occupations he mentions "have
misused their relationship," these laws should not govern the behaviors of people in
these occupations. I wonder, does Dr. Loewy also believe that "relating with
patients according to some" set of ethical standards is also "artificial and
destructive?" Given that laws and ethical standards tend to reflect the mores of a
people, it would seem to me that the well-socialized physician would conform to the
laws and ethical standards without thought. Only the poorly socialized physician
would feel compelled to conform his behaviors to the law and to the ethical
standards of his/her profession.

Now, I'll take another approach. Let's assume that physicians don't touch and hug
their patients as frequently as they used to do. And, let's assume this indicates that
physician-patient relationships have not just changed but changed for the worse.
What Dr. Loewy does not address is why we have gotten to this point. Who are the
key players responsible for the deterioration of patient-physician and teacher-pupil
relationships, to the extent that they have occurred? Among the players are
physicians and teachers; some of Dr. Loewy's colleagues and some of my colleagues
are among those responsible for the conditions decried by Dr. Loewy. They
victimized patients and students resulting in social action to curb the victimization
one effect of which was to undermine the old relationships that existed between
subordinates and superordinates.

Are Dr. Loewy and I personally responsible in any way? I may be, but I am as blind as
most when it comes to self-analysis -- somebody will have to point out what my
contributions to the problem have been. But, Dr. Loewy indicts himself. He could
have been at the forefront in encouraging treatment protocols designed to augment
the trust patients had in physicians. But he apparently was not. Indeed, he appears
proud of the fact that he sedom used chaperones and seldom draped patients in
spite of the fact that at the time he was practicing there was ample evidence that
doing both (when the physician was male and patient female) augmented the trust
patients had in physicians and diminished the likelihood of patients misconstruing
physicians' actions (I mentioned Joan Emerson's 1970 publication in an earlier
statement).

Dr. Loewy, in his second post, moves from the micro- to the macro-level by
suggesting that the breakdown in patient/physician trust is a consequence of the
current healthcare system. Because of "managed care" physicians can no longer "help
all those in distress regardless of their being friend or foe, race, colour, creed or
economic standing." And, he attributes patients' distrust of "their physicians" to
patients' awareness "of how the 'system' is constructed." Again, Dr. Loewy does not
acknowledge physicians' role in bringing about the very system he attacks. This role
is nicely articulated in Paul Starr's "The Social Transformation of American
Medicine," an historial/structural analysis of the ascendancy of allopathic medicine.

Dr. Loewy ends his last post with "Let's talk about your views of trust and how it
might be related to personal modesty." Before I do this, a little preface. The
contributors to this blog have conflated issues of modesty and issues of dignity and
self respect. The three are strongly related; indeed, the latter is generally
considered a synonym of dignity. But, I'd prefer to use the term "dignity" rather
than "modesty" because "dignity" shows up most frequently in the documents to
which I alluded in earlier posts. It's in those documents that "human dignity" is
conceptualized. With that said, two of my "views" which I have derived from a few
posts to this blog, simply put, are 1) the greater the unnecessary indignities
through which an actor is put by another individual, the greater the loss of trust the
actor has in the other individual and 2) actors' distrust of those who occupy a
particular status is augmented the greater the number of status occupants who
unnecessarily compromise the actor's dignity. - Ray
Wednesday, November 07, 2007 8:43:00 PM

Maurice Bernstein, M.D. said...
Ray, thanks for the revelation of yourself but also for the excellent commentary
analyzing Dr. Loewy's replies. I am not sure but it seems that Dr. Loewy is as much
of a neophyte in this "blogging stuff" as you are since he appears to still have trouble
posting and I am not sure exactly why. In any event, I will copy your comment and
e-mail it to him and see what happens.

I want to make one correction to your last post. The sentence you refer to "Let's
talk about your views of trust and how it might be related to personal modesty."
was my words since the text of Dr. Loewy was in italics and the last paragraph not
in italics was mine. However, as you expressed it, I understand your view.
..Maurice.
Wednesday, November 07, 2007 10:06:00 PM

Anonymous said...
I see now. I didn't notice the change from italics to words without italics. Putting
your name at the end should have allerted me -- estoy tonto.

I may have done Dr. Loewy a disservice by interpreting his words incorrectly. I
imagine he'll let me know if I was off base. -- Ray
Thursday, November 08, 2007 2:59:00 PM

Maurice Bernstein, M.D. said...
Here is Dr. Loewy's response to Ray:


Dear Moe,

It is not my habit to invent things out of whole cloth. This is but a small amount of
the vast material available on the web. About the 80's there was a paper in. I
believe, the Lancet which showed a village whose relationships were totally
devastated when someone came up with a pphysical sign which showed that there
had been sexual affront (presumably by the father) on the daughter. Those children
were taken from their home, placed somewhere and a year or so later the test did
not prove accurate or specific. The families were ruined. I enclose a few things
(book and articles). I am not in the least interested in the name but in the way I
was brought up people signed letters and when they gave an opinion were ready to
stand behind it. I find (and perhaps wrongly) a seething hostility permeating this
contribution. Why, I do not know or care. Father's and teachers fearing to take
their child on their lap or even just to comfort an eight year old has been told to
me by many teachers and has been written about in both lay and professional
articles.

To my understanding in civilized and professional relationships one avoids slurs.
Statements like: "I am inclined at the moment to consider this statement as existing
somewhere between hyperbole and preposterous" are generally avoided in
professional correspondence. Gentlemen do not, and that without extremely good
reason, speak this way to one another in this way. The difference in relationships
between physicians and patients is stark--something told to me by my colleagues in
practice (I was trained, taught and practiced if you count residency, fellowship
andpractice before retooling and going into Bioethics--to which I think elemental
courtesy to one another is a cornerstone. It is difficult for mutual trust to develop
in the stark setting we now have. Briefly, when I was in practice a first and yearly
visit took 2 hours (one for history, 30-40 minutes for examination and 15 minutes
or more to explain what my thoughts were to the patient. The patient has not only
(and quite understandably) developed little trust in a person who in most cases is
an employee and, therefore, has a loyalty split between his/her employer and
his/her patient.

That relationships have been "sullied by law" I mean that many physicians do not
ask"what is best" but "what is legal." I suggest that following some laws is distinctly
unethical. One need only look over the last century to become convinced of this.
Would you follow a law which says that physicians can treat "unregistered alien" (a
different species, I presume) only in an emergency and must report to the police
any patient he suspects of having illegally entered this country (albeit exploited,
denigrated and often insulted). Marx was quite right: this is wage-slavery.

The touching an hugging may or may not be appropriate--that depends upon the
context and the individual disposition on both sides. At a different University I was
asked for quite a few years running to "hood" the graduates. I invariable shook
hands with the males and embraced the females (that's me, someone else may not
be comfortable). Our associate Dean called me into his office after the first time
and told me that this constituted sexual harassment. I asked if anyone had
complained. Of course no one had and telling him "like it or not I will continue to
be me and that I would surely not hug him. I continued to be myself.

I happen to agree that people develop their mode of relationship with others (and
themselves) and if touching is uncomfortable to them, fine. If it is felt as not
wanted by the patient, the physician (if he/she knows anything about body
language will surely let the physician know this). It is not surprising that they
develop closer relationships with their "younger" physicians--these are often
students or residents and they do have more time to spend.

The loss of trust of patients goes nicely along with a (justified, I think) mistrust of
other institutions. How much solidarity is there in a nation in which 25% of workers
earn $8.50/hour whereas executive officers make vast sums of money. How much
trust can there be when 25% of people go hungry a good part of the year. How much
trust can there be when this magnificent structure which was created here is
betrayed by those who govern for the benefit of those who already have altogether
too much.

It is quite unnecessary to speak to me about the horrors of the last and present
century. I happened to flee late in 1938 at age 11 (a different 11 then our children
today) and really doubt that I need a lesson in what happened.

The long rest of Dr. Barrows letter (and it is .long) I will not go into--it is too
much and I would gladly do so either off or on the blog. I must however take
exception especially to one the epistles in Dr. Barrows note: Are Dr. Loewy and I
personally responsible in any way? I may be, but I am as blind as most when it
comes to self-analysis -- somebody will have to point out what my contributions to
the problem have been. But, Dr. Loewy indicts himself. He could have been at the
forefront in encouraging treatment protocols designed to augment the trust
patients had in physicians.

We are certainly not culpable for many of these troubles today. I dot not feel
culpable for slavery but I certainly feel responsible to see that we begin to act as
co-equal persons to one another, that what was taken be--if that is even possible--
is restituted and that our children are brought up to think for themselves instead of
being spoon fed a usually inaccurate history.

Perhaps I indict myself. I have been active my whole life in the causes of what I
consider social justice both here and abroad. I wonder if Dr.Barrow has ever read
any of my articles or books? And I do not think that I have only talked the walk but
refrained from walking the walk--and paying a price for it. However, I do not
believe that this blog is either a person's analysis or a proper venue to venture into
hostile comments. Dr. Barrows knows nothing of me (and has no reason to) and I of
him.

It is difficult to stop--the explicit and tacit hostility is too great. However when
the following is written it is hard to stop: Dr. Loewy seems to be suggesting that
since laws governing relationships are destructive to those relationships, and since
so few people in the occupations he mentions "have misused their relationship,"
these laws should not govern the behaviors of people in these occupations. I
wonder, does Dr. Loewy also believe that "relating with patients according to some"
set of ethical standards is also "artificial and destructive?" Given that laws and
ethical standards tend to reflect the mores of a people, it would seem to me that
the well-socialized physician would conform to the laws and ethical standards
without thought. Only the poorly socialized physician would feel compelled to
conform his behaviors to the law and to the ethical standards of his/her profession.

Obviously I mean not what Dr. Barrows go on accusing me off. As a Bioethicist it
would be strange if I did so. However, I gladly re-affirm that there are and have
been laws that are and gave been clearly unethical and likewise that some laws
now and in the past have been and should have been resisted. These "laws" or
"ethical standards, however, must change with time just as in homeostasis the
milieux intérieur most accomodate to the milieu exterieur. Furthermore in this
individualistic, capitalist, self-centered society which in many cases is in church
Sundays and without compunction drives by the hungry, the homeless, those without
medical care one wonders how far hippocracy will go. The "I" alone can do nothing;
the "I" as seen as a "we" in socieety it can do much. One hopes by peaceful means
but, if not, than others may have to be employed.

Below a few references:

--------------------------------------------------------------------------------

Hugging the teacher: reading bodily practice in an Israeli kindergarten - all 4
versions »
D Golden - Teachers and Teaching: Theory and Practice, 2004 - Taylor & Francis
... in the ongoing activity or some hesitation on the ... There was an elaborate
`doctor's
corner' in the ... fare in Israeli kindergartens) that the teacher took care to ...


Batillono A:: The Dynamics of Psychoanalytic Therapies of the Early Parent–Child
Relationship.

Rudd JM, Herzberger SD

:Brother-sister incest - father-daughter incest: a comparison of characteristics and
consequences.
Social Work Department, Saint Joseph College, West Hartford, CT 06117, USA.

Social Work Department, Saint Joseph College, West Hartford, CT 06117, USA.
OBJECTIVE: One group of women who were sexually abused by brothers and a
second group who were sexually abused by fathers are compared with the intent to
identify the differing characteristics of each type of abuse and the effects of the
abuse on their adult functioning. Our hypothesis was that there would indeed be
differences in the characteristics of the abuse and its effects, and that this would
necessitate differing treatment strategies. METHOD: Surveys were distributed to
women attending support groups for incest survivors. Of the 62 women completing
questionnaires, 14 women (23%) had been sexually abused by a brother. A similar
number of women (15) who had been sexually abused by their fathers were chosen
from the overall sample for comparison. RESULTS: The absence of the father as a
vital force in family life played a key role in the sexual abuse of women by their
brothers in every case. The duration of the sexual abuse for brother-abused women
and father-abused women was lengthy. The characteristics, including use of force,
are equally as serious for sisters as for daughters. The family circumstances
surrounding the abuse were examined for both groups and the results yielded a
fuller understanding of the incestuous family. Despite an appearance of normalcy,
the level of family-wide disturbances, for example substance abuse, mental illness
and pervasive family-wide violence were profound for both groups. In this study, we
also examine the effects in adulthood of the serious disruption of childhood
developmental phases for both brother-abused and father-abused women, taking
into account the incidence of substance abuse, depression, suicidality, and eating
disorders. CONCLUSIONS: The authors conclude that the characteristics and
consequences of brother-sister incest are of equal seriousness to those of father-
daughter incest. This would suggest that brother-sister incest is one of the current
blind spots in incest research, and one that we cannot afford to ignore. In-depth
knowledge of the dynamics and effects of brother-sister incest suggest specific
treatment strategies are indeed necessary and these are discussed in this paper.
------------------------------------------------------------------------------------------------
-------------



Related Links
Intrafamilial sexual abuse: brother-sister incest does not differ from father-
daughter and stepfather-stepdaughter incest. [Child Abuse Negl. 2002]
Effects of mother-son incest and positive perceptions of sexual abuse experiences
on the psychosocial adjustment of clinic-referred men. [Child Abuse Negl. 2002]
Parenting difficulties among adult survivors of father-daughter incest. [Child Abuse
Negl. 1992]
Childhood sexual trauma of chemically dependent women. [J Psychoactive Drugs.
1995]
The prevalence and seriousness of incestuous abuse: stepfathers vs. biological
fathers. [Child Abuse Negl. 1984]
Radical Reform of Initial Teacher Training for Primary School
------------------------------------------------------------------------------------------------
-------------
Shmuel Shulman:
: Fathers and Adolescents: Developmental and Clinical Perspectives
------------------------------------------------------------------------------------------------
------------------------------------
A paper whose title eludes me : Sexual relations: Am J Psychiatry 122:1132-1138,
April 1966

Dr Erich H. Loewy


This is DoktorMo (Maurice) back on the post. I am not sure how the issue of familial
incest is related to the issue of patient modesty unless this is all part of the changes
in trust. ..Maurice.
Thursday, November 08, 2007 10:40:00 PM

Anonymous said...
Dr. Loewy's and e. ray b.'s comments are interesting... but
what does any of this have to do with patient modesty? Even if we extend the lack
of touching into legal action and the patient's fear of sexual abuse in medical
practice, it is still outside of the basic modesty issue that I believe this blog is
about... or perhaps I've gotten the whole point backwards ???
Friday, November 09, 2007 1:31:00 PM

Anonymous said...
Anonymous, you are, of course, correct. However, I think Dr. Loewy's first
contribution did have something to do with patient modesty (or dignity/privacy).
But as you might have seen in my response, I was having trouble making it relevant.
He went far afield of the subject in his last post.

In that first post, he did write about not using chaperones and drapes and nobody
complained. Maybe this was his way of suggesting that in the past patients trusted
physicians and because they trusted physicians, physicians did not have to worry
about modesty issues. Then all these healthcare abominations occurred, including
managed care, having to lie to do what was best for patients, staffing offices to
turn away the poor so physicians would not have to feel guilty, etc. The
consequence was the loss of trust in physicians. Now, because of that loss of trust,
patients' modesty has become an issue; patients are more likely than in the past to
take urbrage when there is no chaperone or they are not draped. In other words,
loss of trust has lead to negative responses to modesty intrusions.

Dr. Loewy may not have meant this at all, but even if he didn't, it does add a twist
to how I think most of us understand the situation, and I may be incorrect about
this as well. The contributions to this blog suggest that we may believe that the
causal direction is in the opposite direction -- modesty issues have led to distrust
rather than vice versa; that is, when healthcare providers fail to respect our
modesty, the result is distrust. In fact, the reality may be that the two variables are
reciprocal resulting in the proverbial chicken/egg dilemma.

Dr. Lowey also wrote in that first contribution, "Ending up by relating with patients
according to some law is, in my view, artificial and destructive." Now, the only laws
participants in this blog had mentioned up until Dr. Loewy's contribution had to do
with those that would protect patients from unnecessary privacy/dignity intrusions.
Some intrusions described by contributors were, arguably, violations of criminal
law. Expansion of HIPAA was also mentioned in addition to broadening the scope of
JCAHO standards to incorporate insults to patients' efforts to control what happens
to their bodies. In this context, Dr. Loewy's assertion was chilling to me, especially
coupled with his statement that physicians rarely "misuse their relationships," for
the implication of what he wrote was that the laws should not be employed and
HIPAA/JCAHO standards broadened to reduce the likelihood of insults to patients'
modesty, privacy, and dignity. Dr. Loewy declined to tell me whether or not I was
reading him correctly and I subsequently commented on what his message appeared
to be. That woke him up, I guess, for in his last post he made it clear that he had,
as you suggested, gone astray of the issue; he was referring to laws that required
physicians to behave unethically and did not mention any criminal laws and
expansion of HIPAA as being among them. Nevertheless, the issue is relevant as I
have spoken to people in and outside of healthcare who lament, "There are already
so many laws out there, soon we won't be able to turn around without breaking
one."

I think as a medical ethicist with years of experience, (and who, I believe, may still
be at the University of CA where the health center criticized by "amr" in an earlier
post for questionably ethical behavior is located) Dr. Loewy could make a
considerable contribution to the issue of patient modesty, privacy, and dignity.
However, I fear he has been alienated by my posts, so maybe someone who is more
of a gentleperson and less prone to slurs than I can draw him in to a discussion
pertinent to the subject at hand. -- Ray
Friday, November 09, 2007 8:06:00 PM

Maurice Bernstein, M.D. said...
Ray, thanks for a temperate response. One correction- Dr. Erich Loewy is associated
with the University of California at Davis which has nothing to do with the
University of California at Los Angeles (UCLA) medical center. ..Maurice.
Saturday, November 10, 2007 9:29:00 PM

Maurice Bernstein, M.D. said...
Much of the commentary on this thread has been by visitors who express the view
that patient modesty is a very important problem to them. In contrast, I really
haven't had many visitors taking the stand that patient modesty concern to them is
non-existant and why they come to a physician is concern about their symptoms and
disease and the request for treatment and not fretting about modesty issues. In
fact, would any visitor think that the amount of modesty concerns expressed here is
overblown and this is really an issue for only a very small proportion of patients
coming to a doctor's office? Again, I must relate here that I have been surprised and
educated by the furor about modesty on this blog and that after over 40 years of
internal medical practice, I have rarely been informed by a patient regarding this
issue. ..Maurice.
Sunday, November 11, 2007 8:46:00 PM

James A said...
While most of the posters here seem to be very concerned with modesty issues, it
probably boils down to personal preference. I just had my annual dermatology
review (lots of moles, sk's etc) and a physician's assistant was substituted at the last
minute. Seems the doctor had a death in the family.

The PA and nurse are both female. I'm male, mid forties. After a brief interview
with the nurse I was given a gown, asked to undress and the PA would be in shortly.
No direction was given as to what extent I should undress. The regular doc
examines "everything" as they should, so I remove everything and put on the gown.

The PA later enters the room with the nurse and the exam begins. The PA explains
the situation with the regular doc and asks if it is ok that she do the exam. It was
fine with me. Face and scalp are examined first, then the gown is lowered to the
waist and the back and chest are checked. Next starting at the bottom of the feet
everything is checked up to the gown.

She then asks if anything needs to be looked at in the "private" areas. Very
diplomatic. I say that there are areas on my bottom and in the groin area that the
other doc usually checks. She says that I can show any area that I would like checked
and lets me control the gown removal process.

In summary both of these health care providers were very professional and I felt in
control of the situation at all times. True, both saw "everything" while the PA
examined all the potential problem areas and I was undressed completely for a short
time but it was done in a manner that was comfortable to me and again,
professional.

So the "bottom" line is that I had a choice to be examined by the PA or reschedule. I
had a choice to allow the PA to check the private male parts in detail or not. My
personal opinion is that as long as the health care providers are professional and I
have a choice, it doesn't bother me one bit to be seen by two female providers. I
have been seen by both male and female doctors and nurses without incident. It's
just not a big deal to me.

Everyone is different. I'm sure there are those who would have rescheduled and
that's fine. Did the PA and nurse discuss my average attributes after the exam? Did
they giggle and tell the receptionists all the details? I seriously doubt it. The
waiting room was about 50/50 male/female. I can't believe they were
unprofessional in my absence. Next year I'm sure I'll see the regular doc. But in this
situation, the PA did a good job.
Monday, November 12, 2007 8:53:00 AM

Anonymous said...
James A. summed it up well. It's
basically about having CHOICES.
He had the chance to reschedule, he was asked if the gender difference made a
difference to him in his pelvic care. He also felt as if he was in CONTROL and that
he was being treated by professionals. Most of the complaints posted on this blog
are from patients who receive none of these CONSIDERATIONS and no OPTIONS. Dr.
Bernstein, you're surprised (after 40 years of no issues) that this is a matter that
concerns some patients. Might I suggest that you go back though this blog and your
"Naked" blog, gather up a couple of dozen of the worst incidents which show
violations of patient modesty. Print them up on a questionaire which asks
your future patients how uncomfortable they would feel on a scale of 1-to-10 if they
were the patient involved and ask what they might have done... or whether they
would have just suffered though it and become one of your forty years of uncounted,
silent sufferers -- a great, patient silent majority.
CHUCK McP
Monday, November 12, 2007 1:20:00 PM

Anonymous said...
Dr. B. -- I read through many of the personal experience contributions to this blog.
It is pretty clear that selection is at play here; that is, it's only those who are
interested in the issue who are responding and that most have had negative
experiences and think change is warranted while a minority, such as James, have
had positive experiences and don't recognize a need for change.

I have already cited the research with which I am familiar at the moment regarding
preference for the sex of the provider. I suspect that many of those who express a
preference would submit to opposite sex scrutiny if they knew they'd be treated
with the respect experienced by James. But not everyone has had such postitive
experiences.

James -- When a person writes, "everyone is different" as you did, it suggests that
there are no patterns to be found among human beings. I would suggest that, in
fact, most Americans who were treated with the respect and dignity with which you
were treated would be satisfied with their experience whereas if they overheard a
"nurse discuss [their] average attributes. . . giggle and tell the receptionists all the
details," they would leave the facility quite offended. And, one could reasonably
hypothesize that the former would be more likely to return than the latter. The
patterns about which I am writing have been discovered by researchers and
acknowledged by some courts such as the Backus court and EEOC court to which I
alluded in an earlier post. I also suggested in an earlier post, that the point at
which people experience humiliation varies with culture/subculture and past
experiences.

It appears that you left the physician's office satisfied with your treatment. If so,
then I'd say you experienced the same feelings as most Americans would have
experienced who were treated as you were. And, would you have left the office
offended had the nurse discussed your "average attributes" and "giggled" with the
receptionist? If so, then you are probably like most Americans. If not, then you are
probably a statistical oulier. -- Ray
Monday, November 12, 2007 2:09:00 PM

js md said...
I have previously expressed skepticism as to how many patients feel as strongly as
most of the contributors to this thread. I won't repeat myself; I've already generated
enough outrage here. But look back if anyone's interested. C ray b may get us all
further info to answer the question.
James A, everyone has a different level of modesty concern. In the situation you
described, having a chaperone watch my exam, I would feel my privacy more
violated than my modesty. I do have some of the latter as well. For a further
discussion my feelings re chaperones, see my privacy blog.
Monday, November 12, 2007 3:05:00 PM

Anonymous said...
Dr Maurice,

I've been reading this blog for several weeks and would like to respond. I've tried a
few times but my posts have never made it through.

I feel that if the patient was given the option, things would be different. Problem
is, practices haven't changed in 40 yrs so you wouldn't hear it because people still
feel they don't have a choice. I agree that it's just a small portion of people but on
the flip side, if this was an option that number may become quite large. That's also
the reason why the medical professionals don't want to give this option, it may open
up the flood gates. Makes perfect sense.

It was noted in this blog several times that modesty is a product of your upbringing.
I disagree, if anything, I feel your parents try to change you from feeling this way.
Why is there this rule that it's okay if it's in a medical setting? I've felt this way my
whole life, my son who just turned 6 feels this way. What kind of parent would I be
to change him?

This is a big problem that won't get fixed until people learn to speak up ahead of
time. If enough do so, things could change for the better.

JK
Monday, November 12, 2007 6:37:00 PM

Anonymous said...
What difference does it make whether 5% or 99% of patients are concerned with
modesty. Are you saying that if patients with modesty concerns are in the minority
doctors should just stick with the majority and ignore all modesty issues. I dont care
if I am the only one of my doctors patients that have a concern, I should be treated
with dignity and respect. Only expose what is necessary and nothing else. As Ive
stated before here in Australia we dont have annual checks as it seems most
Americans do including children. I fnd this totally unnecessary. My husband and I
check each others skin i check my own breasts for lumps and he checks his own
testicles. If we have a problem then we go to the doctor. Under no circumstances
would we allow a healthcare provider of the opposit sex give as care. After reading
this and other blogs I have lost faith in the proffessionalism of the health care foeld
and while I know you cant put all health care providers in the same basket I am not
willing to take the risk. As for double standards is it any wonder men in particular
dont go the the doctor when they should. If I need an intimate exam a drape is
given and privacy is given while I change on the other hand on the two times my
husband has needed to be examined to sheet and no privacy given to change. He
now refuses to go to the doctor at all.
Monday, November 12, 2007 7:10:00 PM

Anonymous said...
JK's comment of Nov. 12th, 6:37 P.M. is absolutely on the money. It's the "flood
gate" issue the medical profession is worried about. Bring up the matter of option
and suddenly 80%+ of patients find the issue important.

My big beef is with the double-standard here. The "women are more modest" logic
is nonsense. What fueled the female gains in modesty is a willingness (fostered in
feminism) to complain and the need among male doctors for female chaperones to
cover them for possible malpractice and criminal charges.
This compounds the issue by keeping even more female staff in place because HMOs
won't allow doctors to charge for a double-inventory of staff by gender. If 60% of
newly-minted doctors are of the female gender, by grace of affirmative action, then
where is the same movement in the area of nursing and medical tech workers?
Currently, only 14% of the nursing school enrollment is male. Males have double the
dropout rate from the nursing profession as females. The reason often given by
them on allnurse.com and male nursing blogs is the domination of the job site by
female supervisors who treat them like they are second-rate staff. A while back on
this blog, js md called these gender staffing levels (that
influence male modesty) "traditional". First off, I disagree. Secondly, so what? The
female domination of nursing, the "Nightingale Syndrome", is only 150 years old.
It hadn't even fully penetrated the British workhouse infirmary
before the start of WW1. It was that conflict, with its enormous casualities, that
really raised the need for far more female nurses. It quickly became their world.
Men were doctors, women were now the nurses. Today, the several thousand year
old tradition of male physicians has fallen in a generation but no one is questioning
the levels of females in nursing and med-tech fields.
The Order of the Knights
Hospitalier were handling nursing duties in the Holy Land 750 years
before Nightingale packed-up for the Crimea. There's no great absolute tradition of
females as medical support staffs. This is important to remember because it's only
the vested interests of this group that is helping to shore up the flood gate which
holds back modesty progress. Due to the homophobic component in their own ranks,
men only need a
rebalancing of staff to probably 1/3 males in total to cover for their modesty
requests. If this was in place, the entire modesty issue could be readily handled,
instead of being constantly suppressed. Women could still be accomodated and the
atmosphere around patient modesty would, in effect, become far more matter of
fact. Totally unlike the current unspoken rule, "Patients: Don't ask. Staff: Don't
offer."
- CHUCK McP
Monday, November 12, 2007 10:08:00 PM

amr said...
Dr. B (11/11/07 post regarding 40 yrs experience)

It might be that your sensitivity to the issue in the first place has mitigated the
issue?

Dr. Sid Schwab has an excellent blog. He is a semi-retired general surgeon. Here is
an entry he made about modesty and the operating room.

He writes in part: “I think I've always empathized with my patients, whatever the
situation. Dress -- or lack thereof -- was a thing of unspoken concern, and I don't
recall it ever being mentioned in training. It was matter-of-fact, job at hand, not
an issue. ….. Finally, it's just "let's put on the paint and get to work." Been there,
seen that. I know it's a concern for many people. Whereas I can't say that modesty
and dignity are maintained at all times in all operating rooms, exposures are pretty
universally met either with decorum or boredom. As long as it happens after going
to sleep, is it OK?”

I believe that the “OK?” bespeaks of his “dissonance” and that after years of
practice he has come to treat modesty in the OR as important as in his office
treatment room.

A comment made to the entry by a female plastic surgeon (rlbates said...) “I have
never gotten over my modesty (or prudishness)even after all these years as a
surgeon (graaduated med school in 1982), so I try very hard to respect my patient's
modesty. I appreciate that you do too.”

If privacy and modesty were really not issues (voiced or not), why are there doors to
examining rooms and curtains around beds in hospitals? And why did UCLA just
complete a new hospital that is completely single patient rooms? If the medical
industry universally respected modesty/ privacy, then it would be like James A’s
experience.

At the crux of Dr. Loewy’s commentary I believe is that without the time or
inclination in today’s healthcare environment to create the space of trust between
patient and Dr., how the patient is treated (including modesty issues) plays a part
of trust or distrust. That being said, I believe that the experiences that most of
have is positive. There seem to be enough bad experiences though that cause
distrust.

Office Etiquette: Allnurses discussion about undressing in front of the Doc. It would
seem that it again becomes a “Trust Issue”.

--amr
Tuesday, November 13, 2007 10:23:00 AM

Anonymous said...
I’d like to share with this group a few experiences that I’ve had over the last few
years that required some service done in the OR and how I took it upon myself to
get the care and services that I required.

First, I’ve had to have two surgeries on my shoulders (one on each shoulder). It was
to correct shoulder impingement. I just turned 30 but I had the shoulders of a sixty
year old, so each doctor told me. I tried all the traditional things that would
prevent surgery (physical therapy, medicine, etc.) but after a year, I was just ready
to get it fixed. So, when I went in for the consult with the doctor that had been
treating me for a year, he told me what he was going to do, how long it was going
to take and how long the recovery was going to last. He never mentioned during
this time, how I would be prepped, what/if any anesthesia was going to be used, he
completely avoided the whole procedure part. Fortunately, I had done my own
research and asked him to get it done in this manner (nerve block with only local
anesthesia). He wouldn’t do it this way, so I thanked him for his time and all the
help and went to another doctor and got the procedure done how I wanted it to be
done.

On another occasion, I developed a cyst on my ear that required removal. The
surgeon didn’t want to do it in his office due to the location and lighting and
requested I go to the hospital for him to remove it there. I agreed. When I was put
in the pre-op cubicle (or whatever you want to call them) the nurse came by and
handed me a gown and asked me to remove everything and wear only this. This
gown may have come to my knees but that pushing it. Needless to say, I wouldn’t
accept that. When she came back I was getting my things together and she asked if
I was going to put it on, I had to laugh and just said ‘it’s just an ear.’ I probably
said that two or three times but I’ll never forget the expression on her face. I
politely said that if I was going to have to wear this, there wasn’t going to be a
procedure today. As I was leaving, she called me back and handed me a pair of
scrubs and said I could leave my socks and underwear on. This after I got the “it’s
hospital policy” speech.

It was hard on me in each of these cases because they happened at the hospital
where my wife is the CFO. She had a lot of comments from the staff about me
choosing a different physician and about walking out of a procedure almost, she also
had to hear this when we chose a different hospital for the deliveries of our
children. We went were we were provided the service we desired and the staff to!
My wife was granted same gender care through both births, no questions asked. By
demanding and looking ahead, I was able to get everything done that I needed with
my dignity intact! I truly believe that if enough people would just voice their
concern and demand better service, things would change. Sorry for the book I’ve
wrote, just wanted to give some examples of how I’ve been able to get around
keeping my modesty and getting the procedures done at the same time. Some may
tell you that it can’t be done, but once you start walking out, they may have a
change of heart.

Thank you Dr.Bernstein for starting this blog, I hope it serves as tool for you to
better educate your students in the future.

JK
Tuesday, November 13, 2007 4:48:00 PM

Anonymous said...
Possible project for Dr. Bernstein or Dr. Sherman. I'd do it myself but I believe it
needs to be a doctor requesting the info, a doctor with a modesty blog, an opinion
maker in this area.

On October 24th, a posting from
KYLE appeared here and Dr. B. provided a link at 02:31 P.M. It was an internet
advertisement
for the gender-sensitive services of St. Michael's Hospital in Toronto, Canada. It
went by without notice or additional comment and I think the readers of this blog
should be revisiting it at this time. The wording the
hospital's copywriter used is very much in keeping with the arguments that have
appeared here for the past year and a half regarding this kind of patient modesty.
Might I suggest that one of the good doctors contact St. Michael's patient advocate
by
email and ask: (1) What prompted the hospital to make this aggressive move --
good business, patient requests, threat of legal action, etc.? (2) What kind of
response has the hospital experienced? Are people re-scheduling to take advantage
of same-gender care? Is the hospital proactive in pointing out the option with every
appointment scheduled? How much
positive patient feedback have they experienced since the gender-sensitive care
policy was put into place?

The point keeps coming up here that those seeking this kind of service are few in
numbers. Here's a chance to get a significant real world sampling.
Personally, I think this is the coming trend, not the exception.

Finally, my hat's off to JK for standing his ground on unnecessary nudity. What the
patient modesty movement needs most is the troublemakers. Keep it up, JK. (TJR)
Tuesday, November 13, 2007 7:25:00 PM

Anonymous said...
JK -- You write, "It was noted in this blog several times that modesty is a product of
your upbringing. I disagree. . ." Here's what John Macionis (2007. "Society") writes
about the subject: "Modesty, too, is culturally variable. [For example,] if a woman
stepping into a bath is disturbed, what body parts does she cover? Helen Colton
(1983. "The Gift of Touch: How Physical Contact Improves Communication,
Pleasure, and Health") reports that an Islamic woman covers her face, a Laotian
woman covers her breasts, a Samoan woman covers her navel, a Sumatran woman
covers her knees, and a European woman covers her breasts with one hand and her
genital area with the other" (p. 149). When people from these nations immigrate to
this country, they bring their cultural practices with them and these cultural
practices tend to be passed from one generation to the next. As the U.S. becomes
more ethnically diverse, practices associated with modesty also become more
diverse. Rightly or wrongly, the greater the ethnocentrism among healthcare
providers, the less likely these new immigrants and their offspring will receive the
health care they need. In the long run, this could have a profound financial effect on
the nation in addition to a loss of productivity.

I imagine many people envy the self-confidence, gumption, and cool-headedness you
demonstrated in the face of providers who declined to honor your reasonable
requests. Unfortunately, patients are not always in positions to exercise their rights
and privileges as they would like to.

There have been a couple of times I've been able to do so. For example, several
years ago, I was in an automobile accident. A week later, I was unable to finish a
warm-up in preparation to do some bench presses because my right arm was too
weak. I went to get an electromyography to see what the problem was. The nurse
led me into the examination room and told me to remove all my clothing and put
on a gossamer-like hospital gown. I asked her "Why?" She answered "It's policy." I
asked her "Why is it policy?" She answered, "That's the way it's always been." I asked
her, "Why has it always been that way?" She finally tried to answer my question --
"The doctor might want to put electrodes on your leg." I asked, "Why would he want
to do that when the problem is in my arm." By now her frustration and irritation
with me was palpable -- After all, I was violating the patient role. She said, "Ask
the doctor" and left. I took off my shirt, the physician entered and conducted the
examination, I put my shirt back on and left the clinic. -- Ray
Tuesday, November 13, 2007 7:30:00 PM

js md said...
JK. (TJR)
Your idea is a good one. If Dr B is not willing to ask them , I might though he's
probably more likely to get an answer as I could not represent myself as asking for a
hospital. But the answers would be revealing and helpful.
Wednesday, November 14, 2007 11:25:00 AM

Maurice Bernstein, M.D. said...
Just to let you all know, I sent an e-mail today to the public relations dept of St.
Michael's Hospital in Toronto with the questions that TJR suggested. Their website
describes a response time in 2 business days. I included all my credentials so they,
hopefully, may know that my request for information was valid. So..let's wait and
see what response we get. It should be interesting. ..Maurice.
Wednesday, November 14, 2007 12:35:00 PM

Anonymous said...
I found this blog while searching for "patient, pelvic exam, privacy." I'm a survivor
of a violent rape twelve years ago. A breast/pelvic exam is a genuine ordeal for me.
I've been seeing the same doctor for the last five years, or rather I've mostly seen
his PA, a very nice young lady who has always seemed concerned and caring. Mainly
I've been seen for med checks because I take Zoloft, at the maximum dose, for
PTSD. The PA knows this, and even though I am very reluctant to discuss details, she
knows I have problems with being touched and with physical exams.

Today I had my first gyno in almost seven years. I went into it feeling optimistic,
since I was seeing a female PA who knew about my history. It was a nightmare.

I was put in an exam room on a busy hallway. From its open door, there was a
direct line of sight to the reception desk and anyone who might be standing there.
The lab was just across from it, usually with several people waiting for patients
loitering along it.

I was kept waiting for over an hour. Then the PA came in and said "Take it all off,
top and bottom" and left. I had to sort through the folded stuff on the table to find
what was supposed to be my gown, which turned out to be an open-front vest that
barely came below my breasts. I was still struggling with it when the PA knocked,
and when I said "Please help me with this" she opened the exam room door and
immediately gave an exhibition of me nearly naked to several people who were
standing at the desk talking to the receptionist.

For the record, I'm forty-two and I'm not attractive. I don't think that people are
looking at me lustfully, or that there's any sexual component. The point is that I
don't feel comfortable with people looking at me AT ALL. Especially strangers.
Especially men.

It was all downhill from there, really. There was an "assistant" in the room, a
trainee nurse assistant I think, whose purpose didn't seem to extend to anything
other than staring at me while I was on my back with my legs spread with one
notable exception. I tried to hold a tiny paper sheet around me while the PA did the
pelvic and gave me helpful advice like "Just breathe" and "A man must have invented
this test, huh?" Midway through she realized that she didn't have everything she
needed for the pap smear and so she asked the mouth-breathing tech to go get
something for her from the next exam room. The tech flung the door wide open,
and I got a nice view of a guy not six feet away standing in the hall, who got to see
me covered by nothing but a scanty paper sheet.

When the pap smear was over, the PA said something about occult blood that I
didn't catch, and pushed her finger in my rectum with no warning. When everything
was finally over, the PA told the tech to give me some kleenex to "clean up with",
and I was handed a wad of tissues to wipe myself while they both stood there and
watched.

I cried from the time I left the exam room to my car. In my car I ended up
hyperventilating until I had to open the door and vomit onto the parking lot. I'm still
shaking as I write this. I was a piece of meat again, humiliated and ashamed. I
have worked so hard to get past things and yet here I am again. I don't care if I get
sick, I don't care if I die of cancer, no one's ever going to be able to do that to me
again. Dr Bernstein, you sound like a compassionate man, but right now I hate you
all.
Wednesday, November 14, 2007 7:03:00 PM

Maurice Bernstein, M.D. said...
Anonymous from 7:03pm today, I think there is no disagreement with the conclusion
that your pelvic exam was grossly and I mean grossly mishandled both by the
participants and the office system itself. It is not a compliment to the PA that after
being aware of your past history that she was so indifferent to you and your
environment.

What to do? Please read the commentary by JK on November 13, 2007.
Unfortunately, the participnts had no eyes, no ears and no attention for you except
to get the job completed. At the outset, when entering the exam room, you should
have raised the issue of your modesty concerns and the apparent lack of privacy
with regard to the exam room and hallway as you described it. You should have
asked how this was to be mitigated.. perhaps another room? Then first sign of
concern by you as to what was going on, you should have spoken up, forcefully and
made it clear to the participants that any further impropriety would end with you
packing up and leaving. And then you should have left as JK did.
Unfortunately and I mean unfortunately, the burden to handle the situation is on
you. The participants and the organization of the office system is not going to
change without patient feedback including a dramatic leaving if the patient is still
unsatisfied with the response. Also, later be sure to notify the physician and let him
know what happened and why you left. To say nothing at the time and to do nothing
at the time is the worst thing you can do. Crying in your car and vomiting will not
change anything in that doctor's office. I am sorry that I have to place the burden on
you to carry out but there is no one else. It is you who has to educate and it is you
who has to make the dramatic exit such as JK did. Period! If anyone of my visitors
has another approach which might be effective, please let Anonymous and me know.
..Maurice.
Wednesday, November 14, 2007 7:50:00 PM

Anonymous said...
Anonymous of Nov.14th @7:03:

I’d like to write and tell you to read through this entire blog so you get some ideas
on how to express your displeasure and who you should start with but I think it’s
more important to tell you that “I’m Sorry for What You Were Put Through.” I can’t
imagine what you went through and won’t even attempt to.

Dr Bernstein, it was noted several times at the beginning of this blog that there will
always be the “bad apples.” My question to you or any other physician reading this
is how many “bad apples” or even bad experiences before someone outside of the
people on this blog take notice? I’m sorry, I feel ONE is too many and if I had ONE
“bad apple” in my place of employment, I’d send them packing! Please, don’t throw
the law book at me for saying that or any court cases, we all know that there are
ways to get by the rules.

I believe all this boils down to control and who has it. They want patients to believe
that they have their best wishes at heart but what they don’t say is that it will be
to the extent of their choosing, I also feel that they are taught this way to keep
society in check so they can keep control. It frustrates me to know that so much
COULD be done to protect both the patient’s privacy and modesty but so little is
actually done. At what point do these professionals stop being human?

JK
Wednesday, November 14, 2007 8:13:00 PM

Anonymous said...
At the outset, when entering the exam room, you should have raised the issue of
your modesty concerns and the apparent lack of privacy ... You should have asked
how this was to be mitigated... you should have spoken up, forcefully ... you should
have left as JK did.

Are you even aware of what that sounds like? "You should have closed your bedroom
window, no matter how hot it was outside." "You should have fought harder, all you
had was a broken arm." "If you were a good girl, none of this ever would have
happened to you."

This PA was someone I'd seen for the past several years and who I trusted, even
though it's hard for me to trust. This was someone who knew my past, had seen my
medical records, and was fully privy to what I'd been through. Can you understand
why with each problem I thought "She's not aware of this, she just doesn't realize"?

Sorry I'm not as good a girl as "JK", whoever that is.

Crying in your car and vomiting will not change anything in that doctor's office. To
say nothing at the time and to do nothing at the time is the worst thing you can do.

And now you've neatly shifted the blame back onto me -- this was my fault, because
the responsibility was on me and I failed to act.

I take it back, you're a perfect physician. I have no idea why I bothered to write
anything here.
Wednesday, November 14, 2007 8:23:00 PM

Maurice Bernstein, M.D. said...
Anonymous, given the situation you described, who else is going to act? Certainly
not the staff in the doctor's office. By deed and by speech they were ignoring your
privacy and dignity. That is why, as I have noted in previous postings along with the
other visitors, it must be the patients who singly in their doctors office and
together in a activist group make your views known to physicians, institutions and
the government. Don't expect these caregivers or their associates carrying out or
regulating the practice of medicine to change without some pushing from patients.
I think you should read more postings on this thread and you will see that you are
not alone. ..Maurice.
Wednesday, November 14, 2007 9:21:00 PM

Anonymous said...
Of course, I'm totally shocked and moved by this patient's two recent postings. I
hope the 42 year old lady will realize she came to the right place and we all thank
her for sharing her feelings. I hope she will read the whole blog and, like so many of
us meeting here, vow that she will never again be the casual victim of this brand of
medical insensitivity. I do hope that after she has read more of the
thousand or so postings here and on the "Naked" site, that she will realize that Dr.
Bernstein is the closest thing she is going to find to both friend and physician in this
movement for change. I never vomited in the parking lot but I once backed into
another car because I was so bewildered and angry at having allowed myself to be a
modesty victim. Dr. Bernstein is only trying to show you that you must empower
yourself. None of this is your fault and that should never be your focus. I would start
by immediately contacting your doctor and all others concerned about how you felt.
Don't be polite. Rip their heads off! Then go somewhere else, read them the riot act
in advance, and start a new chapter in your health care. Remember that your
wounds can be the source of your new strength. WJB
Wednesday, November 14, 2007 10:32:00 PM

Anonymous said...
Anonymous from Nov 14:

As others have already said, I too am shocked and appalled by your treatment. As Dr
Bernstein said, it was clearly mishandled badly.

Please understand that he wasn't criticizing your actions, but offering you
constructive advice as to how you can act to prevent something similar from
reoccurring in the future.

You are clearly still suffering from the traumatic effects of your assault. My heart
goes out to you, and I pray that you find a way to overcome it. That said, I'm going
to be a little blunt - please take this in the spirit in which it is offered.

Only you can choose to stop being a victim - no one else can do that for you. You
have to make the conscious decision to either let it haunt you for the rest of your
life, or to take control of your life back and find a way to put it in a place where
you can deal with it. It's not going to be easy, and it won't happen overnight, but it
can be done - I pray you find the inner strength you need.

Life is built on a series of small successes. A good place to start might be by taking
back control of your medical care. Be assertive - tell them what you expect; be
candid - tell them why; and speak up when you don't get it.

TT
Thursday, November 15, 2007 9:43:00 AM

amr said...
Anonymous 11/14 8:23pm – When I was in my late teens I came down with Mono
and had to be hospitalized for 2 weeks. I was sweating so much that my entire body
had a reaction to the soap in the sheets and I broke out in hives. One day, without
notice, a Dr. came in with his students (10?), lifted up my gown and started to talk
to them about me. I was stunned. It happened so fast, and I wasn’t feeling well,
that it was over before I could even really have my mind react to what had
happened. (I’m male btw). Afterwards, I was so hurt and angry; I really felt
violated. I asked to speak to the chief resident (a female doc), and really told her
how I felt. She apologized and said that she would pass on my feelings. Hopefully,
maybe, it helped some future patient.

All this by way of saying that it isn’t your fault, but nothing will change in the office
unless you speak up. A profound trust was broken. Next time, and there probably
will be a next time, what Dr. B is saying is to speak up immediately and be
prepared to get up and walk out. Talk about the issue with the provider BEFORE you
even get undressed. Set the ground rules before hand. Use this last experience as an
starting point. “Dr. X, I need to discuss with you something that happened to me so
that you understand my situation, so that the previous experience is not
repeated…..”

Also, you are a very good writer. You could write a letter to your doc merely by
providing a brief intro and then including the blog entries. At the end of the letter,
ask (demand) him to call you to discuss the situation.

You could also report him / his office.

If you don’t speak up, then nothing will happen. In your rape analogy, rape is wrong
and it is never the fault of the victim. But if the victim doesn’t report it, nothing is
likely to happen to the perp. If you don’t report it, it is likely that this PA is going
to continue to violate other patients. You can’t be the first person she has done this
to.

BTW “JK” is a visitor to this blog who on 11/13/07 4:48pm posted some
experiences he had with the hospital “system” and how he was able to stand his
ground. He did so by knowing what his limits were and knowing that he had rights.
Many years ago, I was on a PSA flight (remember PSA). The feature article in the
flight magazine was entitled something like: “Your rights are what to assert, not
what you are granted.” Basically, this lawyer was saying that the law is only the
starting point. If you don’t know your rights under the law and assert them, people
are going to take advantage of your ignorance. I’m sorry that I didn’t keep the
magazine.

However, I must say that not all of us have the ability to do that because of the
managed care system we have now. Often you are not given the choices of provider
that JK had to exercise. (I think this has already be stated here.)

-amr
Thursday, November 15, 2007 10:00:00 AM

Anonymous said...
Anonymous -- It sounds to me that you were raped again. What a terrible
experience. Hearing about troglodytes in the "helping professions" makes my blood
boil and my blood pressure rise.

I do appreciate the way you ended your piece -- "No one's ever going to be able to
do that to me again." My wife, a nurse attorney, would say, "That-a-girl" and my
mother, who was both diminuitive and a tough old gal, "That's the spirit."

I hope you will consider participating in the patientprivacy.blogspot.com/ where we
are trying to create change-oriented goals to improve patient privacy and come up
with ideas about how to achieve these goals. I think we're struggling and need
someone with passion (no offese meant to others on the blog) -- Ray
Thursday, November 15, 2007 12:19:00 PM

jdt said...
I have quite a few issues with doctors and I have lost faith in them. To bring up one
I don't understand is why can surgery be done in a emergency without all the blood
work, fasting, etc... and when you have scheduled surgery you go through so much
prep that you end up feeling like crap when you go in for surgery?
I never plan on having surgery ever! IF I were I would want to be awake- I do not
like being not in control and want to know what's going on. I have many more
issues, like I said, but I was wondering why all the extra testing and expense is
needed. Not to mention feeling like crap that day.
Thank you
Friday, November 16, 2007 7:55:00 AM

Maurice Bernstein, M.D. said...
JDT, though your posting really doesn't deal with this thread on patient modesty and
we should try to keep it to that specific topic, I do want to respond.

There are essential blood tests which are drawn for emergency as well as
routine,scheduled surgery. Virtually all surgery has a range of risks depending on the
surgery. The risks may be related to the actual "cutting" or the stresses put on the
body by surgery or it may be related to the anesthesia administered. Even removing
a mole on the skin after the injection of a local anesthetic to prevent pain could
cause a fatal anaphylactic reaction though very rarely.
Blood testing for blood count, typing of the blood, blood sugar and electrolytes are
important as a baseline. Also renal and liver function testing can be routine and
electrocardiogram or chest x-ray may be necessary in certain cases. I doubt any
emergency surgery is performed without some blood obtained.

If you "feel like crap" on the day of the surgery, I would advise that you call your
surgeon and notify him or her more about your current symptoms. It may warrent
delay of th surgery. If you feel "nervous" about it, that may be natural but also tell
your doctor about it since it may repreent concern about surgery or outcome details
that either you forgot or the doctor had failed to inform you.

Of course, some surgeries can be performed easily and with lesser risks by the
patient remaining awake. But most operations do require sedation and/or
anesthesia since without them, the acute stresses of surgery may lead to acute
complications or the restlessness of the patient may make delicate surgery
impossible.

I hope this information helps. ..Maurice.
Friday, November 16, 2007 10:57:00 AM

JDT said...
Maurice,
Thank you for responding even though I was off topic. It helped me tremendously,
nobody explained these things to me. I have been going through alot and it's nice to
have someone get back to me or even respond. I can't thank you enough. JDT
Friday, November 16, 2007 2:36:00 PM

amr said...
JDT – I know how you feel. (“I never plan on having surgery ever!) The whole
business of medicine today is difficult to navigate and is not at all patient friendly,
and it can be scary. I sincerely hope that in the end LIFE winds out for you in favor
of the “system” getting to you. In an emergency, the purpose is to save the life.
The pre-op tests that Dr. B spoke of are all there to mitigate risk of the surgery to
promote a positive outcome to a surgery when surgery, at that moment, is not a
matter of life and death.

Dr. B. I believe that you have partially missed her point about the pre-op blahs.
After the fasting, enema, maybe stopping some meds, or starting others, combined
with the worry over the operation, oftentimes, the patient presents at pre-op
felling crappy with a bad headache from not eating.

Ok back on topic…. ;-)

-amr
Sunday, November 18, 2007 8:24:00 AM

amr said...
JDT – I know how you feel. (“I never plan on having surgery ever!) The whole
business of medicine today is difficult to navigate and is not at all patient friendly,
and it can be scary. I sincerely hope that in the end LIFE winds out for you in favor
of the “system” getting to you. In an emergency, the purpose is to save the life.
The pre-op tests that Dr. B spoke of are all there to mitigate risk of the surgery to
promote a positive outcome to a surgery when surgery, at that moment, is not a
matter of life and death.

Dr. B. I believe that you have partially missed her point about the pre-op blahs.
After the fasting, enema, maybe stopping some meds, or starting others, combined
with the worry over the operation, oftentimes, the patient presents at pre-op
felling crappy with a bad headache from not eating.

Ok back on topic…. ;-)

-amr
Sunday, November 18, 2007 11:03:00 PM

Anonymous said...
If anyone in intrested I have put all the news articles about *bad apples* in one
folder and have placed them on a public file sharing site so everyone who wants can
download and read them for themselves. There are over 700 articles in this file.
http://rapidshare.com/files/71171118/doctor_misconduct.zip.html
Thanks
Mike
Wednesday, November 21, 2007 10:56:00 AM

Anonymous said...
js md you write on your privacy blog ---- "The AMA which has guidelines for
chaperones does not address this at all, probably knowing that providing male
chaperones would be a burden for many offices. But I think that patient privacy
rights here should be primary."

Could you please explain to us how this is any different than requesting same gender
care (only in certain situations, as in exposure)at a hospital? I agree with this
statement, however, if this became a practice at offices, than it should apply to all
medical settings or you'd have a double standard. Your willing to require this at
offices were staffing levels are low but not at hospitals were they're high? I'd just
like to understand your view. Being employed at the office may be, in the doctors
mind, all the justification s/he would need to use assistants or aides as chaperones,
it depends on how one would view it.

JK
Wednesday, November 21, 2007 10:45:00 PM

Maurice Bernstein, M.D. said...
For an interesting commentary by an obese female visitor who finds that doctors
consistently fail to want to perform a physical examination on her (along with my
response)go to today's (November 22,2007) Naked thread. If you have comments on
the posting, please write them there and not on this thread in order to maintain
continuity. Thanks. ..Maurice.
Thursday, November 22, 2007 8:28:00 AM

js md said...
JK,Chaperones by definition are observers. They are not medically necessary for
whatever is being done. They are there to increase the patient's comfort, not to
decrease it. If they decrease the patient's comfort, the patient ought to have the
right to refuse them.
Assistants, technicians etc. are there for patient safety and the situation is not
comparable to my mind.
Thursday, November 22, 2007 10:36:00 AM

Anonymous said...
Again js md, I agree with what your saying but the fact remains that some doctors
won't go through with an exam without the presense of one so that, to me, means
if I want treatment, they are necessary. My point was that if you would burden
offices with this resource, it should apply to ALL medical settings. Yes, it would be
difficult to manage but change isn't suppose to be easy. If the patients safety is
first, why put him or her through something that could have a long term affect on
them emotionally? I work in the computer industry and change occurs often and fast
but we MANAGE to keep up so we can stay competitive and make money.
JK
Thursday, November 22, 2007 10:48:00 PM

js md said...
I know what you're saying JK. But most doctors will do exams without a chaperone
present except for pelvic exams, and then most would want an actual assistant
there anyway. If you looked at my blog you'll have noted that a physician wrote he
offers chaperones to all his female patients but most prefer not to, even though the
chaperones are of course same gender. I believe few physicians would insist if the
patient objected. Most patients just don't realize that they can speak up and make
their preferences known.
Friday, November 23, 2007 11:34:00 AM

Anonymous said...
I'm the anonymous poster from 7:03pm on Nov 14. I thought others might be
interested in how this situation resolved.

When the PA who did my pelvic exam called with the results, I asked her if I could
schedule a meeting with her to discuss the appointment. She agreed immediately.
When I got to the office that day we sat down and talked. It was definitely
awkward, but I think the conversation was constructive. Basically what it boiled
down to was that even though she is fairly experienced she is still early in her
career, and she'd never had to do a gyno exam on a patient with a history like
mine. In the nearly five years I've seen her she knew I hadn't gotten an exam, but
she felt hesitant to bring it up since I didn't. When I finally did, she was determined
to do my pelvic herself since we had so much prior history, rather than handing me
over to someone I hadn't seen before.

Long story short, apparently everything went wrong for her as well as me. She was
being shadowed by a trainee medical assistant that day, she was running late, and
she had decided that the best way to handle my case was to try to keep things
casual and light so I wouldn't feel stigmatized. She didn't think about the position of
the exam room or the lack of a movable curtain until it was too late. She herself
was very nervous and uncertain during the procedure, and even though my distress
was clear she didn't know what to do about it and couldn't think of any other way to
respond other than to get things over with as quickly as possible.

This is what the PA told me, and based on my past dealings with her I believe her.
It was clear to both her and the office staff that something had gone wrong -- I was
crying as I checked out -- but she was afraid to contact me first, as she thought that
might make things worse. During our talk she asked me to tell her in detail what
had gone wrong during my exam, and what she could do to prevent that in the
future.

I was genuinely surprised that she was as scared and at a loss during my visit as I
was. It's hard not to think of doctors as people who know everything. I was working
hard to overcome my fear of having a gynecological exam, and unbeknownst to me
the PA was working just as hard to overcome her fright at her first time of doing an
intimate exam on a rape survivor.

That doesn't make what happened to me any more acceptable, but I suppose it does
underline how important training and education are.
Friday, November 23, 2007 8:23:00 PM

Maurice Bernstein, M.D. said...
Thanks Anonymous for giving us the followup on your experience. You show that
there are two sides to every conflcting situation and it is worth knowing what the
other side is experiencing. In this case, the followup communication you carried out
with the PA was therapeutic and constructive both for you but also for her. That is
why in all my commentaries in all my threads I have called for
communication,communication,communication. Again, thanks. ..Maurice.
Friday, November 23, 2007 9:38:00 PM

Anonymous said...
Anonymous -- Can you tell us what you told the PA about what went wrong and how
she could improve?

Your story is very instructive. As I read your last entry I couldn't help thinking that
the PA may have, in fact, been a victim of her education. I've never read anything
published by PA's about their education, but I have read a number of publications by
physicians about their education. To the person, they claim that they were
instructed to always act as though they are in control and know what they're doing,
even when they are unsure of themselves. They should never reveal their
weaknesses. If one fails in these endeavors, the patient will lose trust in them.
Maybe the PA was acting on this advice and, in your case, it backfired. Had she
openly expressed her uncertainty and worked in parnership with you, your
experience may have been very different.

It appears as though the PA tried to explain rather than justify her behavior. If so, I
find that refreshing and you seem to have found it reassuring. So many people fail
to conceptually distinguish between justification and explanation. One can explain
the most outrageous cases of "man's inhumanity to man" but it's the epitome of
cynicism when one uses those explanations as justifications. -- Ray
Saturday, November 24, 2007 9:33:00 PM

Maurice Bernstein, M.D. said...
Ray, I can't speak for other medical schools than the Univ. of Southern California or
for the "hidden curriculum" that goes on in training year 3,4, internship and
residency, but in the "Introduction to Clinical Medicine" course that I
facilitate..never, never, never has there ever been guidelines to the faculty
regarding teaching the first and second year students to be always acting " as
though they are in control and know what they're doing, even when they are unsure
of themselves." Or that "they should never reveal their weaknesses. If one fails in
these endeavors, the patient will lose trust in them." I have never told the students
anything like that and I am sure that none of my faculty colleagues has done so
either. I have never thought of myself in these terms in the relation to our patients
and therefore I would never teach them such misleading techniques. In fact, we
teach them to be honest in talking to patients. Moreover, patients themselves can
sense when a student or physician is stumbling over their techniques or diagnoses.
When I was an intern and early resident and had difficulty entering the spinal canal
for a spinal tap, I would tell the patient my difficulty and say I will get assistance
from a superior. When I can't come to a conclusive diagnosis, I tell the patient what
my thoughts are but also suggest that I may want the assistance of a specialist.
Patients have more trust in physicians who are honest in their interactions with the
patient. Patient would rather have the doctor direct his or her interest to the
betterment of the patient and not to be directed for the betterment of the
appearance of the doctor. ..Maurice.
Saturday, November 24, 2007 10:55:00 PM

Anonymous said...
Js md, I can see that we can agree to disagree. Seriously, I’m not trying to give you
a hard time on the issue. I’m just looking at it from where it would be more
beneficial and make more sense. I’ve never had to deal with a chaperone so that
may be part of the reason I’m questioning you so much.

Anonymous from Nov.14th @ 7:03 --- Glad to hear everything worked out for you
and hopefully you’re at peace with it. It’s also positive to hear that the PA
committed to change and recognized the mistakes. As bad as that experience was
for both of you, it sounds like you each learned from it and that’s always a positive.

JK
Sunday, November 25, 2007 7:17:00 PM

gve said...
I have been told I need a TRUS biopsy. I contacted the hospital which I was due to
have it performed at and requested an all male team. The nurse I spoke to first said
"I have never heard anything so ridiculous in 20 years nursing" I asked to speak to
the radiographer who would perform the procedure (a man) who was not interested
in helping me by providing a male nurse (he did however insist that an assistant was
absolutely essential).

I contacted the hospital patient liaison service and asked for their help - same
response.

I contacted the same hospital with a freedom of information request about the
possibility of females having all female teams for their treatment in Obs/Gyn
procedures.

I received the following response
"Please find below the Trust response to your enquiry.

The Trust has no formal arrangements in place, but where women request this we
endeavour to meet this need. We are very fortunate in having 6 female consultant
gynaecologists/obstetricians in the South and 2 females in the North of the county
area with a further one female in a locum position at present.

All our gynaecology nurses are female, and currently we have only one male midwife
so women are generally attended to by females, especially if this is requested. We
are also fortunate enough to have some dedicated female consultant anaesthetists
to support the service.

The only time when this could prove difficult to achieve is when there is an
emergency admission or procedure out of hours when the on call rota is divided
between all members of staff. In these circumstances it may be difficult to facilitate
an all female team, but every effort will be made to try and accommodate any
reasonable requests.

Yours sincerely
etc"

I am "communicating communicating communicating" I am being told no no no!
Monday, November 26, 2007 8:58:00 AM

Maurice Bernstein, M.D. said...
gve, sounds like you are writing from the U.K. Nevertheless, I suspect those of us in
the U.S. would find a similar response at some institution.

I think your institution's behavior and written response to you is grossly sexist and I
think you should make a "fuss" and not ignore it. You should have a sit down
discussion with the administration and get direct responses with explanations to
your concerns. You deserve nothing less than this. Good luck. ..Maurice.
Monday, November 26, 2007 11:01:00 AM

Anonymous said...
I'm a bit confused by gve's post.
Gve, did you write as a general enquiry asking for policy regarding females (or) as a
man
asking what the policy was regarding women seeking same gender staff for OB/GYN
as opposed
to your treatment up to that point? If you did get them to reveal information to you
without
the direct connect to your request, then I would bring them their own words and
threaten legal
action. I believe you're in the UK and I don't know what the law is there. In the USA
we have a
1964 ruling (BFOQ) which links
privacy to modesty and then allows
requests for same to trump discrimination in gender hiring. Therefore, all US
medical/health care institutions have the ability to balance staff by gender. If they
are unable to comply in non-emergency situations, then they haven't used the BFOQ,
they are required to use, to protect privacy (which is linked to modesty in pelvic
care by the ruling). In the US, medical insitutions are always resisting this need to
comply because far too many nurses and med-techs are female and nothing is being
done to reduce their precentages in the labor pool through affirmative employment
action. Undoubtedly, this is the same stonewall you're running up against in
England. Good luck in your direct attack on it. Remember, it only takes one ruling
to start the snowball of change rolling. CHUCK McP

P.S. Dr. Bernstein, what response did you receive from St. Michael's Hospital in
Toronto regarding same-gender care in ultrasound procedures?
Monday, November 26, 2007 3:33:00 PM

Maurice Bernstein, M.D. said...
CHUCK McP, good question and thanks for reminding me. No, I haven't received any
response though the request was sent 12 days ago and they indicated on their site
that questions would be answered in 2 working days. I guess I'll try again. ..Maurice.
Monday, November 26, 2007 4:21:00 PM

Anonymous said...
Dr. M -- I appreciate your approach to student instruction. Your earlier posts would
lead me to believe that your approach is different from those experienced by some
medical students in some medical schools.

My hypothesis that the PA may have been a victim of her education was based on a
number of publications by physicians about their medical school careers. Among
these, the highest quality publication was, arguably, by Melvin Konner (1984.
"Becoming a Doctor: A Journey of Initiation in Medical School). I relied on recall
when I suggested that med students were taught to appear as though they were in
control even when unsure of themselves. It may have been, as you suggest, that
Konner was writing about the hidden agenda in medical school education, for he did
write extensively about it.

You have made reference to the hidden agenda in medical school education several
times in this blog. Konner and Conrad in a 1988 publication (can't remember the
title) tell their readers about how the hidden agenda in med school is
communicated. I'll let them speak for me.

I referred to Konner's publication when I presentd a paper in Chicago a few years
ago to explain, in part (and only in part), what Erving Goffman (1961. "Asylums")
calls the mortification process which includes the unnecessary intrusions and
indignities that some people have described in this blog. Here are some excerpts.

The mortification of patients' selves is made possible by at least two phenomena,
one of which is the adoption of a unique language that communicates contempt for
patients. This language, which is part of the hidden curriculum of clinical training,
takes two forms. First, healthcare students are introduced to a specialized
vocabulary which, by denigrating and making fun of patients, helps sanitize and
legitimize their mortifications (David Simon, 1999. "Elite Deviance," p. 281).
Goffman, for example, identifies denigrating terms used by staff in asylums
including "worry wart," "nuisance," "bird dog," "fish," and "swab." Konner also
introduces his reader to denigrating vocabulary words used by healthcare providers.
He gives the reader a vocabulary lesson that includes over 100 terms, 36 of which
are pejoratives referring to patients. The ones I have heard used by healthcare
providers in the last few years include "GOMER" (acronym for "get out of my
emergency room" -- refers to "an old, decrepit, hopeless patient whose care is
guaranteed to be a thankless task; usually admitted from a nursing home"), GOMERE
("female gomer -- pronounced 'go-mare,' as if it were a feminine ending in French
which, though an ironic sort of gentility, gives the old demented woman a sort of
touching respect even while allowing the provider yet another level of mockery"),
M.U.O. ("marginal undesirable organism," synonymous with "dirtball" and "worm"),
"crock" ("patient with nothing physically wrong; appears to be short for 'crock of
shit,' but the latter full phrasing is never heard; a hypochondriac or somatizer;
candidate for 'psychoceramic medicine'"), and F.L.K. ("funny looking kid; on a
pediatric service, a child whose facial or other physical characteristics suggest the
possiblity of genetic or chromosomal disease").

When confronted, the people who used these terms were quick to point out that
they "mean nothing by it." However, when asked if they would use these terms in
front of patients or their families and tell them what they mean, they invariably
insisted that they would not. One respondent, in fact, proclaimed with unmasked
irony, "I wouldn't be so cruel as to do that."

Language that denigrates patients is also communicated through crude and
offensive humor. Offensive humor may take the form of making light of patients'
misery. I have many recent examples of this type of humor, but I'll let Konner
speak. He writes about one professor who was a physician and scientist and who was
chosen as professor of the year by medical students. His idea "and, not surprisingly,
that of some of his colleagues -- of how to relieve the sheer boredom of the
lectures, was to make fun of patients and their illnesses. . . Vulgar jokes about
patients are a ubiquitous feature of medical social life, excused as a 'necessary
defense mechanism' in the face of illness and death. But he was not an intern
shooting the breeze; he was a physicaian and scientist talking to a large class of
first-year medical students who had not yet had any official experience with
patients." Konner also describes a young woman who, with the encouragement of
the professor, presented a vulgar poem to the class that ridiculed a patient with
syphilis. The professor later gave a lecture on "the plague," and projected a picture
of a syphilis victim's face on a screen that "was grotesquely misshappen, bolbous,
swollen, and deep purple in color." He then "proceeded to make lame jokes about
the patient that drew peals of laughter from the audience."

In the same vein, Conrad writes the following: "Crude jokes and gallows humor
about patients become part of the everyday scene of medicine. Although making fun
of patients may release stress, it also sets doctors farther apart from their patients.
. . The situation of the medical students, and later [the physician], does not lend
itself to caring for and about patients. Quite the opposite is the case; the situation
often encourages the definition of the patient as an adversary or even as an
'enemy.'"

Medical students are not alone; evidence available to me suggests that nursing
students are also exposed to a hidden agenda and I'd bet my bottom dollar so too
are other healthcare students.

If the system that exists today is even remotely similar to what was described by
Konner and Conrad, and I have reason to believe it does exist in some places, it is
no wonder that patients' needs to preserve their modesty, self respect, and dignity
can be ignored with such facility in some healthcare organizations. -- Ray
Monday, November 26, 2007 5:35:00 PM

Maurice Bernstein, M.D. said...
Ray, the medical school is fully aware of the "hidden curriculum" the only thing I can
do in a positive and constructive sense in my position is to warn,warn and warn
again medical students in their first and second years what they might experience
ahead as part of the "hidden curriculum".
I suggest to them what might happen and something about the conflicts with their
superiors when their superiors fail to follow humanistic medicine. And I tell them
that at our school they have faculty who are aware of the humanistic approach to
treating patients and those working in healthcare. They are aware of the stresses of
third and fourth year students and the pressures which may be put upon them by
unthinking,uncaring or just busy interns,residents and attending physicians. These
faculty are present to help mitigate the ethical dilemmas that the students face
with their superiors. But then after they leave our medical school..then what?

Terms:

Those terms regarding patients which you describe, I have heard that they have
been used and it is sickening to me. We doctors all, "but for the grace of God", may
end up being one of those patients who would identified by those names.

With regard to the expression "hidden adgenda", I doubt that the unethical behavior
and communication to which the students and interns are exposed is presented to
them by intent as part of their intentional education, that is as a specific adgenda.
I think it simply represents bad habits of the superiors which are intermixed with
the technical aspects of medicine, therefore I would think it being more an
unintentional "hidden curriculum" buried within a necessary educational process.

Ray, thanks for reviewing this aspect of a doctor's education since I think it surely
affects how the doctor is going to behave in the later clinical years and could easily
be related to much of the modesty issues described in my threads. ..Maurice.
Monday, November 26, 2007 6:24:00 PM

Anonymous said...
You're correct, Dr. M. I meant hidden curriculum not hidden agenda. My pittifully
small brain was thinking one thing and my hands were typing something else. Glad
you caught it. Yo estoy estupido hoy. -- Ray
Tuesday, November 27, 2007 2:37:00 PM

Anonymous said...
I hope this question stays on topic, if not, I apologize.

I’m still reading this blog and trying to catch up with all the points that have been
made thus far and reading the corresponding links as well (I’m getting a head
ache!). A conversation started by JD on the topic of leaving underwear on during
shoulder surgery is one that I have a question about and I hope Dr. Bernstein or JD
MD may respond. As I stated earlier, I’ve had to undergo two shoulder surgeries in
the past two years. I chose a different physician during this process because certain
expectations that I had, couldn’t/wouldn’t be met by the other physician. One of
my concerns was how I was going to be handled during the prepping stage of surgery
and this is why I waited so long to get my shoulders fixed. We’ve all heard or read
how you’d be handled in a tradional hospital, exposure is almost a given. But, by
me choosing to have this procedure done at an outpatient facility separate from a
hospital, not only was I allowed to wear my underwear (socks to), I was awake
through much of the surgery and even had a short conversation with the nurse.
Never was I totally stripped of my gown for prep (they just pulled it down to my
waist), No one came into the OR while I was there, I even moved myself onto the
OR table. It was a good experience for me (besides the recovery, that hurts). With
all this said, why wouldn’t I get the same treatment at a hospital? I realize that
they each have different protocols to follow, but the proof is in the results and if
you have the same results, wouldn’t that in itself be enough to institute a change
from within? I understand that they do this for emergency circumstances; I just
don’t understand that if this was necessary (as they claim) then why can I go some
place else and have it done differently? Doing something because it’s always been
done this way is NO EXCUSE! Are hospitals not concerned that they may be loosing
buisness to these facilities? I know that I’ve changed the minds of two co-workers of
where to have the same type procedure done (local hospitals lost their buisness),
and much of their decision was based on not being exposed. Funny what really is
important to someone when you ask them.

JK
Wednesday, November 28, 2007 1:13:00 AM

js md said...
JK,
When this topic first came up, I would have given you the safety line as to how it's
always done here. But I've seen enough now to realize that for many operations it
likely makes no significant difference. I agree that underwear can be cut off in
seconds if needed, like they do in the ER.
I'm sure if they got this request more frequently they'd accommodate people. They
just don't want to change their procedures for what they consider to be the rare
person with unusual or weird requests.
Wednesday, November 28, 2007 10:41:00 AM

Anonymous said...
Jsmd, I believe that most of those posting here are dedicated to making the rare
request, COMMONPLACE, and the unusual and weird, NORMAL. They're tired of
being mocked for having these concerns by staff that doesn't want to be bothered
(even with plenty of advance notice).
-- CHUCK McP
Wednesday, November 28, 2007 1:00:00 PM

Anonymous said...
Thanks for the response JS MD. I agree that it’s a matter of changing their
procedures, what I don’t agree with is the fact that this outpatient facility was
owned by the same hospital that requires patients to endure this. Many hospitals
now (at least in my area) build these facilities to lure physicians to them and have
them conduct their surgeries there. Why do they overlook this there but not in the
hospital? Do you feel it’s more the surgeon’s preference or the hospital? It doesn’t
make any sense to enforce it at one place, and then say nothing at the other. I truly
feel blessed to have had the experience that I had, after reading some of the other
post. By accommodating my request, I felt like I was being treated as a human
being, not a piece of meat or a job. I to would also like to get to the point where
these are ROUTINE instead of weird or unusual. JK
Thursday, November 29, 2007 12:03:00 AM

amr said...
To: JK 11-28-07 1:13 am (and 11-29 post)

I really appreciated your post on what you did regarding your shoulder surgery. The
hospital WILL NOT know anything until you tell them about what you did and how
you influenced your co-workers. This IMHO is a perfect opportunity to make our
voices heard. I would suggest that you write a letter to the CEO of the hospital and
copy the officer responsible for patient relations. Tell them that you chose the
outpatient facility (and why), and that they were this time lucky that they owned
it, or they would have lost all REVEUE from you. I would directly challenge their
hospital policy vs their out patient policy. Sterile technique is sterile technique. I
would also directly speak to your comments on the blog regarding being treated
with respect. AND I would reference this blog and the one started by JSMD. I
wouldn’t stop there, I would cc your doc and call to make an appointment to speak
with someone at the hospital and find how they react. I would put it on the basis of
what can they do to win back your business.

Also, and this might not be the blog for it, but when documented cases can be
made, naming hospitals / doctors is more effective. If they are not named, then
there is no pressure to change.

--amr
Friday, November 30, 2007 11:56:00 AM

Maurice Bernstein, M.D. said...
amr, I agree that this is NOT the blog to be "naming names" (as I have previously
explained)but I also agree that at some point behavior of institutions that warrent
change should be identified in some venue. Particularly if the concerns have been
directly and personally discussed with the institution and explanations or intent to
change is then still inadequate. ..Maurice.
Friday, November 30, 2007 12:19:00 PM

Anonymous said...
Amr,

Thank you for the suggestion. The last procedure I had was over a year ago and the
physician that performed it is practicing at another facility now so I dought any of
my concerns or displeasure would have any weight right now. I do recall the first
conversation that I had with the surgeon regarding his procedure as opposed to
hospital and he told that many just don’t perform in the manner he does, I guess
that’s why it takes so long to get in to see him. The one mistake I made was not
telling my original physician why I chose to have it done elsewhere. As I stated in
my earlier post, I thanked him for all he had done for me and just left it at that.
Had I known then, what I know now, I would’ve scheduled an appointment and let
him know why I chose someone different. Today, being somewhat of an expert on
shoulder surgeries at my place of employment (close to 1000 individuals work here);
I’ll recommend him to anyone that talks to me about how my procedure went and
the recovery. I know that I’ve changed two individuals’ minds but I have also
recommended him to at least 10 other people this year. This is bad to say, but I
feel proud to stick it to all the local hospitals in my area (4 within 30 miles of my
address) and I’ll continue to do such until things change. I’m still curious as to
whose policy really gets precedence, the surgeons or hospital? I suspect that it would
be the surgeons but I’ve heard different. If any surgeon is reading this blog, I’d
appreciate your input. JK
Wednesday, December 05, 2007 9:54:00 AM

amr said...
To further the discussion about office layout: My wife had to go in to get an MRI on
her remaining breast as part of the more aggressive cancer prevention / early
detection follow-up. I was allowed to be with her in the MRI room, but not in the
control room because of “HIPPA”. There were several violations of patient privacy
that I noticed at the center.
1. The door to the control room always remained open. Although there was an
alcove into the control room so that you would have to stick your head into the
control room to see the MRI room, anyone doing so could possibly see the patient.
2. The door to the MRI room was never really closed behind the tech as she entered
the MRI room. Finally when the door once was wide open, I asked if I could close the
door and reminded her about patient privacy. She did say she was sorry, and that
they had started to do more of these types of studies here, and they were relearning
how to be more descrete. There is a shade that can be lowered in the control room,
which she did in fact lower at some point.
3. I will say that making sure my wife was minimally exposed did occur, but the
opportunity for her to be exposed to someone in the hall did exist because of the
door and shade situation.
4. The facility had at least 5 MRI rooms. I freely wandered the halls checking out
the facility. (I made sure that a MRI was not in use before checking things out.) For
some of the MRI rooms there was a common control room managing 2 MRIs.
Therefore, the designers of the facility had no consideration for the privacy of
patients in and amongst the techs.

The facility though did have designed in the ability to protect patient privacy.
However with doors left open and shades not drawn, those built-in facility designs
were bypassed. It was up to me to make comments.

Now to be balanced, because they were very careful to minimally expose her when
she was being positioned, actual exposure was going to be unlikely. However, what
I speak to here is that the safeguards that would have made it a moot point were
not used. It would have been a simple thing as a matter of procedure to draw the
blinds to the control room and close the door to the MRI when entering.

This issue here is one of training and a little common sense. My wife pointed out to
me that the cost of not sharing a control room would drive up the cost of service.
Also, it could mean that one or two less MRI stations could be fit into the
floorspace.

--amr
Thursday, December 06, 2007 9:58:00 AM

gve said...
A few weeks back I posted a response I received to a freedom if information request
I made about an all femaleteam for obs/gyn procedures. Here it is again -

"The Trust has no formal arrangements in place, but where women request this we
endeavour to meet this need. We are very fortunate in having 6 female consultant
gynaecologists/obstetricians in the South and 2 females in the North of the trust
area with a further one female in a locum position at present.

All our gynaecology nurses are female, and currently we have only one male midwife
so women are generally attended to by females, especially if this is requested. We
are also fortunate enough to have some dedicated female consultant anaesthetists
to support the service.

The only time when this could prove difficult to achieve is when there is an
emergency admission or procedure out of hours when the on call rota is divided
between all members of staff. In these circumstances it may be difficult to facilitate
an all female team, but every effort will be made to try and accommodate any
reasonable requests."

I then made a similar freedom of information request for men facing a transrectal
ultrasound with prostate biopsy (which is a procedure only men have done) this time
I received the following reply -

Given the many factors involved in the delivery of care and treatment to patients,
the Trust, whilst always willing to consider specific requests, could not give a
guarantee that such requests could be met.


Spot the difference!
Friday, December 07, 2007 11:44:00 AM

Anonymous said...
"Every person is stripped totally naked some time during the preparation procedure,
if general enesthesia is used."

I found this comment on one of the VOY links above. Could one of the good doctors
respond if this is accurate even if I was assurred by staff that my underwear would
remain on? JK
Saturday, December 08, 2007 1:05:00 AM

Anonymous said...
Dr.Berstein,

Have you given any thought to putting a hit counter on this blog. Might be
beneficial to know how many people other than those posting are paying attension.
Just a suggestion, you can download them for free, just google ‘hit counter.’ JK
Saturday, December 08, 2007 11:19:00 PM

Maurice Bernstein, M.D. said...
JK, thanks for your interest. I have a rough idea via the Sitemeter
information..about 15-25%for either entry or exit threads of my 300 daily visitors.
I'll look into another hit counter for more exact and fuller counts. ..Maurice.
Sunday, December 09, 2007 8:20:00 AM

amr said...
To JK from 12-8-07:

Although I’m not a doc, I have done extensive research on this matter as a part of
my issues regarding this topic. See My Blog Entry Above regarding body prepping
and nudity in the OR.

Part of my entry above: “The reality is that the process of prep although very
procedurally defined as to outcome, is done by several people, and the order of who
did what, when, and what type of prep is required, dictates how long you were
exposed. Your entire body is being operated on, and the teams responsibility is to
have your entire body come though without damage. So positioning on the table is
vital to a successful outcome. They NEED to see your body alignment in order to
make sure that you will come through the operation without skin sores, or nerve
damage. It’s pretty hard to do that with a gown on, or at least lifting the gown up
to look at the alignment. Once you are draped however, only the part of your body
that is needed for access is exposed. Even your face sometimes is covered to
preserve your body temperature.”

I would hope and pray that your request was honored, especially if they assured you
that they would keep your underwear on. Depending upon your surgery and the
length of time that you were on the table and the position that you were placed,
someone would still probably have lifted the gown briefly, to make sure that your
spine was aligned. However, with your underwear on, your “privates” would remain
“private”.

Is it possible to speak with your Doc to get further reassurances? The bottom line is
“trust”. What does your tummy say about how you were treated?

Take care,

--amr
Sunday, December 09, 2007 10:47:00 AM

Anonymous said...
Dr. Bernstein,

Can you please tell me how a female patient can make sure all of the medical
doctors, nurses, and OR Tech are females for an ob/gyn procedure? Do any hospitals
have special forms that patients can fill out to request this arrangement?

MR
Sunday, December 09, 2007 10:00:00 PM

Maurice Bernstein, M.D. said...
MR, if you read the many posts above you will get the view that there is NO way for
a female patient to "make sure all of the medical doctors, nurses, and OR Tech are
females for an ob/gyn procedure." With regard to "special forms that patients can
fill out to request this arrangement", the answer is most likely NO and that is the
point of most of the postings on this thread. The best you can do is before hand tell
your concerns and wishes to your doctor and then depend on one of the main
responsibilities of a physician: TRUST. Good luck! ..Maurice.
Sunday, December 09, 2007 11:13:00 PM

Anonymous said...
Dr. Bernstein,

The reason brought up this issue is because I'm very upset about what happened to
one man's wife who had a hysterectomy. I don't know her personally. They had
requested that the surgeon, assistant, nurse, and anesthiologist be females. That
worked out, but there was an Operating Room Tech who was a male. I don't want
something like this to ever happen again. Do you think that maybe this happened
because they forgot to ask for a female OR Tech? The husband is not crazy. He just
loves his wife so much. You can find the story below.

My wife had a hysterectomy recently. Her Gyn is a female and per her request the
assistant Surgeon was a female as well as the anesthetist and the circulation nurse.
When my wife was taken to the OR(she was already drugged) quite to her surprise
and disdain there was a male in scrubs in the room. We later found out that person
was a OR Tech whose duties include preparing all supplies and the OR and handing
the surgeon supplies (instruments) during surgery. Not too big a deal right.
For those who don't know what happens prior to surgery let me briefly explain.
The patient is placed on the OR table and is anesthetized. When the patient is out
the fun starts. For a vaginal hysterectomy the gown is removed or pulled up so far
as to make it useless for privacy. The patient is then prepped, scrubbed from just
below the breasts to the anus. This includes spreading the vagina and cleansing the
inside. this of course is done whle in the lithotomy position and everthing spread
wide for all to see. When complete the patient is left in that position and naked
waiting for the surgeon. When the surgeon enters she, with the help of the OR Tech
then place the sterile drapes on the patient covering all but the surgical site.
Needless to say, this is a very private and personally sensitive operation that I
believe should be limited to female personnel only. That would have been our
choice.
Monday, December 10, 2007 9:53:00 AM

Maurice Bernstein, M.D. said...
Anonymous from today December 10 2007, I presume you are MR from yesterday. In
any event, in order to provide some documentation of validity to the scenarios
presented, it would be appropriate that if the scenario was not a personal
experience by the visitor or family member, that a reference be given as to where
or from whom the story was obtained. Such as, a relative or friend or some other
source and without naming names except for the naming of a reference blog or
other internet or news source. This request is simply to try to prevent diluting the
value and significance of this thread with "made up" stories represented as a real
experience. ..Maurice.
Monday, December 10, 2007 11:27:00 AM

Anonymous said...
Got assurance from two different physicians that my request would be honored. He
had it noted on my chart and said that this rule was really for nursing and that he
thought, and I quote, it was a dumb rule to start with for such a minor procedure as
mine (repair torn knee cartilage, 20-30 minute procedure). I had to contact three
different people to get this secured. Still uneasy about using general anesthesia but
I don’t want to rock the boat to much; I’m grateful for my one accommodation. I
almost made it through the year without any problems; maybe next year will be
kinder? Still curious as to who really calls the shots? From my experience, it’s been
hospital, physician, and now nursing policy. I guess all you can really do is
communicate and hope for the best outcome. JK
Monday, December 10, 2007 1:34:00 PM

Anonymous said...
Dr. Bernstein -- I recently happened upon "studentdoctor.net" and a posting there
entitled "pelvic exam on anesthetized women." I skimmed through the posts and got
the impression that the largest percent or a significant minority of the student
posters defended the practice of nonsensual (or non-specific consensual) pelvic
exams on anesthetized patients. My initial impression, without studying all the
postings in detail yet, is that were all those who posted allowed to verbally express
their opinions, those who favored the practice would drown out those who
questioned its ethical propriety.

To defend the practice, some medical students used the old worn out, "How are
students to learn?" while others tried to defend the practice as a benefit to
patients; still others defended the practice by conflating necessary and unnecessary
pelvic exams; some argued that patients in general benefit by this practice; others
argued that they have a right to engage in the practice; and some agreed that
informed consent does not apply to this practice.

In an earlier post, I cited research ethicists who report in the American Journal of
Obstetrics and Gynecology their and others' conclusion that a significant number of
medical students' ethical position regarding the practice in question disintegrate
between the time they begin and the time they end their OBGYN rotations. Some
contributors to "studentdoctor.net" must already be there; if not, it is chilling to
imagine where the disintegration of their ethical principles will end.

I'd appreciate your impressions of the contributions made to "pelvic exam on
anesthetized women," if you have a mind to take a look at them. -- Ray
Thursday, December 13, 2007 6:28:00 PM

js md said...
Interesting thread Ray. Here's the actual url.
Different points of view, some of which are valid, such as not all of these pelvics are
done for a purely learning experience, but also to feel the pre-op abnormalities
better. But informed consent should always be the cornerstone.
Friday, December 14, 2007 9:31:00 AM

amr said...
Ray - Here is a direct link to the blog you were referring to: Pelvic Exam Med
Student Blog. This will provide “easier access” (pun intended) to the site you
referenced. My quick read of the posts showed a few things to me:
1) Last post was in Oct of 04 – this is not an actively discussed topic.
2) All sides were aired
3) It is still a common practice as of Oct 04, and I have no reason to believe that it
is otherwise today.
4) As of 04, only CA had enacted legislation against the practice
5) The level of maturity shown by the bloggers was in some cases stunningly absent.
Perhaps this is the most disturbing aspect of this blog. It makes you wonder who it
is you are allowing to care for you, let alone allowing to touch “any” part of your
body.

The issue is that it is an accepted medical practice, in the name of education, to
violate the trust of the patient, both by omission and deed.

Dr. B – In your reference to trusting your doc in your Dec 9 entry: “The best you can
do is before hand tell your concerns and wishes to your doctor and then depend on
one of the main responsibilities of a physician: TRUST”: With the net providing a
never-be-for view into the hearts and minds of the upcoming medical professions,
TRUST, must be earned. This is true of any professional, not just a doctor.

I will have to disagree with you regarding all that can be done on this issue of
voicing concerns and trusting the doctor (from the same blog entry). The patient
can stand up and walk out if they find upon reaching the OR that their wishes were
not met. This requires that no meds are given of course prior to entry to the OR,
and the patient must state that no consents will be signed until reaching the OR.
They can require to see and meet all people that will be in the OR and voice that no
one will be there other than who they just met. They can hand a document to the
doctor and circular nurse stating the patient requirement with the verbiage that
they understand that the patient elects to not have the surgery should these
requirements not be met, and even have them sign the document that they
understand the patients needs and agree to meet their needs. This signed document
is important legally, in that shows that a communication was made and heard by
the staff. Though not a lawyer, I believe that if the operation then proceeded and
the agreement was ignored, the surgeon and/or hospital and staff could be guilty of
battery.

This all assumes that the surgery is elective and that the choices made here (health
vs modesty vs educational object) do not effect the patients health and the patient
is forced to compromise for the sake of “life”. This is the compromise that we as
patients must sometime endure. Thus the THE SACRID TRUST of doctors and
medicine is compromised.

I’m pretty sure that there would be some sort of consequence for the patient
however. The hospital and / or doc may elect to not treat the patient. Or,
accommodations might be made, just as we saw happened with JK (Nov 13 entry).
If the operation doesn’t take place, that would mean lost revenue for both the
hospital and the doc, so it would be interesting to see what would happen.

--amr
Friday, December 14, 2007 10:52:00 AM

Maurice Bernstein, M.D. said...
I see nothing ethical, morally right and perhaps even legally acceptable for students
to perform pelvic exams on women under anesthesia in a teaching hospital where
the consent for surgery was general and not specific for such a teaching exercise.
Further, there is only limited experiential teaching value for this violation of the
female patient's autonomy.
Why? Because, in practice the student or intern or early resident or physician in
practice are mainly going to be doing pelvics on awake patients. The practice
should involve the better ways of communication and behavior with the patient
before, during and after the pelvic exam. In addition, in the awake patient, the
pelvic muscular tone is always a confounding factor in performing a thorough pelvic
exam and it is learning the anatomy and pathology despite this factor that is part of
the value of performing the exam on an awake patient. As for resources, medical
schools employ pelvic exam teacher-subjects who are quite willing to have pelvics
done on them and even provide detailed education to the student doing the exam.
Also, awake patients will give permission to the student with a physician facilitator
for a pelvic exam.

If there is a "standard" of pelvic teaching practice that involves the use of a
anesthetized patient examined by a number of students or others, that "standard",
based on my reading, is going to be discarded as has been the use of nursing
students compelled by the school to be the object of another student nurse
performing a pelvic exam. ..Maurice.
Friday, December 14, 2007 11:24:00 AM

js md said...
This thread has stimulated me to look closer at the process of informed consent. It's
obviously critical for such issues as pelvic exams under anesthesia.
I have posted some thoughts on my blog. Please take a look and add your thoughts.
Friday, December 14, 2007 4:36:00 PM

Anonymous said...
Ray,

With regard to non-consensual pelvic exams, you might find of interest the article
"Using Tort Law to Secure Patient Dignity", by Robin Fretwell Wilson. Here is a link:

link


CLW
Friday, December 14, 2007 9:35:00 PM

Maurice Bernstein, M.D. said...
ATTENTION: Based on the suggestion by js md, I have started a new thread called
"Patient Modesty: Volume 2".

The rules: I will still permit comments to be written on this present thread "Patient
Modesty: A More Significant Issue?" but I would suggest for continuity that followup
comments be kept on the posting site where the original comment appeared.
Therefore, if the comment began on the "Patient Modesty: Volume 2" all followup
comments should continue there. I would also suggest that if any visitor would like
to comment about this posting format change itself, write it on the Feedback
thread rather than commenting about it here or on the new thread site.

Finally, I started new issue about patient modesty on my new site that really hasn't
been discussed here previously. It is a discussion of whether modesty applies to
infants, small children or up to what age. And, if modesty applies to infants and
children WHOSE modesty does the concern represent? Is it the modesty of the
parents? etc, etc.

Remember DON'T comment about that issue here. Go to "Patient Modesty: Volume
2">. I hope all my visitors approve of the change. ..Maurice.
Friday, December 14, 2007 10:31:00 PM

Anonymous said...
I can't stand my gynecologist, she's a pompous know it all who acts like she has to
talk down to me even though I'm an RN with a couple of books published. I won't
take her designer drugs or any of the tests she wants because I have zero desire to
undergo any medical procedures or chemo, or surgery ever! Still the only reason I go
to her is to get my BiEst RX and I wouldn't see a male doctor for this if my life
depended on it. I tell her nurse to let me know 2 minutes before she plans on
coming into the exam room so I don't have to sit there shivering in a paper gown
for 15 minutes.

I find it interesting that you think male doctors are authority figures that I have to
look up to. PLUUESSE!!! I won't give my authority to anyone. I'm sorry for those who
do.
Saturday, December 15, 2007 3:41:00 PM

Anonymous said...
JS-MD, In your comment ofDec. 14 you stated that pelvic exam in the OR should only
be given "to feel the pre-op abnormalities better" I say humbug to this prictice as
well. In most surgery situatitions the paitient has had an examination before she
enters the OR and the surgon knows exactly what is wrong with her. Besides after
he or she brings out the knife everything will be exposed. This just seems like
another empty ritual that is hard to break. In the case of my wife, she had a
complete pelvic examination the day before she had surgery as well as one 6 weeks
eariler. Now her bowling ball size fibroid did not go away all by itself the night
before surgery so why waste even a few minuntes doing an empty exam before
surgery.
Mike
Monday, December 17, 2007 5:21:00 AM

Anonymous said...
amr OR dec.14, i 95% Agree with your soulition to modesty in the OR. I'm not sure
that medication could be held off untill the moment of entry into the OR or if 100%
of the staff could sign off on on the modesty issue. However I do belive that the
paitient should meet the surgon and anesthiologist before being medicated and
these 2 doctors as well as the RN who helps with all the pre-op prep could sing off
on the modesty issue. BUT, YES, if the paintien has to sing papers then the surgon
and hospitle rep. should also have their names on a binding contract.
Mike
Monday, December 17, 2007 5:37:00 AM

Anonymous said...
Anon. Dec 15. I think a lot of people look at providers as authority figures. Dr.s in
paticular but to a large degree most providers, we tend to "blindly" follow
instructions from them and rarely challenge or question. While I think that is
changing to some degree, years of tradition still play a part in this. Personally, I
think this is true male or female, my elderly father had a female primary physician,
she would perscribe a method or treatment or medicine and he would agree without
question. When we were in the car he would have a million questions including "do
you think that is right"?(like I would know anything). He would never think of
questioning her. Likewise, if a nurse tells us, strip down and put a gown on, most
people will do it even if they wonder why they have to....so I think it is as much
position as gender though I could see where in our traditionally patriarchial society
male providers may be given even more authority...we have come a long way to
equality but aren,t there yet.

Out of curiosity, when you say your would never go to a male gyn, why is
this...don't think they identify?....modesty...? This is paticularly interesting as you
are a RN. I am glad to have other providers contributing, I hope you will encourage
some of your co-workers to join in. JD
Monday, December 17, 2007 7:56:00 AM

Anonymous said...
Thank you js md, Dr. B, amr, and CLW for your responses to my post having to do
with comments on "studentdoctor.net" regarding non-consensual pelvic exams.

I conducted a quick and dirty (took me most of a day) content analysis of a random
sample of 70 posts representing 49 individuals on "studentdoctor.net" regarding non-
consensual pelvic exams by medical students on anesthetized patients. Ten didn't
address the issue and, in fact, usually begged the issue. Of the remaining 39
individuals, 30 (77%) favored the practice and 9 (23%) opposed it. One of the 30 was
not in medicine but indicated he was interested in becoming a medical student and
two of the 9 were not in medicine. That leaves 36 respondents in medicine (either
physicians or medical students), 29 (81%) of whom favored the practice and 7 (19%)
who did not. One of the 7 opposed the practice only because of the threat of law
suit, not because he considered it unethical or wrong in some way. That leaves 6
(17%) respondents who believed that non-consensual pelvic exams by students was
ethically/morally wrong. One individual in each category identified herself as
female. The one woman who opposed the practice pulled no punches. She wrote, "As
a woman and a med student I will be filing criminal battery charges against the
physicinas, students and hospital if I am anesthetized and any procedure is
performed on me [that] I did not consent to" in a non-emergency situation.

The justifications expressed by those who favored the practice can be aggregated
beneath the same categories identified by scholars to understand phenomena such
as criminal gang behavior and events such as the My Lai Massacre, the Tuskegee
Syphilis Experiment, and the more recent Abu Ghraib incident.

I'll name these justification categories but won't elaborate on each here. They
include 1) "normalization" (e.g., "Everybody does it."); 2) "denial of injury" (e.g., "It
doesn't hurt the patient."); 3) "denial of responsibility" (e.g., "The attending
ordered us to do it."); 4) "denial of the victim" (e.g., "The patient signed the
general consent form."); 5) "appeal to higher loyalties" (e.g., "It is necessary for the
education of the student" and "It benefits patients in the future."); 6) condemnation
of condemners" (e.g., "Informed consent is the creation of lawyers and I hate
lawyers."); and 7) "appeal to special status" or "don't you know who I am?"
syndrome.

The latter justification category is unique to people who occupy high prestige
positions. Some students wrote of their "right" to do pelvic exams on anesthetized
women or that they had "paid" for the privilege. Some referred to their
"professional" status and some of these students saw themselves as occupying a
status, for all intents and purposes, equivalent to that of the attending physician
who had students conduct pelvic exams in order to confirm his own diagnoses. In
short, the students in question believed they were entitled, by virtue of their status
as medical students, to practice pelvic exams on anesthetized patients with or
without their consent.

These justifications may not represent the thinking in medicine, but I suspect they
do given findings I have cited earlier in this blog. Their use, especially "appeal to
special status," and the boldness with which they are expressed suggest that the
practice in question is very entrenched. And, history suggests, I would submit, that
entrenched practices can only be dislodged, short of revolution, by legislation. --
Ray
Monday, December 17, 2007 5:23:00 PM

Maurice Bernstein, M.D. said...
Ray, thank you for your impressive analyis and dissection of the issue. I would be in
favor of legislation to hopefully finally eliminate this practice which has been
carried out without informed consent of the patient.

As I have already noted here, in common practice, we never anesthetize women to
perform a routine pelvic exam. If it was even done, there would have to be such
great need for the exam to override the risks. As a teaching tool for later value, in
my opinion, pelvic under anesthesia is unneeded and without informed consent, in
ethical terms is unethical, period.

I am most intrigued by your classification: "appeal to special status" or "don't you
know who I am?" syndrome. This brings up an entirely different aspect of the term
modesty and I think that the presence of "professional intellectual modesty" is an
essential component of being a good and ethical physician. A doctor can be skilled
and yet also be modest. To lack this modesty can lead to mistakes and,in addition,
misbehavior in relating to patients and colleagues.

In fact, after a bit of research on my part, I would like to start a thread specifically
on medical professional intellectual modesty. Maybe Ray and others can help me
with this thread. To keep this current thread on patient modesty pure on ths
subject, write any comments or suggestions about a medical professional modesty
thread to me by e-mail (DoktorMo@aol.com) or on my Feedback thread. Thanks..
..Maurice.
Monday, December 17, 2007 7:48:00 PM

Maurice Bernstein, M.D. said...
"But now I feel violated, betrayed and disgusted. I've never been in a hospital and
(my) first experience is the worst thing ever."

This expression of personal dismay and disgust came from Sean Dubowik, who while
under anesthesia at Mayo Clinic Hospital in Phoenix, AZ for gall bladder surgery had
his penis which bore the tatooed slogan "Hot Rod" photographed on a cell phone by
Dr. Adam Hansen,the chief resident of general surgery, who at the time was
inserting a catheter and noticed the tatoo. The doctor later showed the photo to
other members of the surgical staff. Read the entire story of this recent event
written for the Arizona Republic by Kate Nolan.

Pertinent to the discussions here on this thread, according to the article "Under the
Arizona Medical Practice Act, unprofessional conduct can include viewing a disrobed
patient in the course of treatment if the viewing is not related to diagnosis or
treatment. The statute also bans conduct that may be harmful to the health of the
patient."

Does this incident stir emotions in any of my visitors? ..Maurice.
Thursday, December 20, 2007 8:24:00 PM

JD said...
The incident itself speaks very poorly of the Dr. he should be severly disciplined, if
Mayo does not terminate him, it speaks poorly of them. How could you trust a
facility that would allow him to remain on staff. The incident sheds a cloud on the
whole medical profession. But there are some side issues here that have been
expressed in this thread. 1st off he showed the picture to several staff members,
but only one took action? What about the rest, sort of goes to the cone of silence on
allnurse. And what are the odds that a Dr. was the only one present when the
picture was snapped, no one stopped him. Another point we argued here is the
nescesity of a patient being naked for wrist surgery. The arguement was safety,
sterile environment, so why are staff allowed to carry a cellphone camera into the
OR that has been who knows where. Why is it so easy to compromise a patients
concerns under the name of safety yet we allow providers so much leaway. (side
note, I read a study that nurses who wear wedding rings carried a significant higher
amount of bactieria on thier hands, yet I see many nurses w/rings) The Dr. at best
made a huge error in judegement and should pay dearly for it. If he had snapped
this picture through the wall of a dressing room he would be in jail. This is getting
national attention, I heard it on a Chicago radio station, kind of shoots the we are
all professionals doesn't it. But to me, it shows more then anything the us and them
mentality. There is one set of rules for providers, and one for us the patients when
it comes to modesty. While I am sure Mayo is unhappy that the tipster leaked the
patients name....I would bet their commitmment to find the person who leaked the
story is more about the disclosure of the incident than the identity leak. These
incidents just lead credence to all of the issues we have covered here and in Dr.
Shermans blog...while it may be an isolated incident, it casts a wide shadow on the
medical community that patients do not confine to that Dr, or that facility.
Friday, December 21, 2007 5:47:00 AM

Maurice Bernstein, M.D. said...
I would like to make a suggestion regarding the origin but not the defense of the
surgeon's behavior. I suspect the surgical resident's formal professional training and
even his current training have been in institutions permitting an environment or
staff behavior not strictly related to the operation or the patient on the table. This
would include music, usually selected by the surgeon, to be played or the
engagement of the staff in extraneous conversation.. all in the name of the relief of
psychologic tensions within the operating room staff, particularly the surgeons and
anesthesiologists. Perhaps th argument is that tension leads to inattention. If this
has been a standard of practice in these institutions and elsewhere, it becomes the
norm. The patient, as an individual and unique person, usually also covered with
drapes, may then potentially disappear and becomes simply the object being
operated upon. Finally, the surgeon's behavior may be related to his lack of
professional modesty, an expression of superiority. It then becomes psychologically
and morally easy to snap a picture and show it off. Anyway, that is my explanation
of Dr. Hansen's action but as I said not his defense. ..Maurice.
Friday, December 21, 2007 8:09:00 AM

TT said...
JD,

In all fairness, there are some health care providers that do the right thing. Case in
point: Yesterday in Portland, Oregon, a contract anesthesiologist was sentenced to
5 years in prison for felony sex abuse. He was convicted of fondling the breasts &
buttocks of two young women in their late teens/early 20's while they were under
anesthesia for oral surgery at a local clinic. His actions were observed by nurses
present who reported it to their supervisor, which resulted in the oral surgeon filing
a complaint & report to the state medical board.

The curious part of the whole thing is that when the oral surgeon provided the
records of the patients as part of the investigative process, he blacked out their
names, which hindered the progress of a criminal investigation. His rationale was
that if they knew they had been abused under anesthesia it would cause them
mental duress and lead them to not seek medical treatment in the future. The court
ordered him to turn over the names, which allowed the grand jury to complete it's
work and return the criminal indictments.

Both victims were present at the sentencing, and both expressed their outrage at
not only the abuse, but of the fact they were not informed it had occurred. They
were almost as angry with the oral surgeon for not telling them as they were at the
anesthesiologist that abused them.

So here's my question Dr. B (maybe it belongs in a different thread): Is it ethical for
a physician to withhold from a patient the knowledge that they were the victim of
abuse while under sedation or anesthesia?
Friday, December 21, 2007 9:30:00 AM

jd said...
TT There is no doubt there are providers who do right. Even more true is that only
a very very small percentage would do something like this Dr. did. I think there is
however a more widespread acceptance of violations of this nature than what you
cited, the physical molestation of young females would be viewed much more
seriously than the violation of a patients (esp male) modesty. We discussed here a
post on all nurse where a young male patient under anesth. was viewed by numerous
female nurses because of the size of his penis. While some nurses on the blog
condemned the incident, some actually cried no harm no foul, and almost all of
them advised against reporting it. I think this is more to point with this paticular
instance and subject. I would think someone had to know he had taken the picture,
but not knowing surgery procedures I dont't know if it would be common for a Dr. to
be alone with a patient at that stage of the operation, one would think if he was
under anesthesia the ansethiologist would have been present and surely there was
conversation about the tattoo among the OR staff if the Dr was so interested as to
make such an devastating error in judgement...but that is only conjecture.
And I would assume the patient confidentiality comes into play on the investigation
with the oral surgeon, he did report the incident, so he showed some concern for
the patients, maybe poor judgement rather than devious intent...

Dr. Bernstein. I didn't quite understand your reference to lack of provider modesty
earlier but I think I get it now. I think this makes a lot of sense, we give providers a
lot of control over our bodies that we would give no one else...I could see where it
could develope into a feeling of superiority or entitlement....and fuel what I
thought was an us and them mentality...do you think the system "teaches or
facilitates" that mentality or does it just kind of develope from the way providers
are treated, something along the lines of professional atheletes who run into trouble
with the law so often becasue they get to believing the press that they are
special...also do you think this is an individual thing or could there to some degree
be a more widespread profession lack of modesty, and I by no way mean everyone or
to an extreme degree. But it does seem the "cone of silence" is in place and
justification or at a minimum concealing what some providers see as "minor'
breeches in ethics are some what widespread? Are you and I talking about the same
thing when I refer to us and them mentality and you speak of lack of professional
modesty? JD
Friday, December 21, 2007 12:49:00 PM

Maurice Bernstein, M.D. said...
JD,yes, lacking professional modesty ("I am skilled and I am something special. I
know more and I can do more than that patient. I don't have to live with all the
rules others have to obey. Etc..Etc."), the physician is "us" and the patient is
"them". Of course, this conclusion is unrealistic. Without the patient, the surgeon or
other physician could do nothing but trim their own toenails. It is the patient who
brings to the doctor the critical information in the form of a history. It is the
patient who brings the pathology and allows the physician to examine his or her
body to find that pathology. It is the patient who provides the legally required and
ethical informed consent for further testing and treatment. And isn't it the patient
through one way or another provides the means for the doctor to get paid for his or
her services? Without the patient the doctor has nothing. Doctors have got to keep
in mind that as important a player in the final act is the doctor, without the
patient the play would never get there. Yes, JD, you got it right. ..Maurice.
Friday, December 21, 2007 2:09:00 PM

Anonymous said...
I wouldn't be surprised if/when the details of this camphone incident become
known, that the whistle-blower is a female member of the staff. There is a great
deal of institutionalized ill
will between male doctors and female staff. It was a female nurse who turned in the
anesthesiologist in the second case mentioned here. But no female appeared to
make any administrative moves against female action of this kind if the
perp is a female. I'm sure the
sisterhood protects its own much
more than it protects males in all aspects of medical battery.
I don't think this will change until we have an equal number of male and female
policemen in the medical profession to cancel out the advantage of either sex in
regard to these matters.
-- CHUCK McP
Friday, December 21, 2007 2:21:00 PM

TT said...
"I am skilled and I am something special. I know more and I can do more than that
patient. I don't have to live with all the rules others have to obey. Etc..Etc."

It's called a demigod complex, and it doesn't happen just to physicians. You can find
examples of it in any profession where a person has a perceived power or authority,
including professional athletes, actors/entertainers, politicians, clergy, police
officers and judges.
Friday, December 21, 2007 10:03:00 PM

Maurice Bernstein, M.D. said...
TT, I know, I know.. but on this bioethics blog we are focusing down on the
attitudes and behaviors of doctors. I would still like to set up a separate thread on
professional modesty as related to physicians. I am having a difficult time trying to
find resource articles discussing this issue. I wonder if TT or any of my visitors can
help and provide some references which I could use in preparation of such a thread.
Any help in this regard would be much welcomed. ..Maurice.
Friday, December 21, 2007 10:49:00 PM

TT said...
Dr. Bernstein,

I understand completely the focus of this this topic and didn't mean to detract from
that- just pointing that it is a recognized behavior that has a name and is not
exclusive to physicians.

As to resources, try this link:
http://ombudsman.europa.eu/speeches/en/2005-06-03.htm

In the references there are a couple of Articles cited that may have applicable
information (those by Shorter & the Emanuel's) - will let you know if I run across
anything else.......
Saturday, December 22, 2007 10:52:00 PM

Mike said...
Afew thoughts on the cell phone photo doctor.
(1) doctors expect you to turn off your cell phone while on their time and in their
office or exam room. I would think that they would extend you the same courtesy
while you are in their hands during surgery, but again there is the double standard.
Cell phones and pagers should be left in the locker room and not brought into the
OR.
(2) Since this case has gotten a lot of attention the doctor in question may get a
tougher punishment but if it goes as the normal punishment he will get a token slap
on the wrist. Perhaps he will have to take a refresher course in patient relations
and a $2,000 fine. Personaly I think he should loose him prividlege to practice
medicine and have to do something completely different for a living. When other
see how he wasted years of his life then perhaps they will think twice before doing
something like this. The problem in a nut shell is that this doctor did not see any
harm from doing this because there is not a track record of severe punishment for
past action of other doctors. You could argue that it would be a waste of his
training not to give him a second chance but somewhere a line needs to be drawn in
the sand and examples made.

Mike
Sunday, December 23, 2007 2:16:00 PM

Anonymous said...
Just as a follow-up to my December 10th posting, the procedure went great and my
request was honored. It was by far the best experience I’ve had. We had a slight
disagreement with a few questions on the consent form but we were able to work
around them. I was quite surprised by the pre-op nurse when she handed me my
gown to change into and asked me if I would like some underwear for the
procedure. After making three different phone calls to three different groups of
people, this was their standard all along. I asked her what prompted this and she
told me that it helps put their patients at ease and just wasn’t necessary as they
mainly did orthopedic procedures (shoulders, knees, carpel tunnels cases, etc…).
They complete more surgeries in a week than the local hospital in my area does in a
month and they’ve had no issues with infections. Everyone was courteous and very
respectful, I never felt uncomfortable at all.

Just a couple of notes:

This was my first experience (not that I can remember any of it) with general
anesthesia. As JD pointed out in one of his post, that alone normally causes a need
for exposure. Here’s his response:

“The reality is that the process of prep although very procedurally defined as to
outcome, is done by several people, and the order of who did what, when, and what
type of prep is required, dictates how long you were exposed. Your entire body is
being operated on, and the teams responsibility is to have your entire body come
though without damage. So positioning on the table is vital to a successful outcome.
They NEED to see your body alignment in order to make sure that you will come
through the operation without skin sores, or nerve damage. It’s pretty hard to do
that with a gown on, or at least lifting the gown up to look at the alignment. Once
you are draped however, only the part of your body that is needed for access is
exposed. Even your face sometimes is covered to preserve your body temperature.”

Well, this wasn’t at all what I experienced. Never was my gown removed and I
wasn’t given the anesthesia until the doctor was ready to cut, I actually helped
position my knee. Right before I went into the OR, the anesthesiologist came in to
introduce herself and asked me some questions and listened to my heart with a
stethoscope. She listened through my gown and just lifted it to put the electrodes
(or whatever they’re called) on my chest before surgery. I doesn’t bother me to
show my chest but just the fact that she done it this way, said a lot to me.

It’s obvious to me that exceptions/accommodations can be made without
jeopardizing your health (I’m living proof of that!), but is there any materials/stats
available that actually support having procedures done without undergarments?
There have been several noted on this blog that supports using them but have there
actually been test that confirm to do it in this manner? This would be an easier pill
for me to swallow if there have been cases noted where undergarments caused an
infection or complication with surgery but I have yet to find any. Has anyone else
tried to find this information? JK = Jimmy
Monday, December 31, 2007 12:12:00 PM

Anonymous said...
JK
You were fortunate, I intend to start asking in these situations. But even more to
the point, if you google surgery shorts or sugery modesty shorts you will find there
are disposable shorts designed specifically for surgery, they have slits down the sides
and velco closures at the waist and cuff on each side. Provides coverage, access, and
can be quickly removed in an emergency. The ad lists a fly for catherters and sterile
packaging...to me there is little excuse for not offering these garmets..glad to here
your experience wend well JD
Sunday, January 06, 2008 4:55:00 PM

gve said...
I recently had a total hip replacement, which I endured without advance comment
about my dignity in theatre. I have since developed what appears to be an infection
of the hip. Yesterday I required an aspiration of the hip to check for infection. The
rituals I was expected to follow included changing into a gown (no problem with
that) and being naked beneath the gown (which I refused absolutely). I was initially
(reluctantly) offered disposable underwear which is flimsy and transparent. I
declined and insisted I be allowed to wear my own underpants, the procedure was to
be via local anaesthtic, so I was able to hold my underwear out of the way while the
procedure took place. Everything went fine and the doctor doing the aspiration was
fine with my insisting on wearing my own underwear. What is most worrying is that
it was felt that it would be ok to have me naked from the waist down, while there
were 9 (yes, nine) staff in the room participating in/watching the procedure. Given
that I was awake throughout, I would have been dreadfully embarrassed had I been
forced to follow the ritual. STAND UP FOR YOURSELF and keep stating what you
want and point out the nonsense of the ritual being followed, sooner or later things
will change.
Friday, January 11, 2008 8:32:00 AM

TT said...
gve,

Well done in sticking up for yourself.

I'm curious, why were there 9 people in the room for this procedure? Seems
excessive to me for something as simple as an aspiration - seems like 2 or 3 would
have been adequate. Did you ask? You have the right to know who is present and
why, and to ask that those not directly involved in and necessary for the procedure
leave.
Friday, January 11, 2008 9:54:00 AM

Anonymous said...
I can say this forum surprises me because I was unaware this was such a large issue
and others care about this.
My husband had surgery. Inguinal hernia repair. We were told the doctor would do
the shave/skin prep in the OR. Found out the medical director/anesthesiologist lied
to him. The female circulating nurse did it "all" once he was sedated. It made us so
mad we couldn't believe it. We had a terrific relationship and sex life and since that
surgery it tremdously damaged our intimate life. The thought of my husband laid
out naked and two females viewing and handling his genital for 10 minutes and
shaving him made both of us livid. This should be discussed with people. There is no
respect or decency. All they want to do is get the job done and bill it. You are
treated like a piece of meat. The nurses were rude to me and I was told I couldn't
be with my husband in PACU because he was a "big boy". What rude and
condescending behavior. I am an RN and I could not believe the whole experience.
The surgeon falsified the entire H & P, PACU nurse falsified their charting, the
patient spent 30 min in the OR with no surgeon while on general anesthesia and
only the RNFA closing and finishing the case. Never again!!!
Friday, January 11, 2008 1:37:00 PM

Anonymous said...
I think you made a statement that has more relevance than it appears on the
surface. I can say this forum surprises me because I did not realize it......that I
think may be the key.....has anyone ever really researched the issue in a manner
that would be useful in arguing the cause. Is this widespread as we on this blog feel,
or are we the small vocal minority as providers would contend....how would we find
out? It would make our case much stronger if we could produce numbers which could
translate to the almighty $. JD
Friday, January 11, 2008 7:46:00 PM

Anonymous said...
I think the issue discussed here about privacy, dignity, respect, modesty are
probably in a minority. OR nurses say they provide all of that for their patients and
they are the patients advocate, however, the general public going in for surgery
focus on other things beforehand. They have a picture in their mind of laying on a
table completely draped, with a big light overhead and people all garbed in sterile
attire. They are worried about waking up from anesthesia, pain, post-op pain, etc.
It is only after that these other privacy and modesty issue surface. The patient does
not know that their gown has been completely removed and they have been
scrubbed for 10 minutes and perhaps cathed. All of this done by the opposite sex.
Male OR staff do female surgeries as well. When heart surgeries are done the entire
body from the neck to the toes is scrubbed. Female patients are positioned frogged
leg and the inside of the vagina and anal openings are swabbed with cleansing
solution they are using. There isn't any dignity in all of that. Granted it is done to
cut down on bacteria, but most patients don't know this stuff. Nor are they
informed as to who on the team will be doing it.
Saturday, January 12, 2008 11:35:00 AM

Anonymous said...
read cone of silence on allnurse. I think there are some valid reasons there, for me
personally, I don't want to know, I don't want to meet the OR staff, don't want to
know anything about that stuff, but that is me. It doesn't mean I agree with how it
is done and I will continue to push for my rights, but if I am going in and going to
be exposed to a bunch of females, I don't want to know all about it and I sure as
heck don't want to meet them.

One thing that is evident in this wonderful blog, we are all different in what we
want. I think most people want more condiseration...I think the fact that we are
think we should do something about it makes us the minority JD
Saturday, January 12, 2008 5:04:00 PM

Anonymous said...
I went for a colonoscopy and was not very happy with the experience. It was the
first one I had so I really did not know what to expect. While waiting for my turn I
was in a "holding area" and it was one big room. People on guerneys on one side
were the ones going in and the nurses' station in the middle of the room, the other
side were people that had had the procedure done and were recovering (so to
speak). A man was getting off of the guerney for discharge and as I lay there I see
his entire genital area. The nurse was seeing to it that he was getting off the
guerney without falling but she did not pull the curtain or use a half sheet to cover
him. Then there was a man that came in after I did and he was in the pre-op area
across from me and was moving his legs all around, I had to lay there and look at
his genitals. No curtain pulled. I won't go back to that place and I won't have my
family go there. This is what you get in today's world of healthcare! Unbelieveable.
Sunday, January 13, 2008 1:21:00 PM

Anonymous said...
I hope you will make your feelings known to the people in charge, it is tough
sometimes to make your feelings known to the people that can really do something.
This group is on your side but we can not help. At my local facility, after an
experience that I found offensive I e-mailed the patient advocate, twice with no
reply. So I did a little research and wrote the VP of patient relations and cc's the
president and board of directors...got a reply...not what I wanted but I got their
attention. Even if you plan to never return, it will make you feel better and might
actually help someone else JD
Sunday, January 13, 2008 2:41:00 PM

Anonymous said...
Anonymous from January 12th @ 11:35 & January 13th @ 1:21:

I’d have to agree with you that the issue discussed here is in the minority. What’s
more amazing is how little people really know about what happens to them while
they are under. As I’ve stated here before, I have changed three co-workers minds
about where they had their procedures done at (now 4), one was actually scheduled
at a hospital the others were leaning toward using them. After I told them of my
experience and told them what to expect at a hospital and how much exposure was
involved, it was a no brainer for them. In fact, they were all shocked by what they
were going to be exposed to. People need to learn for themselves what to expect
because that information will not be volunteered to you. Until we start speaking up
and expressing our displeasure, little will change. I’m doing all I can to help my
family and friends, my kids will know how to protect themselves, I’m going to tell
anyone that will listen but we have to say something at that time, it does nothing
after the fact. Once enough do so, change will come. Jimmy
Sunday, January 13, 2008 7:14:00 PM

Anonymous said...
A question to today's 1:21pm "Anonymous" poster -- Are you male or female? Either
way, what occurred to you and the men you describe is outrageous. But it's more
than that if you are female; it is a civil breach. For someone to expose a person to
images of naked people, especially of the opposite sex, against their will is
litigatable. Authorities at the hospital where you received your colonoscopy should
know that as should those who administer HIPAA. -- Ray
Sunday, January 13, 2008 7:45:00 PM

Anonymous said...
“Granted that this is done to cut down on bacteria”

I’ve given this a lot of thought and it has never made any sense to me that they put
your body through all of this and yet they do this with the same set of scrubs on that
they put on at their house and never change between cases. Common sense tells me
that if I’m ever going to be required to bare all for a procedure and be humiliated
for the sake of sanitary or infections by g*d I shouldn’t be alone. The staff working
on my case should have to bath in the same stuff as I, should be required to wear
the same gown (with nothing under it for protection), and should have to remove it
and place a sterile drape over their body. If they want to say a patient has to do
this for sanitary reasons, they must comply as well. Have every hospital do this for
one day then ask their opinion on protecting patients modesty, they may find it
important then. Jimmy
Monday, January 14, 2008 1:57:00 AM

Anonymous said...
with regard to the exposure of male genitals during the colonoscopy, I did voice my
anger to the operation. What is commonplace today is the group of GI doctors open
and operate their own centers, instead of using a hospital outpatient area. The GI
groups are large and they pool their money and open their own center. There
evidently is much money to be made. They do 20-30 procedures per day! It is busier
than a fast food restaurant. Only difference is at Burger King you get it "your
way"!!!

When I complained about what happened the facility said nothing.
Monday, January 14, 2008 6:05:00 AM

ds said...
Just a comment here about people suggesting you complain to HIPPA, JCAHO, etc.
After a very upsetting surgical experience, we did file formal complaints regarding
violations of privacy issues. Long story short, they were blown off. Only JCAHO
posted an "ethics" violation on their record. It stays for 3 yrs and is dropped. Who
even checks that? Most people don't even know what that agency is. So bottom line,
it amounts to tough luck. So sorry you had a bad experience.
Monday, January 14, 2008 6:09:00 AM

Anonymous said...
One thing I found is if after sending letters or e-mails with no response I send
something to them certified mail and mention possible Hippa violations etc in the
letter they tend to respond, they are guarded as they assume it is a possible lawsuit
in the making. And while we may not get the response we want, I still think there
is value in the effort, silence is taken as acceptance. The more people we can
convince to speak up the greater chance of change. If we can convince them we are
going to take our money eslewehere and convince as many as possible to do the
same, they MIGHT be a little more responsive....your treatment was unexcusable,
you might have well have been cattle. I am not one for public scences, I wish I were
becasue that would have been an appropriate place for one, make them as
uncomfortable as they are making us...oh and by the way, did you know they make
colonoscopy shorts, disposable, opening in the back...being how they charge about
$2,000 for a colonoscopy, $5 for a pair of disposable shorts wouldn't be to much to
ask. JD
Monday, January 14, 2008 10:05:00 AM

ds said...
Where do you find these shorts? It would be worth it to provide your own. When you
have a sigmoid or colonoscopy done as you know you are on your left side with legs
drawn up and as the lube the area ( I hate to be graphic here, but there is no other
way to express this) and put the fiberoptic tube in the area the camera is there at
the tip of the device and your entire genital area is blown up 3-D in color on the big
screen. All to see and show for all in the room.
Monday, January 14, 2008 1:21:00 PM

Anonymous said...
If you google modesty shorts, colonoscopy shorts, or disposable exam shorts you will
see several sites where you can obtain them, unfortunately they are usually
wholesale any by the case, I have made up my mind the next time I have one I am
buying a case and donating the rest to the facility...the cost vari's but it would be
worth it...I had a female antest & two female assistants, I only wish they would
have put me out before I got to the exam room and saw who all was there Good
luck and I hope you get something that not only helps you, but perhaps those who
may come after you...JD
Monday, January 14, 2008 4:58:00 PM

gve said...
If you would like to see some information about theatre rituals (and especially why
they are actually invalid) do a google search for the following "operating theatre
rituals". If you check out the book "advanced perioperative practice", page 51 you
will see that removal of undewear is generally NOT essential. I am fairly sure it is
practiced to emphasise the control and power of the health care providers and for
NO other reason.
Tuesday, January 15, 2008 1:58:00 AM

Anonymous said...
Speaking of not seeing who is in the room---I don't know if it is better or not. After
my husband surgery, I then knew that the woman that was standing at the foot of
the bed in the OR holding area was the person that shaved the pubic hair, did a skin
prep cleanse that involved side to side to the table, from the navel down to the
scrotol area and his PENIS. All of this handling and viewing for approx 10 min. Then
wiping the solution off and drying. The hair by the way is picked up with a lint
remover. How ducky. So now I have her face in my mind. Then the First Assist
cleaned the wound up afterwards (drapes removed) and put the dressing on. I didn't
see her so I can only imagine in my mind. Which is better, I don't know. I didn't like
any of it. And was lied to about the whole thing.
Tuesday, January 15, 2008 5:23:00 AM

Anonymous said...
Jimmy's comment about skin prep..there are studies that show that when a person
requires immediate surgery because of an emergency (accident, etc.) there is no
time for this lengthy 10 skin prepand no infection rate higher than when they do all
of the scrubbing.
Tuesday, January 15, 2008 12:49:00 PM

gve said...
A few days ago I posted about a minor procedure I had just had undertaken, (hip
aspiration). Having had a few days to reflect on the procedure I am now absolutely
furious with myself for allowing it to proceed with 9 staff present (most of whom
appeared to be doing nothing other than watching). The radiographer present
(guided aspiration) looked at me with complete disdain throughout the procedure,
from the moment my gown was raised and my own underwear was exposed.

I have had time to reflect on how I handled the situation at the time, I was
vulnerable, felt awkward etc, (while the staff present were in their own "natural
habitat"), I said nothing about the attitude of the radiologist or the number of
spectators. It was almost as though it was happening to someone else, I felt
powerless to say or do anything. I am posting this because I have said I will always
stand up for myself in future, I fully intended to do so, it was though I was somehow
paralysed at the time.
People say nothing because the power balance is so greatly loaded against them,
you feel so awkward and can find no words to express exaclty how you feel at the
time it is happening. Providers really MUST start to consider the way people comply
through such paralysis and stop confusing this reluctant compliance with
acceptance.
Wednesday, January 16, 2008 6:32:00 AM

Anonymous said...
Commenting on "gve"'s feelings: It is so true that most patients feel the same. That
is how the industry gets by and get away with how they approach care and patient's
modesty. People feel intimidated and vulnerable. They feel they don't have the right
to speak up. Everything happens so fast.

Female nurses think it is funny (ha,ha) if a male is exposed and they are caring for
them. Many will laugh about it. Some have said, "oh, I have seen and handled more
penis' than a hooker."

I have also heard many men say they would prefer a female nurse because they don't
want a man touching them for fear he would be gay. Or a male patient would think
another man would compare genitals (size). I think a female would do more
comparison than a male nurse. Would men want to hear their wife say such a thing?
Like they would enjoy a male nurse?

Until many more patients object and speak up things will not change. OR nurses
even act shocked if you raise a question about a female doing genital based
procedures on male patients. They say, "oh, is that a problem???" Like they have
never heard of this before. Would a male walk into a doctors office and disrobe in
an exam room and have a female walk in and do something like that? How
comfortable or acceptable would that be.

And yet they take you in an OR suite and then everything is OKAY. It is because they
either sedate you or put you under and you don't know who is doing what to you or
how exposed you are or what is being said. If people were informed there would be
objections.
Wednesday, January 16, 2008 12:02:00 PM

jw said...
I am surprised as to the opinions stated here regarding patient's modesty. There is a
surgery center with a website in which the surgeon answers questions. It really turns
into a nifty way for the surgeon to gain patients. He speializes in one area of
surgery that involves mostly men and the groin or abdominal area of the body. My
point here is that there was a question from someone that involved modesty and not
being accepting of having female staff in the OR especially for the prepping. The
surgeon said he was unable and unwilling to accomodate a patients' request as this.
Several people that are regular bloggers PUT this person down so much they so much
as called them a "sicko, mentally deranged idiot" for not accepting the surgeons way
of doing things. What do you suppose is with that?
Thursday, January 17, 2008 4:38:00 PM

Anonymous said...
JW,

I can tell you that the first thing that I would do after I got that response from the
surgeon is to find another surgeon. Most can’t control the staff in a hospital
environment, for a patient to request an all male team, he would have to go above
the surgeon for this approval. The fact is that we are rare and those that find us
deranged or a sicko are really just worried about their future/careers. After all, we
are not complying with their train of thought even though it is our body and we are
putting money in their pockets. I’m sure that we’ve all seen and heard this before,
frankly I don’t care what they think. To be honest, I feel the same way towards
them. Jimmy
Thursday, January 17, 2008 10:13:00 PM

Anonymous said...
Can you post a link to that web site. I would like to see it. I would to know if they
would accomidate for religous reasons JD
Friday, January 18, 2008 7:09:00 AM

Anonymous said...
gve -- I'd like to comment on your statement, ". . . it was as though I was somehow
paralysed at the time. . . Providers really MUST start to consider the way people
comply through such paralysis and stop confusing this reluctant compliance with
acceptance."

Some healthcare providers have actually written about what you describe here. A
nurse by the name of Joan Emerson, for example, wrote a piece (now a classic in
social-psychology) about how male physicians doing pelvic exams, their female
nurses, and their patients contruct their realities during the process of pelvic
exams. The whole examination, Emerson suggests, is structured so that patients
can, in the author's words, disassociate or dissociate from themselves, or, as you
say, experience a sort of paralysis. Of course, psychologists and psychiatrists have
written about how people who are in stressful situations -- such as rape victims --
experience the same thing. It's an adaptive response, that occurs concomitant with
physiological reations, to what the person feels is a highly stressful, traumatic or
repulsive experience.

I've cited authors of studies in this blog who suggest that both male and female
patients are most likely to prefer physicians who are the same gender as they if
their medical conditions involve genital or anal examinations. Other studies
demonstrate that one-third to one-half of ob subjects objected to having been cared
for by male nurses. If scientifically acceptable survey results cannot persuade
providers that compliance doesn't necessarily mean acceptance, I don't know what
will. But, even if providers "stop confusing this reluctant compliance with
acceptance," I don't think much will change because of, among other things, an
entrenched culture of entitlement which has been recognized by many scholars
including Paul Starr in his widely cited "The Social Transformation of American
Medicine." This culture persists in spite of efforts by the feds, the states, the
courts, and even some healthcare providers (who run the risk of being treated like
pariahs) to break it up. Indeed, my personal experiences suggest that the culture of
entitlement may have trickled down to people in the lower prestige healthcare
occupations including unlicensed assistive personnel some of whom appear not to
have even completed puperty. -- Ray
Friday, January 18, 2008 5:01:00 PM

JAKE said...
Hi,
To the women who is an RN and her husband had hernia surgery and needed to be
shaved and they were told the doctors was going to be doing the shaving and it
turned out to be a female nurse doing the shaving?
1) Your a nurse, how many times do you really think doctors are going to shave
patience?
2) Your a nurse, how many times a day in every facility around the country do you
think a male patient has a foley inserted, is prepped for surgery (shaving) or is
exsposed to female caregivers without an option?
3) Your a nurse why did you not have your husband shave at home you knew he was
going to be shaved?
4) Your a nurse take your anger and help change the Double Standard male patients
must go through in our health care system.
5) I am not being rude just a little confused.
Saturday, January 19, 2008 9:41:00 AM

JW said...
To JD:
The site is http://hernia.tripod.com
Once on the site there is a link for Discussion Board.
Saturday, January 19, 2008 12:11:00 PM

Anonymous said...
We changed dermatologists because the group we went to had a young female
assistant enter the exam room with the physician. She stayed the entire time. Her
purpose supposedly was to document on a small computer the doctors findings. For a
full body skin check this to us was uncomfortable. A male strips to his jockeys.
Granted he is not naked but it was not what we were comfortable with. When ask
for only the physician to be present we got puzzled looks. Is our society that
unphased by all of this I wonder?
Saturday, January 19, 2008 12:53:00 PM

Anonymous said...
Jake,
Your questions in hind sight sound simple. Yet, at the time it was not. I am a
retired RN. I never worked OR. I had some OR rotation in school many years ago. As
a student I never witnessed a skin prep, the patients were draped when I was in the
room. My husband had hernia surgery twice prior, more than 15 years apart. Both
previous surgeries were all males in the room and he was prepped by males. When
he asked about the prep this time he was told the male surgeon would take care of
it in the OR. There are times surgeon do this, granted most are done by the female
circulator ( learned afterwards!). He did not shave at home because the
anesthesiolgist told him not to because he could nick himself and it could cause an
infection. After being told his male surgeon would be doing it, he was comfortable
with that. I did not know how extensive the skin prep is. I researched it afterwards
much to our dismay. It seems even when you try to ask about this part of the
surgery, they avoid the subject and are not forthcoming with the information. We
were lied to and completely misled. He would have cancelled the surgery and gone
elsewhere if he had known. It was elective and not an emergency or life
threatening. Hindsight is 20-20. I cannot do anything to change the double
standard, and there is a DOUBLE STANDARD. Men have to speak up and my husband
certainly will in the future if the need arises. We definitely need more men in
nursing so male patients have a choice.
Saturday, January 19, 2008 1:06:00 PM

Anonymous said...
Annoy. Jan. 19

If you go to Allnurse.com and search cone of silence you will find some interesting
conversation on this very subject as nurses justify not disclosing or misleading
patients for what they consider the benefit of the patient. Sort of "your better off
not knowing". Its right on this subject.

I disagree that you can't help with the double standard. You being female and a
former RN would probably be given more credence than male patients. Please speak
up and speak up loud and often the more people they hear from the greater the
liklihood they will hear it.

I understand how this happened to you and your husband,it sounds like you took the
steps needed to protect his modesty, it was the providers who failed you, somewhat
betrayed your trust. I hope you will tell them so and hold them accountable JD
Sunday, January 20, 2008 8:31:00 AM

Anonymous said...
JD...thanks for the supportive comments. We did feel we ask appropriate questions,
but found that we were not given the whole story or told the truth. They simply DO
NOT discuss this with patients. It is stated in most patients' rights documents that
it is the responsibility of the patient to ask. We did ask and were lied to. Ironically,
most patient are so unfamiliar with the routines of the healthcare field and surgery
specifically they do not know what to ask. I would not know what to ask a car
mechanic, because I am not knowledgeable on the subject.

I feel it is a cop out. It throws all of it back on the patient. The other issue is that
many smaller facilities are limited with staff. The smaller ASC's (ambulatory surgery
centers) are physician owned and may or may not have male nurses for the OR.
Many surgical techs are male, however, they usually do not do skin prepping. They
are sterile. The circulator is not sterile. Thus, they do a non-sterile procedure. The
shaving is done with an electric razor now days. Loose hair picked up with adhesive
tape (like a lint roller). I delved into all of this after we found out we had been lied
to.
Believe me they all knew how "pissed off" we were. We filed complaints with every
agency on the planet. We even wrote to the corporate officers and received a
response from their legal counsel and the head of all surgery centers. We contacted
the surgeon, administrator, and anesthesiologist/medical director.
I am sure we were the talk of the place for quite some time. Nothing changed. All
the agnecies did nothing. There was no way to right a wrong, no satisfaction. Just
amounted to a great deal of stress and unresolved anger. The
doctors/administrators/nurses, etc. don't give a damn about anything. They walk
out of there everyday and get in their dirty car and drive home, pick up a paycheck
on Friday and that is it.
Sunday, January 20, 2008 10:06:00 AM

JAKE said...
Hi,
I still amamazed you being a nurse you did not realize what a double standard there
was for male patients and what they go through usually very embarrassed but silent
about all the exsposure (but I do know realize the double standard was not the
reason for your post it was because they lied to you). Have you considered going to
one of your local news channels or newspaper who just LOVE to blow up a story if
they can, you could problay remain anonymous. You can do a lot more then you
think for future patients being a retired nurse and all (like JD said) you seem strong
and you are very angry go after them even further. With your knowledge of the
medical field and how they did you and your husband wrong GET THEM for lying and
I do not mean a lawsuit but if you can help break a story you will take money out of
their pockets and that will make them think long and hard about lying to patients
again.
Friday, January 25, 2008 2:56:00 PM

Anonymous said...
its quite simple. SPEAK UP , ASK QUESTIONS PRIOR TO THE PROCEDURE/EXAM ETC.
If you speak up take an active role this wont happen. You are paying for a service.
You tell them what you expect and if they cant accomodate go somewhere else. The
more people who speak up the less this will happen. If your male and dont want a
female doctor politely say you require a male doctor. Dont be aggressive be
assertive. RM
Saturday, January 26, 2008 8:34:00 PM

JAKE said...
NO IT IS NOT THAT SIMPLE...
You failed to mention the Double Standard that happens in the hospital and I am not
talking about the ER many times that is life and death.
When I was 18 yrs. old I had to have an operation I was addmitted two days before
the operation I had 6 enemas all by female nurses I was shaved in my room by a
female aide from the upper thigh to the nipple line. 20 hrs. after the shave the
night after my operation I had 2 female nurses insert a foley. I was later diagonesed
with Non-Hodgkins Lymphoma cancer. About two weeks after the operation I was
the first patient to have a Lymphangiogram test in my hospital. It was 8-9 hr. test
due to complication I had to have a full body skin check every hr. on the hr. to
make sure I was not having a reaction to the dye which was in my feet in between
each toe. It was the most embarrasing 3 weeks of my life and for a teenage male to
have that kind of exsposure to the oppisite sex and worry about getting an erection.
Who was I to complain to? I was on my fathers insurance, I was also brought up not
to disrespect your elders, so if a doctor or nurse said this is how it is going to go
that is basically how it went.
Patient are not taught how to be patients, nurses or aides never explain ahead of
time that anything is ever going to happen, they walk in with the foley or shave kit
and explain what it is and start the procedure within a minunte and a half. The
GREAT do not ask/do not tell policy. Today I can speak up for myself but for first
time untaught patient in the hospital it is a nightmare and I can not imagine I am
the only male this happens to.
Sunday, January 27, 2008 2:24:00 PM

Anonymous said...
You couldve spoken up and said no I want a male. Yes I agree at 18 it is not an easy
thing to do. What I am saying is that if everyone just does as they are told and
doesnt question what is happening nothing will change. Why put youself through
embarasssing situatons that you are not comfortable with. Its the patients body you
tell them who you are most comfortable with. I have three tumors, when operated
on I insisted that a female nurse (I'm female) put in the catheter before the op with
just her my husband and I present. I also insisted that I wear underwear and that my
husband perform and personal care in my recovery or otherwise I would have not
had been operated on. I wasnt aggressive in my approach which helped. I have no
doubt medical staff talked behind my back, but I dont care. For me I wouldve felt
sick thinking of several people in the room while I was naked when things can be
done differently. I also insisted no students. I feel for you but as far as Im concerned
unless patients speak up nothing will change.As for the insurance side of things I am
from Australia so that doesnt apply here. We have medicare which takes care of
medical expenses or you can chose to have private health insurance and go to a
private hospital. You have no problem being assertive in response to my comments,
I sugest you take that assertiveness with you to the hospital next time. RM
Sunday, January 27, 2008 6:29:00 PM

Anonymous said...
Jake,

I hear your frustration. My wife had a similar issue when she was sixteen years old.
She had an ovarian cyst that needed removal and even after she told her mother
that she preferred/wanted to see a female doctor, she had to see a male because
she was on her mother’s insurance. You don’t have many options as a teen, the only
thing that you can really do NOW is make sure it never happens to you or your loved
ones again. We are living with the past generations mistakes, we need to speak up
and teach our kids otherwise. If enough people speak out, they will be forced to
change these rules. Jimmy
Sunday, January 27, 2008 6:42:00 PM

Anonymous said...
Jake

You are on the money with don't ask don't tell. Go to allnurse.com to the forum and
search cone of silence. The nurses on the forum admit exactly what you are saying,
they don't tell as they feel it is best for the patient....of course that depends on
where you are standing or laying as the case may be
Sunday, January 27, 2008 6:45:00 PM

js md said...
Having cancer is hell, Jake, especially when you're young. I'm not excusing the curt
treatment you got and the lack of explanations offered ahead of time.
But it's not just a gender issue. I remember vividly as a med student being given a
tour of the radiation therapy department in the sub basement. There was a teenage
girl on the floor getting a x-ray treatment for Hodgkin's. She was completely naked
and she looked like she was scared to death. So it's not just men who were treated
like that. This was long ago BTW. I don't know what it would be like today.
Sunday, January 27, 2008 8:02:00 PM

Maurice Bernstein, M.D. said...
I want everyone to know that I am all in favor with the patient modesty issue that
has been written about both on this thread and on the Naked thread. As I have
written before, I and other medical school teachers have been intensely aware of
the modesty issue and that making students aware and respectful of what patients
expect with regard to their modesty is an essential underpinning to teaching them
how to perform a physical exam. So it isn't because I am trying to deminish the
meaning or be critical of those who bring up the issue of patient modesty because I
am not. However, I just want to add what I feel there is an important and really the
most important factor that should be on the patients' minds when their physicians
and other healthcare workers are diagnosing and treating their illness and which
virtually nobody in all these commentaries has touched upon.

What is it? It is simply that the goal is to make the correct diagnosis of the illness,
to establish the correct treatment and carry out the treatment with the least risks
and promote the greatest benefit for the patient. Unfortunately this can't always be
the case for every patient. So when a patient goes to a doctor with an illness, I
would think the major thought in the patient's mind would be "will the doctor find
out what is wrong with me..will the testing be successful and won't hurt me..will
the doctor find a treatment for my illness and will the doctor know how to apply the
treatment..if it is a surgical treatment, will the doctor have the skill to fix things
and not have something go wrong and if something bad happens during the
procedure, will the doctor know what to do..will I recover or will I be sicker than
when I started with the doctor?" I know that is what, as a patient, I was truely
concerned about and my modesty was a trival issue of my concerns. I frankly feel I
would sacrifice all my physical modesty for everything to go right and I recover and
am cured. But nobody on either thread seems to be expressing that view.. a view
that modesty though important and steps need to be taken to preserve it as much
as possible and for doctors, nurses and technician not intentionally or without the
use of a potentially mitigating methods abuse the patient's right to modesty, yet
that modesty is not the main goal of medical care.

Again I say, modesty is not the main goal of medical care and a prudent and
conscientious healthcare team may at times have to sacrifice some patient modesty
in order to do a good job which should be also the main goal of the patient. But
nobody has written anything about the goal of getting the disease under control and
hopefully cured. And this goal is not a given. This will not always happen. There is a
possibilty it may not happen and that should be uppermost in the patient's list of
concerns with modesty down on the list.

Again,I am not critical of those who emphasize the importance by some patients of
their own modesty and how those in healthcare may and often do ignore their
patients in this regard. And I am not critical of those who want to change rules of
behavior of physicians and nurses to attend to and attempt to mitigate this issue.
But I think getting well and returning to a healthy and satisfactory quality of life
should be the main thought in all patients.

Any comments? I am sure there will be a few. ..Maurice.
Sunday, January 27, 2008 8:22:00 PM

Anonymous said...
Dr.Bernstein,

Getting healthy is by all means the most important goal with any issue that you’re
struggling with. The fact is that you can get healthy and not have to sacrifice your
modesty. That’s been my issue all along. I don’t care to work with female nurses at
all, but if intimate needs arise, I just want a choice then. That shouldn’t be too
much to ask since I own my body and I’m paying for this service. Those two facts
alone over-ride any equal employment or discrimination laws. Also, underclothes
shouldn’t be forbidden from the OR with as much bacteria that’s already there. If
you’re having a procedure done in the OR that doesn’t involve the genital area, it
SHOULD be covered. People shouldn’t get exposed because of an old, UNPROVEN
hospital policy. Finally, I’m writing here today having gone through two shoulder
and a knee surgery, infection free, as healthy as ever. I was allowed to wear
underclothes even with general anesthesia. Thousands of people do the same, why
haven’t hospitals got the clue? I’m living proof it wouldn’t hurt anyone. If the
ultimate goal is the best treatment and fastest recovery, why would providers add
that stress to a patient? I believe this question has been asked by several with no
response. Jimmy
Sunday, January 27, 2008 9:06:00 PM

Maurice Bernstein, M.D. said...
Jimmy, I am not in disagreement with you. In fact, I have encouraged on these
threads that the writers get together into activist groups to encourage and demand
change of procedures and policies which ignore patient modesty. But what I am
trying to express is that as you say "ultimate goal is the best treatment and fastest
recovery" and I say other concerns should be secondary to that goal. But none of that
is being written here. ..Maurice.
Sunday, January 27, 2008 9:29:00 PM

TT said...
OK Dr. Bernstein, let me play devils advocate.

In your post of 8:220pm, are you saying that the end justifies the means?

:-)

TT
Sunday, January 27, 2008 10:06:00 PM

Maurice Bernstein, M.D. said...
TT, no, disregarding patient modesty is generally not a means for a successful
diagnosis or treatment since at the least it may degrade or abort a productive
doctor-patient relationship and it is not the humanistic approach to medical care.
That is not what I am writing about. I am writing that patients should consider the
goal of medical diagnosis and treatment is for a proper and correct diagnosis and a
safe and effective treatment and their main concern, if any, should be for that and
not about personal modesty itself. I doubt in most medical practices there is no
rationalization that denial or purposely ingnoring a patient's modesty itself is a
means for producing a satisfactory medical diagnostic or therapeutic outcome. So
no.. such denial or ignorance is not a means to accomplish the end. If it is shown
that such a relationship is accepted by some physicians without empirical proof of
its validity, then such a relationship should be abandoned. ..Maurice.
Sunday, January 27, 2008 10:53:00 PM

Anonymous said...
Dr.Bernstein,

I don’t disagree with what you’ve said at all but when I said “the ultimate goal is
the best treatment and fastest recovery” I meant it as if you don’t accommodate
the patients request for same gender care for certain needs, your hindering that
patients care and recovery. I can tell you that if I wasn’t able to find the care that I
wanted, I’d have two bad shoulders and a bad knee to boot today. It’s just not
typical in the healthcare field and providers feel burdened when someone makes it
an issue. As far as getting together an activist group? I have little knowledge on the
subject but feel it would be great to start provided you have the right pieces
involved. This has been briefly discussed on js md’s blog. Jimmy
Sunday, January 27, 2008 11:01:00 PM

Maurice Bernstein, M.D. said...
Jimmy, I look at the issue as a balance of comfort. The patient must feel
comfortable with the doctor's behavior to accept treatment and the doctor must feel
comfortable with what is expected of him or her as part of the diagnostic process
and treatment. If the doctor's expectations are shown to be without scientific merit
or irrational (such as the question of "sanitary" or "safety" practices in the operating
room or for other diagnostic or therapeutic procedures) then the doctor and the
profession should be educated and practices changed. You can't expect a physician
to perform the best when he or she is experiencing discomfort of one form or
another. And I also agree that one should not expect a patient to want to deal with
a doctor who makes the patient feel uncomfortable in one form or another.
..Maurice.
Monday, January 28, 2008 8:33:00 AM

Norm said...
I have read whenre a number of medical providers suggest having a family member
at your exam.My wife and I have been doing this for a number of years for all of our
exams but are not aware of how widespread this is or to what extent the member
presence at exams is,i.e. all exams,minor surgical procedures?
What problems are encountered when this is requested?
reasons for doing this are pretty simple, we provide additional info to the physician
and we also assist one another in remembering the test results, meds to be taken
and other vital information sometimes soon forgotten.
Issues of modesty are generally mitigated by the others presence.

Your thoughts comments, and additional information would be appreciated
Monday, January 28, 2008 11:53:00 AM

Anonymous said...
RM as was stated it is not as easy as it may seem. Just as I can not know what it is
like being a female in Austrialia, I do not expect you to understand what it is like
to be male in the USA. We have been taught-condictioned to just accept having our
modesty compromised,we were taught it was not manly, in the 50's it was common
for males to be requried to swim nude in school while females were givem suits,
and more recently, males protesting females in male locker rooms was treated as
the sole issue sexism by the atheletes not their modesty, and males declining
female providers were branded sexist. It has only recently started to go the other
way. So as easy as it may seem its not easy to over come generations of training
and condictioning

Dr. Bernstein
I don't think to many people would dispute when it comes to priority, the outcome
is the most important thing. For most people I would assume that is a given. One
that goes without speaking. At least for me, that is an easy call. I think the issue
that is more to the point of this blog is that providers use that line as an excuse to
ignore patient modesty for the sake of convience and efficency, translated as
profits. Issues such as not even asking if there is a gender preference when it is
possible, not providing garments that would provide sufficent coverage vs the open
back "ICU" gowns, allowing "visitors and observers, etc all have nothing to do with
safety and outcome. To a large degree we have to assume providers are capable and
the outcome of the procedures are going to be positive. We have little or no
knowledge of what they are capable of and when it comes to support people, nurses,
techs etc we often have no choice. Most of what has been posted here is what
providers don't, not what they can't do to make patients more comfortable. The
example I posted where I had a female tech do a scrotal ultra sound when a male
was available, and I wasn't given a choice...I have to assume both were equally
capable or they would not have been on staff. Now if you told me you can have the
female tech or the male janitor do the ultra sound....I would have gladly chosen the
female tech. While I am sure there are some who would put their health second to
modesty, the vast majority are not asking for modesty to be primary, we do
however want it to be important not some trivial after thought or even an
inconvienence to providers. Just as we have to be cognicent of providers primary
purpose being the outcome, providers need to be cognicent they can not just
dismiss our modesty as insignificant which is not the same as secondary. If I felt
they were being reasonable and doing what they could, there would not be a
problem...I do not feel that is the case by any stretch of the imagination JD
Monday, January 28, 2008 5:52:00 PM

JAKE said...
Dr. Berstein
I did not have half the problem with the modesty as I did with the lack of respect
from my doctors and nurses in the do not ask/do not tell policy.
I was treated no different as a young first time patient as a used car dealer would
bypass many facts about a car to a first time buyer. (hear comes the sucker).
I was referred to my surgeon my parents did not attend I barely understood what the
man said to me about needing an operation let alone knowing what questions to
ask. My visit with him lasted no longer then 8 minutes he must of seen a questioned
look on my face. He never mentioned why I was being admitted to the hospital 2
days before my operation. He also delivered the news of my cancer in less time then
he told me I needed a operation and went on vacation for 9 days in between all of
that. We had no relationship I actually thought he was quite a jerk for not taking
the time to explain anything to me. The nurses could have told me what the doctor
ordered before they walked into my room with the Foley,enema bag and shave kit. I
also had that tube inserted in my nose the night before my operation which brought
tears to my eyes, the first time I ever heard about that tube was when the nurse
walked in the room with it. I had no clue had to be a patient but guess what I was
an incredible patient I did everything I was told to do. I went through unreliable test
and procedures very little of the test was even explained to me and being 18 yrs.
old they did not have to consult with my parents nor did they need there
permission.
I am still dealing with some serious long term effects of the chemo and operations
but YES I am ALIVE. Most of the doctors did do I fine job with their skills not always
with a beside manner. I do many things could have been done different by Doctors
and Nurses because they are the ones who went to school for saving life's and trying
to make patients comfortable before and after any service. I did not experience a
BALANCE OF COMFORT.
I saw many different doctors and some were much stronger then others in there
over all package of skills. The doctors are to be credited but so am I, I looked at
Stage 4 Non-Hodgkin's Lymphoma Cancer and basically laughed at it. Prior to my
cancer I was in a terrible state with my parents and my life (even a high school drop
out) I returned to high school shortly after that I spoke to my boss and he figured
out how I could return to work when I was able. I stayed very strong in my head and
never stopped living my life I even started improving my life from day one. My
Oncologist told me two years into readmission he thought I was going to die and he
told me HIM AND I DID EXTRAORDINARY THINGS TOGETHER.
My post earlier was not even directly about modesty but how do health care
providers better inform patients and not try the ambush approach.
Jake
Monday, January 28, 2008 7:52:00 PM

amr said...
JD – You write: “While I am sure there are some who would put their health second
to modesty, the vast majority are not asking for modesty to be primary, we do
however want it to be important not some trivial after thought or even an
inconvienence to providers. Just as we have to be cognicent of providers primary
purpose being the outcome, providers need to be cognicent they can not just
dismiss our modesty as insignificant which is not the same as secondary. If I felt
they were being reasonable and doing what they could, there would not be a
problem...I do not feel that is the case by any stretch of the imagination “

I was going to write exactly along these line, but I could not have put it any better.
It is a matter of necessary exposure vs convenient exposure, or thoughtless
exposure, or prolonged and unnecessary exposure. It is a matter of too much for too
long, which goes to the dehumanization aspect of the event.

In my wife’s on-going saga of surgeries and procedures, she had to have her belly
button revised. For this 30 minute procedure, she actually never removed her
clothes. It was a local, and just her abdomen was exposed. It was just her doc and 1
nurse, and she said they were careful to keep her warm as well. So much for even
street clothes near the sterile field. And I would venture to say that the practice of
large area prep of bodies in the OR has more to do with tradition than science. I
saw a picture on the net of a woman being prepped for neck surgery. Her body down
below her breasts were been painted, and the picture showed her entire abdomen
bare with a hint of her pubic area exposed. I suspect the gown had been completely
removed – for neck surgery.

For her colonoscopy (sp) they told her she could keep her top on. This was all great
and good. Except I did notice the doctor leave the procedure door open after the
procedure following my wife’s. But in fact the patient was not exposed in any way,
so that was ok… I guess. They did though have a big sign on the procedure door that
stated that no one was to enter the room unless first requested to do so. So again,
these are steps in the right direction.

--amr
Tuesday, January 29, 2008 12:13:00 AM

Anonymous said...
Maurice,
I think the field of nursing and medicine focus on your statements of the end result.
Patients must endure everything to get to the end result. Like someone else stated
on the comments it depends if you are the one standing or lying. It is a
macheavellian approach in my opinion.

Question: Why isn't this issue of genital based procedures discussed with a patient?
Tuesday, January 29, 2008 4:56:00 AM

gve said...
The issue of outcome being of prime importance is of course self evident. There is
nothing to say that outcome and modesty need be mutually exclusive events. The
point of having to constantly keep speaking up is indicative of how the patient is
seen as an unecessary evil in medicine. The patient should NOT have to keep
speaking up. Medical professionals are meant to be just that, professional, why can
they not better inform patients of what to expect AND show them proper respect at
ALL times. I have been a complete pain in the ass for my own local providers, I live
in a prt of the UK. I have involved my member of parliament, the local hospital
complaints procedure etc etc. They have now given in. Whenever they can
accommodate a same gender provider, they will, no exccuses and no hassle for me.
What still offends me is that they will probably still treat the majority (the silent
majority) with the same disdain and arrogance and offer them no such comfort.
Providers need to do the asking, NOT the patients.
Tuesday, January 29, 2008 9:18:00 AM

Anonymous said...
I had to have a pelvic/scrotal ultrasound and I called several facilites to inquire
about male/female ultrasound techs on staff. Only two places out of 6 had a male
tech on staff. I decided on the one place and then had to wait for 1 month because
the guy was on vacation.

When I told him I wanted a male tech he looked at me like I was strange. He said,
"well, I do female patients." So in other words why would I mind if a female did my
u.s.?? When a female is done her private parts are not exposed. Her abdomen in
done. A male is completely exposed and for some time.

Again, the double standard!
Tuesday, January 29, 2008 11:12:00 AM

Anonymous said...
Anonymous 1-29, 12:00am
Once again, the provider judges a patient from their point "well I do female
patients" has nothing to do with how a patient feels, it is how a provider feels and
they are not exposed. And if he needed one, would he prefer one of his male or
female co-workers did it. My guess we would hear the "its different when you work
with them. It is easy to say that when you are not the one being exposed. Read the
allnurse.blog and see how they feel when they are asked to perform procedures on
eachother during training, or when they are the patient...many feel exactly like we
do when they are in our shoes..JD
Tuesday, January 29, 2008 6:21:00 PM

Norm said...
I have been reading the modesty blog for some months now and the exchange of
information is sometimes overwhelming, and the comments all seem to recognize
the many complications inherent in examining, testing, feeling,palpating etc that
goes on in the medical profession for various reasons.
I am not a particularly modest person, but have noticed when in a hospital setting I
become less so to the point my wife will either say something or cover any exposed
parts.
I also become apprehensive if my spouse is to have an exam which will expose her
to a provider of services of the opposite gender, and remind her to request a same
gender examiner or technician.
As has been mentioned a numbner of times in the blog, circumstances dictate the
extent we can go to have a service performed, if it is a voluntary circunstance such
as a scheduled exam then we have a modicum of control over who to see and the
gender, same a goes for scheduled Ultrasounds, Ekg's etc and we have ample time
to make a same gender request. In an emergency that all changes and the best we
can do is depend on a family member to help maintain our modesty, sometimes this
helps.
I find that in our case ( my spouse and I) being present at each others exams goes a
long way to alleviating the anxiety that normally occurs as we face an exam or
procedure.
I have discovered many people are engageing in this practice and have seen
statistics alluding to the fact that it is helpful to both physician and patient.
Not to digress to much but I have also found statistics on this subject are woefully
lacking, it would therefore be helpful to know if any policies, rules, laws exist
regarding SO, spouses or family members attending each others exams.
Which begs the question, what type of exams are we talking about,speaking for
myself my SO and I attend each others personl exams such as Prostate checks, pelvic
exams,sinus problem exams etc,this includes a cardioversion in the ER and minor
surgical procedures at a Dermatologist office.
Back to the point, this arrangement has had a tendency to mitigate the anxiety we
both undergo when faced with a medical exam or procedure, it also assists one
another in retaining a modest dress ( if thats possible in a paper gown) when in the
Physician office.
Our Physicians have generally all been a very receptive group to this arrangement
and seldom have a problem with the physicians. I have however had a problem with
a dermatologist recently who insisted my wife leave the room during a small basal
cell cancer removal on my neck, the same type of thing my wife observed only three
months prior in the same office by the same physician.
The ensuing verbal exchange between the doctor and myself when I objected, and
asked why, was not the most pleasant exchange. The Doctor did however get her
way, after telling me I was a big boy now and didn't need my wife there.
How does one challenge this unanticipated change of events when you NEED the
service that you are scheduled for.
Enough rambling. Comments are invited.

Norm
Thursday, January 31, 2008 10:59:00 AM

Anonymous said...
I had an interesting experience today that is a perfect example of our recent
discussion. I went to a urology center to see my urologist for an annual check up. As
I was sitting in the exam room waiting for him I could hear the nurses at their
station which was right accross from my room. The door/walls were thin and I could
hear part of the conversation in the adjacent room and all of the conversation at
the nurses station. One of the nurses took a call from another Dr. (whom I know)
and said let me check, I heard her tell him let me check, I heard a knock and the
door to the adjacent room open and close and could hear her talking (muffled) to
who I assume was the Dr., she left the room and told the Dr. on the phone "he is in
the middle of a procedure", I she went back and forth with him and said Ok I will
ask but he already said he would have to call you back, I heard the door open again,
more conversation, she returns to the phone and said he is in the middle of a cystro
and the scope is in, she traded conversation and then said fine I will give him the
message, knock, the door opens and closes, more conversation, she leaves and I
hear her and a couple nurses laughing, she says "Dr. X was so ticked, that poor guy
looked petrified". While I could only hear part of the conversations, it was pretty
easy to put the pieces of the puzzle together. The nurse/recpetionist whoever she
was went in and out of the room three times while this guy was having a
cystro....she evidently was not actively involved in procedure. My routine exam with
my doctor (not the one doing the cystro was excellent, could not have been more
professional by all involved...but if what I think happened, actually happened...I
would be really mad. That appears to be a perfect example of the patients modesty
not being secondary, but insignificant...
Thursday, January 31, 2008 5:56:00 PM

Anonymous said...
I agree this type of thing is horrible and completely uncalled for. Many doctors have
a rule that the door if closed (with a patient) is NOT opened. Also to note is that
exam doors do NOT have locks on the door knob, therefore this is a possiblity. I was
in the room once with my husband and he was having a rectal exam (DRE) and his
rear was facing the door. I was nervous that something like that would happen.
Because the door faced a hallway that looked directly out to the waiting room. How
embarrassing would that be.
Friday, February 01, 2008 6:57:00 AM

Anonymous said...
I had a scan today for suspected gall stones. The nurse who met me did not
introduce herself. I assumed she was doing the scan. Next thing she asks me to
remove my shirt and loosen my trousers. I did so. The nurse then started to place
some paper towelling inside the waist band of my underwear to protect my clothes,
she did not ask or say anything before doing so. I was quite angry. she then left the
room via a different door(leaving the door to the corridor I had entered via
unlocked). When she returned with the doctor who was to do the scan, I asked if the
door could be locked. Her reply was "nobody will come through that door, so there is
no need". I insisted. What she did not know is that on arrival, the place appeared
deserted and I had walked in to that room looking for someone, but nobody was
about. So ANYBODY could walk through the door. Even when you speak up, your
concerns are seen as unnecessary.
Friday, February 01, 2008 7:21:00 AM

Anonymous said...
What is interesting about that story is-
if the doctors was mad that means the policy is not to interupt the doctor. Also how
could another doctor think what ever message he had was more important then the
patient with the doctor in the exam room. You have to LOVE THAT BALANCE OF
COMFORT. (but on the flip side I was not there).
Friday, February 01, 2008 1:53:00 PM

Anonymous said...
I have been in many exam rooms in doctors offices and the walls are paper then
which makes it unavoidable to hear all that is said in the adjacent exam room. This
is really a violation of the HIPAA law. Your information discussed with your
physician should be confidential. I found it very discerning that whatever I said could
be heard by others. What kind of privacy is that?
Saturday, February 02, 2008 4:46:00 AM

Anonymous said...
Likewise I was getting bits and pieces through closed door, sometimes things are
not as they seem. Even if I discount all the unknowns, I was thinking this poor guy,
to have another female walking in and out while that was going on would be awful,
and I hope the converstaions aren't coming to him like I can hear them. The layout
is typical waiting room with the open window to the nurses/receptionist then open
doorway to the hallway to the exam rooms from the nurse/receptionist. I would
assume everyone in the waiting room heard everything as well. Even without names
it would have been awful to not only experience that, but walk out wondering how
many people out there knew what transpired. I personally know the doctor that
called in, did not surprise me he demanded immediate attention. I was however
surprised the nurse/receptionist kept going back and forth. There are 3-4 urologist
at this facility and over the 3-4 years I have been going there my Dr. and his staff
have been very cognicent and respectfull of my privacy. I think it shows several
things, different Dr.'s have different levels of respect and I think it was also a case
of it really does become just another day at the office for these folks. I honestly feel
the staff there are pretty nice people. I think it has just become so routine to them,
they forget the other side. The key there is they forget, not intentionally inflict
anxiety on thier paitents, and as we remain silent...they have no feedback to think
otherwise JD
Saturday, February 02, 2008 6:26:00 AM

Anonymous said...
JD---
Since I read your posts you might find it iteresting to review the posts to
allnurses.com and go to specialty nursing forums-specifically OR Nursing. These
nurses are burned out and state they are doing us all a favor and seeing patients
genitals is NOT a perk! Gee. It is irritating to see how they perceive things. Look at
Patient Modesty and also on the general forum Male/female nurse issues.
Saturday, February 02, 2008 10:15:00 AM

Anonymous said...
To Norm's remarks...

Maybe they teach..you are a big boy in school! I had a recovery room nurse tell me
that when I was pissed that I wasn't allowed to be with my husband in the area post
surgery! I was really ticked off with that flippant remark! She was about ready to
have teeth missing.

We go into exams together usually and the doctors have not objected. Some docs do
not like the wife present when they do the DRE for the prostate check. Why? Don't
know. My husband had a urologist suggest a ultrasound guided biopsy on the
prostate and when I asked if I could be present he really skirmed. Said he usually
does not have spouse in the room. When I pressed him he said I could stand at the
head of the table. What this is all about I don't know. Your derm was ridiculous to
not allow your wife in the room for something so simple as that. I had a huge piece
of skin surgically excised in an exam room and my husband was present.
Saturday, February 02, 2008 11:31:00 AM

Maurice Bernstein, M.D. said...
I can see only two reasons why surgeons or hospital administrators would be against
a family member in the operating room at the specific request of the patient: 1)
The family member beomces hysterical and distracts or physically interrupts the
operation. 2) The family member faints, falls and may injure themselves, suddenly
becoming the second patient to attend to in the operating room and temporarily
distracting the operation. If there could be ways to prevent or mitigate these two
possibilities, then certainly a family member could attend---UNLESS the real reason
for not allowing family in the operating room is for secrecy of what is happening
there--but that wouldn't be the reason, would it? Doctors and hospitals want to be
open and transparent about their practices, don't they? Oh! You say that they don't
readily admit to and apologize for their mistakes? Not so open.. Hmmn. ..Maurice.
Saturday, February 02, 2008 1:29:00 PM

amr said...
Dr. B --- WOW ! Your first two reasons are real – add a 3rd, making the doc
nervous. But, I never thought you would actually voice the “real” reason family are
not allowed in the OR. Good for YOU! Mistakes are made all the time in the OR.
Thankfully, most of the time, they are “correctable” – but sometimes not
unfortunately. --amr
Saturday, February 02, 2008 2:54:00 PM

Norm said...
DR. Berstein,
I appreciate your comments and I would agree there are some instances where a
family member has fainted while present during a spouses or family members
procedure( I know of at least one such occurance in a Dr's office) and that certainly
complicates the procedure,it could also endanger the patient depending on what
was happening and the timing of the family member fainting or becoming
hysterical.
In my particular situation however,I was not permitted the courtesy to respond as to
why, and since the physician had been through a recent experience with us it
wasn,'t because she feared my wife would complicate things for her or me. I
perceived it as a power play pure and simple, and obviously I lost because pursueing
it could have compromised my welfare, or at the least delayed the surgery.
I have benn in the medical profession for many years and drawing blood was one of
the things I did,I have never refused a family members presence and at times I had
people faint on me, and once had the patient and family member get dizzy, it does
make for some interesting manuvers attempting to handle it all at the same time.It
did not however cause me to change my policy but only to be more wary of and
screen the participants more intensely.
I must admit I have had a few occasions when a Doctor admitted a mistake, I was a
bit flabbergasted but at the same time admired them for this.

I suppose I could change Doctors but there aren't to many in this area doing MOHS
procedures, and since she is on our insuranace PLAN, well what does one do?

Norm
Saturday, February 02, 2008 3:26:00 PM

Anonymous said...
Annoy. Feb2, 10:15 Go to allnurse and search cone of silence, it is an interesting
thread where nurses talk about witholding information and from patients and family
for their own benefit....they seriously are doing what they think best...and it may
expose (excuse the pun) one of the basic issues in this thread....where is the line
between where providers should exert control over the patient and where the
patient has or gives up control. Does the medical provider have the right or even
the obligation to determine what the patient should or should not know, and what
degree of modesty a patient should or should not give up to allow them to conduct
medical procedures as they see best as they define it. We as patients have in the
past accepted without question these things....now we are starting to question
this...at what point do we give up the right to decide what is best for us? Granted,
physicians know far more medically, but does that trump our right to choose
soemthing that in the eyes of the providers...is not the best option? Should they
keep information from us even if they think it is in our best interest....ie the
patient will be striped naked prior to surgery....should they be able to tell a patient
NO you can not wear underwear for shoulder surgery if the patient is willing to
accept the risk (as they see it),,,, JD
Saturday, February 02, 2008 7:39:00 PM

Maurice Bernstein, M.D. said...
JD,except in a life-threatening emergency where the patient has no capacity to
make a medical decision, all patients who have decisional capacity have the right to
provide informed consent prior to any examination or procedure or treatment. If
the patient finds that they have not been adequately informed or their consent has
not been followed then that could be a matter to bring to the phyician's licensing
board or the court system. But remember, any physician has the legal and/or
ethical right not to accept a patient's decision, to perform any procedure or have it
modified against the physician's judgment,moral vew or standard of care practices.
If a doctor-patient relationship already exists, in order to avoid abandonment, the
physician is required to make an effort to help the patient find within practical
limits another physician, if available, who will follow the patient's request.

I think that the reason many physicians may avoid or defend themselves from
patients' requests to change the standard procedures is because they rarely hear
from patients about their modesty concerns. Procedures are standardized because
they have been repeatedly performed, because they are thought to be more
economical of time, because they fit with the environment where the procedures
are carried out, because they are thought to be "safer" for the patient (which might
be a controversial point) and finally because rarely does any patient SPEAK UP about
their conerns. If patients don't speak up, the physician will assume-- and
realistically why not--unless they read this blog!--that their patients are satisfied
with how the procedures are being carried out. By the way, I read this blog and I
am aware!

So JD, my advice remains for the patient to speak up! And if the response is
unsatisfactory and it is medically appropriate to do so, find another doctor.
..Maurice.
Saturday, February 02, 2008 9:34:00 PM

Maurice Bernstein, M.D. said...
I have just posted on Modesty Volume 2 a comment considering a possible
relationship between patient modesty and a life history of social shyness. This
posting here is simply to notify my visitors of the posting there. If you desire to
write something about that topic, don't write it here but go to this link to respond.
..Maurice.
Sunday, February 03, 2008 11:14:00 PM

Anonymous said...
I have found that discussing or complaining to a doctor about modesty issues reeives
no understanding. I even had a urologist laugh at me. I did not go back to him.

From what I see it would be like complaining about guns to an NRA group.

Many many doctors just don't understand this issue at all.

I see nurses on allnurses.com site say they can accomodate an all female OR staff
but they cannot accomodate an all male staff. Double standard again.
Monday, February 04, 2008 5:58:00 AM

Anonymous said...
I'd like comments on this:

What do you think of OR nurses responding to husbands or wives that are upset with
the opposite sex doing personal genital procedures on their spouses by saying the
spouse is "insecure"?

I'd be interested on anyone weighing in on this including Maurice--MD.
Tuesday, February 05, 2008 1:58:00 PM

Anonymous said...
I think it depends, if the patient themselves doesn't have a problem with it, I don't
think the spouse should demand. If on the other hand the spouse is speaking of a
patient who is either physically unable, or emotionally unable to speak for
themselves, and the spouse is just sticking up or making the patients wishes
known....I don't think it is about insecurity. When it comes down to it, its about
the patient, not the spouse. JD
Tuesday, February 05, 2008 3:03:00 PM


Maurice Bernstein, M.D. said...
I suspect that Anonymous from 1:58pm today is the same Anonymous from 5:58am
today. Please, everyone, if you want to remain anonymous do so..but regularly end
your comments with some consistent pseudonym or initials.

With regard to OR nurses calling spouses "insecure" if reported on any blog including
on this blog, just the postings themselves really don't establish how common this
excuse really is in the nursing profession just as I can't prove by some statistical
analysis how common is the concerns about patient modesty in general by what is
written here. One needs to take a survey of populations which will provide a
statistically significant result. The lack of a valid statistical analysis doesn't mean
that patient modesty is not an important issue for some individuals nor that the
medical profession shouldn't try to attend to the comfort of those individuals who
are very concerned about it. But, again, I want to emphasize that finding
complaints repeated and repeated on blogs can point to an issue but doesn't
necessarily hint at the magnitude in terms of patients affected. I would say if an OR
nurse professionally diagnoses and accuses a spouse of being "insecure" without some
sort of psychological examination of that spouse, that nurse herself, on the basis of
that accusation, is demonstrating her own insecurity regarding how to respond to
the spouse's concerns. ..Maurice.
Tuesday, February 05, 2008 3:04:00 PM

Anonymous said...
Anonymous -- I can tell you how BSN clinical instructors at the university where I
work would respond to a nursing student who told a patient s/he was insecure. The
nursing student would be taken aside and reminded that such a response is
inconsistent with any nursing model (e.g., the Roy Model, the Caring Model); that
s/he has deviated from the nursing role for which s/he is being trained; that she
has violated the code of nursing ethics which, among other things, exhorts nurses to
treat patients with dignity and respect; and if there is a repeat in performance, she
would fail her clinical.

If the OR nurses in question were supervised by someone with an ounce of integrity,
it would be reasonable for the supervisor to take the nurses aside; remind them of
the role they are expected to play as professional nurses; write up notes of
reprimand and include in the nurses' files with the promise of removing these notes
once they complete one or two CLE workshops where they are retrained on the
proper role of the nurse vis-a-vis patients (To keep their licenses here, nurses must
take so many hours of CLE courses a year.); and told that any future disrespect
shown to patients will earn them a written reprimand. -- Ray
Tuesday, February 05, 2008 7:05:00 PM

Anonymous said...
Dr.Bernstein

I have a question related to your last response. You wrote:

‘I want to emphasize that finding complaints repeated and repeated on blogs can
point to an issue but doesn't necessarily hint at the magnitude in terms of patients
affected.’

I agree with your assessment regarding this issue but on a different subject, with
the countless number of physician sexual misconduct cases noted on this blog and by
Mike of HHF group, along with the studies that have been done on the subject, one
would think all those would point to a very large issue that needs to be addressed.
The suggestions made on this blog would actually help reduce that number to a
large degree. I guess what I’m asking is how many more patients are going to suffer
before the powers that be decide to make changes themselves? Besides starting an
activist group, what else could be done to get their attention? It just seems to me
that they have turned a blind eye to this subject and speaking out just won't fix the
issue by itself. Jimmy
Wednesday, February 06, 2008 4:21:00 AM

Anonymous said...
Watching TV last night a show called 'nurses' from new zeland based in the ER dept
was on. I was horrified and it left me thinking is this a true representation of what
happens no matter what country you live in. I dont live in new zeland but would this
happen where I live. The first patient a male had overdosed at a party. All his
clothes where cut off and although his genitals and face had a small blured dot over
them there were several nurses standing around not to mention the camera crew.
Obviously he was not able to give his concent to the camera crew or anything else
for that matter so does that mean he loses his right to dignity. No curtains were
drawn either I may add and no attemt to cover him with a sheet. The second was a
lady who had overdosed. Her top had been removed and again several people
coming in and out seeming to not do anything but watch, with no attempt to cover
her. I am disgusted with the behaviour of all medical staff concerned. Because they
see 100 patients a day and they are busy (although they didnt appear to be) does
that excuse them from not treating the patient with dignity and respect. I am very
quiickly losing all faith in the medical field as a whole.
Wednesday, February 06, 2008 4:59:00 PM

Anonymous said...
I completely agree with the patient treatment in the ER that was shown on TV.
There is no attempt to cover a patient. This seems to be normal and regular actions
on the hospitals' part. I see no real reason for a patient not to be covered, at least
the genital areas. Maurice..what is your opinion on this?
Thursday, February 07, 2008 4:09:00 AM

Maurice Bernstein, M.D. said...
I agree that unless medical inspection is being carried out by the physician for
trauma, there is no need to have the patient uncovered. There is always a need to
keep the patient covered in order to prevent chilling..and for modesty, of course.
What I would be interested to know if the television producers can come up with
informed consent forms signed by the patient or surrogate which approves the
filming and the exposure. ..Maurice.
Thursday, February 07, 2008 6:32:00 AM

Anonymous said...
With regard to some of the last comments here:
I think they have banned video and such from the delivery rooms because if there is
a screw up on the physician/hospital part it could be used in litigation.

I feel the word modesty used with some of the comments here really should be
replaced with the word "DECENCY." Much of what we all share really amounts to
decency. Decency and respect.
Friday, February 08, 2008 4:20:00 PM

Maurice Bernstein, M.D. said...
Decency. Very interesting. That word would change the whole direction of this
thread from considering the property of the patient (modesty) to perhaps the more
pertinent expectation, behavior and rightfully the responsibility of the physicians
and the others involved in the care of the patient (decency).
So the question now becomes not the concern of how much modesty is appropriate
in medical workup and treatment but to what degree various acts of inspection of a
patient amounts to indecent behavior on the part of the physician or others. Very
interesting! ..Maurice.
Friday, February 08, 2008 5:16:00 PM

Anonymous said...
Dr. Berstein,
I would like to know why the genitals are so cleaned for an appendectomy? I can
understand the skin and surrounding incisional area but the penis and scrotal areas?

My wife had a large area of skin removed (2in x 4 in!!) for skin cancer and it was
done in a doctors office, on a dirty exam table, very little skin cleansing, no hair
removal, no draping of her clothing or other areas. Not much sterile and no massive
prepping (from the tips of her fingers to the armpit!).

So why the penis and ..??

Is it really all that necessary?
Thanks.
Saturday, February 09, 2008 12:46:00 PM

Anonymous said...
If you had your genitals cleaned for an apendectomy your surgeon is a sicko. Why
would that area even come into it. The surgeons genitals would be closer to the
incision than yours and you are draped!!
Saturday, February 09, 2008 8:23:00 PM

Maurice Bernstein, M.D. said...
I'm not a surgeon and I can't remember what we were taught when I was doing my
surgery training as an intern some 50 years ago, however before surgeons are called
names, critics of how the patients are prepared for different operations should
check the literature regarding standards of practice. It may well be that the
surgeons are following standard of practice guidelines in the shaving and cleaning of
skin areas. If the standard of practice is not based on evidence based studies which
document the merit of the procedures, then the standards ought to be changed but
patients should not be critical of the surgeons who are trying to follow the rules.
Anyone want to look up appendectomy operative procedure and see what the book
says a surgeon should do in preparation? ..Maurice.
Saturday, February 09, 2008 9:08:00 PM

Anonymous said...
No wonder patients are asking more questions about what happens in surgery when
this kind of behaviour is going on and other doctors backing them up no matter how
rediculous it is.
Saturday, February 09, 2008 9:16:00 PM

Anonymous said...
I direct you to allnurses.com and look at the thread titled:
should males nurses work the OB floor? There are many many entries but one of
significant interest and real documentation from a legal standpoint is posted by
"fagley" listed as male and it is thread # 141. It is long but sites many legal cases
and is very interesting. It is just too bad that this is not widely put to use by
hospitals.

There is another thread by "muscleman" that is very interesting. You can search
under "Muscleman" and will find it. It was truly a bioethics issue and absolutely
horrible on behalf of the hospital staff.

On this note: of the men on this blog a question is, how would you react or accept a
male OB nurse tending to your wife during labor and after delivery? There is much
intimate care involved pertaining to the genital area. On the double standard note,
how would men respond with a male nurse in OB?

Guess men would then know how women would feel with female nurses handling
their husbands.
Sunday, February 10, 2008 11:37:00 AM

Anonymous said...
The question would -should not be how I would feel, but more how she would feel,
she it the patient,she is the one going through it, if she is comfortable and has no
problem, then I would be fine, the staff can not accomodate everyone, the patient
should have jurisdiction, if she is fine, so am I, if it upset her I would have a
problem with it JD
Sunday, February 10, 2008 12:18:00 PM

Anonymous said...
JD-
So true it is the patient that has the say so, however, usually in a close marital
relationship, the feelings of a spouse matter. The feelings are a part of the
equation. This becomes a part of the ordeal and feelings of the whole experience
that both people go through. Medical ordeals are stressful enough without added
factors.
Sunday, February 10, 2008 2:34:00 PM

amr said...
Dr. B,

Concerning the prep for appendectomy: The association of Surgical Technologists
puts out a textbook entitled, “Surgical Technology and the Surgical Technologist”
Second Addition Copyright 2004. Position: Supine (on pts back). Prep: Shave may be
necessary, especially for the male pt. Prep from mid-chest to thighs and laterally
(down to table) as far as possible. As I have come to understand, this is pretty
standard for any surgery involving the abdomen. This means that the pt is fully
exposed (naked) for the prep of the operation, and of course at the end when the pt
is cleaned up. The outer part of the genitalia is of course prepped given the above
description. Generally, any time the position of the pt is other than supine, the pt
will be fully exposed in the OR. Laproscopic surgery in general although wonderful
from the standpoint of pain and recovery time, is more exposing to the pt. Although
small incisions are made, a wide prep is common in case the operations converts to
the more classical open incision approach.

It is still unclear to me how much of this is tradition vs good science.

There are variations depending on Dr preference and specific hospital practice –
suffice to say (as you have stated earlier in this blog) patient modesty is a moot
point – especially in the OR. Anyone in and around the OR suite, be they equipment
techs, sales people, nurses, docs, students, maintenance personnel, housekeeping,
etc, all can and will be exposed to naked patients – not to mention the growing
number of camera feeds emanating from multiple angles in the OR.

Decency: When a pt is exposed for more than is necessary, either body parts and/or
duration, it is not treating the pt with DECENCY. I believe this is true, regardless of
how the pt feels about such exposure. Since this is done at times behind the “Cone
of Silence”, and the pt is unaware – it is not IMHO, no harm no foul. It becomes a
mindset that dehumanizes the pt. As I have spoken about previously, the modesty
trigger is a response to feeling “exposed”. This can be physical and/or emotional. It
can be when a pt finds out they were “lied” to by the profession. It can be also a
way of deflecting the uncertainty of illness. (Who sees “my body” is more
controllable than let’s say terminal cancer.) From very personal experience with my
wife, it was triggered by the uncertainty of outcome. Looking back, it is still hard
for me to integrate given my own feelings about medical modesty.

This journey has not been without its toll on my feelings about the medical
profession.

And… with respect to the last, is it DECENT to perform non-consensual pelvic or
rectal exams on pts? It is clear that many in the profession feel that this is
acceptable practice and is still vigorously defended.

-amr
Sunday, February 10, 2008 5:51:00 PM

Anonymous said...
If would be very upset if my wife were handled by a male OB, much less a male
nurse. If fact, I would be very upset if my wife were to deliver in a hospital.

CLW
Sunday, February 10, 2008 6:02:00 PM

Maurice Bernstein, M.D. said...
For those who are interested about the empiric evidence available regarding pre-
operative shaving related to the prevention of "surgical site infections" (SSI), the
following 2002 review of the extensive literature, a free full text article is available
from the AORN Journal May 2002.

Like I previously said, if the standards of practice established for surgeons is in
error then surgical and medical organizations who set the standards should change
them. Those organizations responsible for the writing of the standards should
likewise be responsible for review and change if necessary and being critical of
physicians who follow established standards and guidelines is unwarrented. All
physicians who practice unprofessional medicine, however, do warrent criticism.
..Maurice.
Sunday, February 10, 2008 8:36:00 PM

Chris said...
Great forum. Question for Dr. B:

Can you request no sales people come into your surgery? I'm okay with the docs,
nurses and necessary medical staff but having sales reps in there doesn't make me
very comfortable. How often are sales people in the room? Thank you.
Sunday, February 10, 2008 8:45:00 PM

Anonymous said...
Standards have gone through change over the years. AMR is correct in what he
cites. YOu can google search AORN Journal articles and a site comes up
findarticles.com and once the AORN Journal article page comes up you can click on
the different years and months. Go to Jan 2002 Guidelines for Skin Prep. It states
that the shaving should be done in a different location than the OR. They knock you
out and have an opposite gender nurse do it all so you don't know. There are males
that do this on a gyn case. A female patient would not know a male would be doing
this either. A person with the AORN informed me not long ago that the newest
guideline is NO removal of hair at all. But, it is up to the hospital and surgeon to do
what they want. As "amr" stated, is this really all that necessary? You cannot
sterilize the skin. Infections still occur even with all of this.
Monday, February 11, 2008 11:33:00 AM

Anonymous said...
Annoy. While I agree with you the experience does effect both spouses, ultimtely
the retaionship that should dictate is between the the physician and patient. I
understand some people have more prooblems than others with spousal
exposure...it is up to the patient and the spouse to set those issues between them
and for the patient to make those known to the physican, or they can discuss it
jointly, we can not expect the physicians to meet everyones expectations. My wife
had a breast biopsy & a follow up to a miscarriage, in both cases the Dr. exposed
her with me present, she didn't care at all, she laughed becasue she said my eye's
narrowed and I looked like I was going to punch him when he touched her..I didn't
know it showed...but she was the patient so what ever made her comfortable...she
was the patient.



Dr. Berstein, the article was very interesting, it went against what appears to have
been common practice (and a point of contention and embaressment to patients) up
until recently, which further validates some of the posts that some practices such as
no underwear, may be more tradition than value. That said, we need to speak up
prior...but to who? Does the physican/surgeon control and have discretion or is it
the facility?? I had an endoscopic exam for ulcers...I had to stip completely and
wear the dreaded "gown", a woman in my office same exact procedure, different
larger hospital, she had to remove her shirt & shoes, left bra on, put on a
gown...that was it....who can make allowance or exception....as a rule Dr or
facility? JD
Monday, February 11, 2008 3:38:00 PM

Anonymous said...
You can view a prep with your own eyes on OR-live. March 26, 2007 there is a
procedure entitled,"Revolutionary Techniques in Penile Implants." Unlike most OR-
live surgical procedures this one actually shows a prep on a male. The hair removal
has already been done. Here it appears like the surgeon is doing the prep, but as we
all know by now this work is 99 percent of the time performed by a circulating
nurse and by percentages of gender in the OR it would be a female. So ladies and
gents this is how you or your husband is handled for any abdominal prep, not just an
implant. (as 'amr' so detailed from the surgical tech publication). Also of note, this
exposure and cleaning is supposedly a 10 min process.
Tuesday, February 12, 2008 5:19:00 AM

Maurice Bernstein, M.D. said...
Here is the link to the video referred to in the previous posting. ..Maurice.
Tuesday, February 12, 2008 7:29:00 AM

Anonymous said...
Sites like that one are very useful because patients can see exactly what will occur
if they so choose.
Tuesday, February 12, 2008 10:30:00 AM

Maurice Bernstein, M.D. said...
I would generally agree that, in terms of technical education, "Sites like that one
are very useful because patients can see exactly what will occur if they so choose."
However, since each patient's anatomy and pathology is a different as well as the
major differences in the general past medical history (including reactions to
anesthesia and other drugs down to whether the patient is suseptible to disfiguring
keloid formation at the operative wound sites) that I have doubts one can count or
rely on the expression "exactly what will occur" to actually happen.

At first glance, I am wondering if sites like OR-Live actually are presenting "direct
to consumer" advertising but with some twists that is different from the currently
common drug advertising.
And I am wondering if some of the twists are truely educational and truely ethical.
That's why I am thinking to take more than one glance and perhaps starting a new
thread on this very topic of "direct to consumer" instruction in surgical technology
(and it presumably is for the consumer and not specifically for the physicians).
..Maurice.
Tuesday, February 12, 2008 11:12:00 AM

Anonymous said...
Dr. Bernstein, THANK YOU for being concerned enough about this issue to ask
patients' opinions! It seems that many doctors or nurses get offended by the very
discussion as though it were a reflection on their professionalism, when in fact,
their professionalism is often irrelevant in the patient's mind.

My husband and I are modest people. Neither of us enjoy having our private parts
viewed or handled by anyone but each other. Nevertheless, we understand that
some medical situations require viewing and handling of private parts, often by
people of the opposite sex. We find that acceptable, PROVIDED THAT we are
informed of the modesty invasion beforehand and given a chance to consent and
make any special requests.

Unfortunately, we learned the hard way that health care providers often do not take
the time or effort to make sure of a patient's prior knowledge and consent of
invasive medical procedures when the patient is going in to the OR and will be
anesthetized. My husband had an appendectomy last week. IF WE HAD BEEN
INFORMED that his groin area would be shaved and a catheter inserted into his
penis, we would have requested a male do these things if possible (at least 3 males
were present in the OR). If no males were available, we would have understood.
Instead, we were left completely in the dark about this. There was plenty of time
before the surgery to let us know about these procedures! My husband did not find
out about the catheter until he asked a nurse afterward why he had discomfort
urinating. After we discovered the intrusions, I began wondering exactly how many
women had viewed and handled my husband's genitals, all WITHOUT his prior
knowledge and consent. Was an enema also performed? What about a testicular
exam? Was he covered modestly when possible, or left naked on the table with his
genitals exposed to several female strangers? The point is, WE DON'T KNOW. We
were never told! Before the surgery, we assumed there would be some genital
exposure, but we had no idea that a stranger (probably a woman) would be handling
my husband's penis to the extent of inserting a catheter into it.

The simple fact that we were not told ahead of time what to expect has caused me
a great deal of emotional trauma over the past few days. I feel as if, in some small
way, my husband was raped in that OR, while I was not allowed to view any of it
and had no idea that he was being violated. It is almost like those unscrupulous men
who slip the "date-rape drug" into a woman's drink and have their way with her,
while assured that she will have no memory of it. I do not at all mean to suggest
that there was any malicious or sexual intention on the part of the doctors or
nurses, but the pain I feel over this secretive intrusion into our marital space is very
real. I absolutely sympathize with the other posters here who have commiserated
about their spouses' modesty being compromised. The really sad thing is, it could so
easily be avoided, and since hospital staff are the ones "in-the-know," they need to
be the ones to speak up rather than assuming the patient is expecting to be
violated. I do not fault OR staff for this, but I do fault hospitals for not making
patient consent for these procedures standard.

I ask you, is it ethical for someone to view and handle someone else's private parts
without that person's knowledge and consent, and to do so while the person is under
general anesthesia? Why is it considered acceptable for hospitals to do this? Dr.
Bernstein, the bottom line is that patients need to be INFORMED ahead of time
when they will be unconscious for an invasive procedure. Hospitals should not
assume that all patients know what to expect, or that all patients are A-OK with
unexpected invasive procedures. All that is needed is a simple standard that any
patient being put under anesthesia be informed beforehand of these procedures and
at least given an opportunity to make special requests, such as same-sex workers
doing the genital handling. The vast majority of patients will be understanding if
same-sex workers are not available. I ask you, why is this not done already?

- Dismayed Wife
Tuesday, February 12, 2008 3:33:00 PM

Chris said...
Dismayed Wife,

I would read through this thread as there are others who expressed the same dismay
you did. It would be time well spent seeing how Dr. B and others responded to this
issue. I bet you will feel much better after you do.

-CM
Tuesday, February 12, 2008 5:50:00 PM

Maurice Bernstein, M.D. said...
Chris left the following comment at 8:45pm today: "Great forum. Question for Dr.
B:

Can you request no sales people come into your surgery? I'm okay with the docs,
nurses and necessary medical staff but having sales reps in there doesn't make me
very comfortable. How often are sales people in the room? Thank you."

My response as a non-surgeon but based on what I understand is that sales people
don't come into operating rooms unless they are patients under the knife. Technical
representatives of surgical equipment companies do appear in the operating room
to help train the surgeons in the use of their equipment. Their presence and activity
should be part of the informed consent by the patient and should be documented in
the chart. Obviously, these "guests" in the operating room have the potential to
view unclothed patients.

With regard to a response to the concerns of "Dismayed Wife" and all the others
similarly dismayed, I will repeat what I have previously written here: Get together
in some activist forum regarding the modesty issues that you find important to
bring to the attention of doctors and medical institutions. And then ACT. For
example, though I am no lawyer, I would think that a group of activists carrying out
non-violent "picketing" in front of a hospital declaring to the hospital and to the
community their grivences if they were ignored by the hospital after direct
communication with the hospital administration would be legal. I'm sure the group
would get media attention. The important point is that by group action in terms of
education and requesting change, occasional complaints by individual patients
probably won't accomplish much. Anyway, that is my opinion. ..Maurice.
Tuesday, February 12, 2008 7:49:00 PM

amr said...
Dr. B – regarding sales people in the OR – if only that were true – they are there –
and apparently in our case, not in the control of the surgeon. This happened to my
wife – so this is personal experience. And apparently it is sanctioned by the
hospital. Back in March 2007 as part of my long entry – in part of this blog above I
wrote the Dr. about this very issue. Although the email to the doc – repeated here
did not explicitly mention sales people, it was discussed. In an email to him we
asked if we needed to explicitly check off the opt out box on the consent form. He
wrote back saying that he does not allow them into the OR, that we did not need to
check it off – all would be OK. We trusted him partly because of the interchange
below:

March 2007 – taken from my earlier blog entry:

Dear Dr. X,

I have watched how you respect your patients' modesty. As a husband, I very much
appreciate your bed side manner in this regard.

As a personal request, could you try and see that unnecessary exposure of my wife
during transport, prep, OR, and recovery, etc. is minimized. I do understand that
there are many players and some of this may not be controllable.

Respectfully,
Mr. R.

p.s. I again want to express my thanks for what you did for my wife in the first
surgery to make this one possible.

He wrote back: “Will do. No Problem.”

(What he ended up doing was closing the operating room. Only his senior fellow
assisted.)

So… Dr. M. Your blog really helped here. It reinforced the notion to bring up the
issues of concern and ask.

---------
(Remember – this is a MAJOR teaching hospital)

Well, 7 months after this surgery, while my wife was in recovery yet again, I was
reading the notes from the surgery in April 2007 and lo and behold, the official
record showed that a suture salesman had been logged into the OR for about 15
minutes in the middle of her surgery. Remember, her surgery is such that her body
is mostly exposed (“unclothed as you would say”) for the better part of 6 hours.
Furthermore, the official record showed that the salesman was back in the OR for
the last hour of the operation. This certainly would have been the time when my
wife was again fully exposed (sorry – “unclothed”) at the end of the operation.

When she found out she was embarrassed and hurt. Letters were written to the doc
asking for an explanation. He was very upset. He brought in his assistant as witness
(we normally only see him). He said that the salesman simply walked into the OR
without being invited in. The doc told us that when he noticed, he got angry and
threw him out. (Apparently the circular remembered the incident because he never
gets angry like that.) It doesn’t of course explain the 1 hr at the end of the surgery.
He claims that at no time did this salesman get close to my wife and that the OR is
such (with people around her), he did not see her. As far as the last hr, he claimed
that the salesman had asked the circular to show him as logged in so that he could
show his bosses that he was on the job. Apparently they have a quota. The surgery
rooms are small with the table in the middle of the room – it is truly hard for me to
believe that this “salesman” did not see my wife, although, our sister-in-law (a doc
at the same institution), says that with how equipment and shelving is moved
around the table, she could see it as possible that the salesman did not see anything
if he had remained at the entrance to the OR. The point is that we made a formal
request in writing separate from the consent form, and the doc responded in
writing that no salesman would be allowed into the OR – there was no need to
resign the consent form (because my wife had not checked the box). And somehow,
that formal, legal opt out was ignored.

My advise to folks is to make a big “X” on the consent form and make a point of the
“X” to the circular and to the Doc. You might even put in writing that you will
immediately request the OR personal in attendance records immediately after the
surgery to verify that your opt out had been followed.

So…. Dr B…. shall we bring up the word: Decency?

Our doc defended his actions in not telling us at the time what had happened saying
that it was somehow not material and he wasn’t going to tell us about oversights
that were not in his control. He was visibly upset. But to this day, I do not know if
it was because he was caught and possibly in “trouble”, or that he was trying to
protect us in some way, and/or truly he was chagrinned that he was not able to
protect his patient (I want to believe this was the case). Either way, it is generally
the cover-up that gets you – not the crime….

The air was essentially cleared, and in fact, my wife has had yet another surgery
with the doc (one I described above regarding her clothes being left on).

An aberration you say?

My father (who is getting up there in years) recently had an operation at another
major hospital in our area. As I was getting out of my car to visit my mother in the
waiting room, I saw two very nice good looking guys getting out of their car in
scrubs. They were taking out OR equipment / supply samples from their traveling
case of supplies. I made a point of walking past them, and lo and behold, they were
from the same exact suture company that “violated” my wife’s space. I followed
them to see where they went. Well, you guessed it, they were going to the OR. As I
turned left into the waiting room, they simply walked right through the doors into
the OR suite as if they owned the place.

Oh – and let’s not forget the camera’s in the OR – there is one monitoring system
that has been written up extensively in the literature, where a monitoring wall for
the OR suites is put in the OR lounge. So anyone in the lounge gazing at the board
will see, “unclothed” patients --- even the salesman that are allowed into the suite,
not to mention anyone there not associated with a particular case.

Surgery and the “unclothed” patient goes hand in hand – it is just a part of surgery
after all. They are all professionals, not a part of the “public”. Its just a pts body
after all, been there, seen that… what is the big deal?

Decency you say? No big deal, the patient agreed to it in the general release form (
to be videoed / photographed etc). So what is the problem, they have consented.
Oh there is that one little issue that if you don’t sign the consent as written, you
will not get your surgery… Well, that is of course the pts choice now, isn’t it? (The
ultimate opt out I suppose.)

Slightly different subject: I saw on the net not long ago a major national TV New
outlet run a story about the new OR rooms. They spoke about the ability to have
doctors confer and concept telemedicine and remote observation of the surgery for
students. If you look, it is not hard to find out about the “unclothed” patient and
the OR. This and the non-consensual pelvic exams issue is out there, nationally and
internationally. It is clear that society has not focused on these issues as important
enough to call their elected officials. Oh, that right, those elected officials listen to
the medical lobby. I forgot…. Dr. B is right, this issue simply is not going to change
until enough pts get together and garner enough attention to be noticed. I truly
wonder if that will ever happen. Teaching the next generation of “professional” – if
done universally (which I have doubts about) would have a wider impact over time.
But hopefully, there are other Dr. B’s around teaching the next gen.

--amr
Wednesday, February 13, 2008 4:43:00 AM

Maurice Bernstein, M.D. said...
Salesmen coming out of their car and going into the OR with the same scrubs on?
Except for the ego pleasing appearance of being a "surgical professional", from a
sanitary point of view, they could have been wearing their business suits as they
entered the OR.

Amr, you acted as best you could on behalf of your wife communicating to her
surgeon but it would have been also wise to complain to the hospital administration
about your findings including your observations of the salesmen. If the airline
system safety or management has a flaw, it is probably better for fixing it to bring
it to the administrators' attention then simply complain to the pilot. ..Maurice.
Wednesday, February 13, 2008 7:50:00 AM

amr said...
Dr. B

Yes, you read it correctly, they walked into the OR suite with scrubs on from their
car. Have no idea where they went inside the suite. I’ve seen surgeons and other
personnel do the same thing. They certainly could have gowned to go into an OR, or
changed scrubs in the locker room. But the point is that sales people are routinely
in and out of the OR. In fact, I have come across positions that are labeled as
“manufacturing rep” (aka saleman) on various websites. The job posting states that
the person will be in the OR during operations as part of job requirement. I also had
occasion to speak with a sales rep for anesthesia. She certainly wasn’t teaching a
doc anything I’m sure. If anything, she was witnessing and learning herself about
the effects of the drugs so she could do a better job of selling. She has witnessed
countless operations. She even told me which hospitals in and around my “area” she
would or would not go to personally based upon watching the inner workings of the
OR’s at these hospitals.

If it had been up to me, I would have made a complaint to the hospital regarding
what happened to my wife. My wife had several reasons for leaving it stand only
with the Dr. – after all, in the end, it is her body.

1) Even a general complaint would have come back to the doc. From what the doc
said, he knew that the salesman was in there against her wishes the 1st time, and
that he did not disclose the oversight. Also, if you take him at his word that the
second time noted in the records was “not true”, then it is clear that someone
falsified a med-legal document. If it was true and the salesman was there for over 1
hr, then you could not characterize the incident as an oversight, and it would have
meant that her had out and out lied to us. “So, Mr. Smith, when did you stop
beating your wife?”

2) She wants an ongoing relationship with him – he is a good surgeon, and who we
believe to be a good person. And escalating the issue, would have ended her ability
to be treated at this institution. She wanted to express her embarrassment and
anger to him, and set things right between them.

3) She was worried about blow-back that might effect her family who are docs at
the same institution

4) And lastly, she does come from a medical family – and “normally” docs do not go
after other docs.

Out of deference to the above, I actually had made a decision not to write about
this in this blog when this occurred because the anonymity veil is thin. But your
comments above prompted me to write to let you and the blog know about our 1st
person experience in this matter.

Medicine is a business – big business; and businesses ALWAYS operates in their own
best interest first. Hospitals are no different. Teaching hospitals etc do what they
do because they can, it benefits them, and they work hard to make sure they can
still do what they want to do. “Decency” / “Respect” are simply not in that
equation. Only a law suit or law will change this situation. The public as a whole is
not watching. I guarantee you that had we complained further, it would have been
referred to the “risk management” office. At the end of the day, my wife does not
want to “opt out” of medical care.

Dr. B – they have us by our short hairs – that is if they haven’t already been
trimmed during prep :--)

PS: I’m a private pilot – and I can assure you that there is a lot that goes on that
the traveling public would be surprised about – much of it having directly to do with
safety. Normally, only realllllly bad errors are reported. What you are taught as a
pilot is, situational awareness: don’t trust ATC (air traffic control) – their frequent
mistakes could cost you your life. I would say that at least 40% of the time I fly, I
have to correct or “clarify” an instruction that is given to me by ATC. The FAA like
the FDA has been corrupted by the politicians and the businesses they are supposed
to control.

--amr
Wednesday, February 13, 2008 9:57:00 AM

Anonymous said...
I am the nurse that wrote of a situation involving being lied to about the genital
prep for my husband surgery back in January. The scenario of the "dismayed wife"
echoed my feelings exactly. I could not have articulated her feelings better. I am so
glad to hear that I was not the only woman in the world that felt the way I did. I
had the feeling that no other woman feels the way I felt. I couldn't believe it was
that way.

Something truly needs to be done about this.

I would also like to personally offer some insight with regard to the sales people in
the OR. I was a sales person. I worked for two different companies for a period of 7
yrs and was present on numerous occasions in an OR. To tell you truthfully I never
saw the patient prior and was not familiar with the consent form that they signed.
So I do not know how or what was divulged to them about my presence. I never was
present when the circulating nurse prepped the patient. On all but one occasion the
patient was fully draped and I saw nothing exposed. On one occasion the patient
was exposed (his buttocks) only because he was a quadraplegic and they were doing
massive debridment on his gluteal area. I did not witness any pre-surgical prep or
nudity. There are many reps wandering in and out of hospitals and doctor offices.
Most of the people they hire for reps, be it pharmaceutical or vendor, are young,
degreed, good-looking men and women. They usually have zero medical
background. They come in with a bachelors in communication or business. They
would trip over something and not know what the heck it is. It is a joke. I don't
think they have any place being anywhere near an active OR suite.

RN Retired
Wednesday, February 13, 2008 1:40:00 PM

Anonymous said...
"RN Retired," I couldn't agree more. There are probably plenty of women who feel
this way but are afraid to speak up. There are also plenty of people who have simply
never had to deal with a surgery for themselves or their spouse, and so they have no
idea of this frightening gap in patients' rights. I find it unconscionable that my
husband was informed before the surgery that a breathing tube would be inserted
into his airway, but he was not informed that a catheter would be inserted into his
penis! He is embarrassed to even think about what went on while he was
unconscious and incapacitated.

At the same time, even if we had known there could be some genital handling, we
would have felt nervous about making special privacy requests. After all, my
husband's life was in their hands, and we certainly didn't want to offend them! I
read several entries from a patient modesty blog on allnurses.com, and was
sickened by the lack of empathy on the part of most posters there. One "WitchyRN"
was offended because she assumed that a patient's privacy concerns were somehow
a personal insult to her professionalism or even an implication that she was a
pervert. She also insultingly referred to the "insecure wife" who has issues with her
husband's privates being handled by another woman. I wouldn't want a woman like
that working with me OR my husband, not because I think she's perverted or
unprofessional in handling genital procedures, but because she clearly has zero
concern about the patient's point of view on privacy.

I am planning to send a letter to the hospital administration, but after reading
some of these posts, I am nervous about being "blacklisted." It is intimidating since
I have a baby due in May, and my OB/GYN does deliveries at that same hospital. It's
no fun trying to fight the system.

Thanks for your insights on the sales reps. It is good to know that at least in your
experience, it was rare to witness an exposed patient. Personally, I would not have
let my husband out of my sight if they had allowed me -- at least to watch through
a window. At least then, I would have known exactly what went on and how
carefully they handled his modesty. It's really scary just not knowing! Do you know
why they usually bar spouses from supervising these things?

- Dismayed Wife
Thursday, February 14, 2008 8:50:00 AM

Anonymous said...
And Dr. Bernstein, with all respect, you did not answer my questions. Why IS it
"legal" to handle an unconscious person's genitals without their consent as long as it
takes place in a hospital? Hasn't there been some discussion about lawsuits over
unpermitted pelvic examinations on women? Why should inserting catheters into
men be any different? The fact that only a few people take the effort to speak up
does not make this practice ethical.

I do plan to send a letter to the hospital along with a sample consent form that I
would find acceptable for them to use, but I'm curious as to why this issue hasn't
been addressed already. After all, patients sign a consent form for being operated
on by a surgeon. Is unconsented genital handling somehow not considered illegal
"battery" while actual surgery -- the very reason a surgery patient shows up -- is
illegal without specific consent? This makes no sense to me. I remember my
husband signing the consent form with his abdomen circled on the diagram. The
genital area was not circled.

I hope that you will drill it into your students' heads to inform patients not only of
surgical procedures, but also any genital procedures that will be done under
anesthesia. To do any less is unethical by any reasonable standard I can think of!

- Dismayed Wife
Thursday, February 14, 2008 9:16:00 AM

Anonymous said...
Why was he cathed?
If it was to make him more comfortable after a surgery by not having it put in while
he was awake and making it easier for him to go to the bathroom. I actually think
they treated him with GREAT justice. I was eighteen and had a operation I was
shaved twenty hrs. the day before by a female and 6 hrs. after my operation had
two young female nurses present for a foley to be put in. I was mordified and I
would have much more wanted them to put the foley in at the end of my operation.
I have no clue what happened after the doctor told me to count backwards from the
number ten. My brothers girlfriends mother at the time was my recovery nurse in
post op. how I know is because she escorted me back to my room and spoke with
my mom. I was only a little embarrassed when I found out she told my mom "I was
talking in my sleep in post op. and saying I wanted my mom" that honestly really did
not bother me and I think she told my mom that to make mother feel better. I have
never for a second worried if this women saw me naked/nude because I was out. My
scar goes pretty low and I had a different color gown on when I woke up in my
room. I have some modesty issues but in my opinion let the doctors and nurses do as
much as they can in the operation room. The fact is we do have to have exsposure
with medical treatment and if caregivers can take care of more while you are out
or you cannot see what they are doing roll with it is much better then being
shocked when two nurses walk in of the oppisite sex and have to put a foley in.
Jake
Thursday, February 14, 2008 2:12:00 PM

Anonymous said...
Dismayed Wife, we would be interested in having you join our group, How Husbands
Feel.
http://health.groups.yahoo.com/group/howhusbandsfeel/

CLW
Thursday, February 14, 2008 8:24:00 PM

Anonymous said...
Jake,
Standards have changed, as you and others know by now, over the years. Guideline
now are to shave hair immediately prior to the surgery and to no longer use a blade
razor but an electric clipper. Hopefully they are disposable head electric clippers
and sanitary. That was the first thing I thought of. Why this man was cathed during
surgery needs to be asked of the surgeon. The only reason I think this is done while
the patient is unaware is to eliminate embarrassment, remove the discomfort of
the procedure, so a female can perform the cath without objection(they don't have
to find a male tech/nurse), and so there is no worry of an erection.

You missed the point though. The complaint from patients and spouses is the fact
they were not INFORMED and thus this happened without the patients knowledge
and consent. Being knocked out should in no way VOID the rights of patients. They
should be able to say they don't want an opposite sex gender nurse if that is their
preference. It is a violation of the patients privacy rights.

RN Retired
Friday, February 15, 2008 4:32:00 AM

Anonymous said...
Jake,

I agree completely, but I think you missed my point. My whole issue is that they
didn't INFORM us what would happen. We know little about surgery and had no
reason to think his genitals even needed to be exposed, much less handled, for
incisions being made on his abdomen. It made my blood run cold to realize, after
the fact, they had shaved his groin and put in a catheter. It made me wonder just
what else they had done behind our backs (enema? testicular exam? left him naked
on the table for the whole surgery?).

Medical professionals don't need to be assuming that laypeople know all the details
of surgery or are expecting to be touched in sensitive areas while out.

Believe it or not, we would have requested, not demanded, that a male nurse
perform the procedure if available. If a female nurse needs to insert a catheter,
fine. If it's better to do it under anesthesia, I'm all for it. But TELL us first. I at
least like to be aware when some stranger is going to be handling my husband's
genitals or my own, for that matter. I don't think that's too much to ask -- do you?

After all, I go to a male OB/GYN myself. But there, I am always aware of what is
happening. Things are much less scary when you KNOW.

- Dismayed Wife
Friday, February 15, 2008 9:50:00 AM

Anonymous said...
Jake,

Not sure if many on this board would agree with all that you said. I, being a three
time surgical patient the last three years, would want to know who all was involved
and how much exposure would be involved. The fact really is that more can be done
to preserve a persons modesty and treat them with DECENCY but doesn’t because of
ritual and the attitude that this is just the way it’s always been done. When you
sign the consent forms, they are vague and give no indication of what happens prior
to surgery. If these were true consent forms, there would be no questions after
surgery, PERIOD. If you’ve taken the time to read all the post of this blog and the
allnurse post you’ll see that they think they do this because they feel it would be
stressful to the patient. I WONDER WHY? It would do more harm to me and many
others to find out after the fact, than before. I have a right to determine who does
what to me.

As far as putting the X in the form to allow other technical representatives in the
room. I would suggest just that, that is what I did and yes, the nurse didn’t like it
but I told her that I wasn’t going to change it. END OF STORY. Anything on that
form you have any question about, put the X there. If they refuse to go through the
procedure because of it, just tell them you’ll go elsewhere. Your probably better off
if they refuse anyway IMO. You can also cross out anything you don’t agree with. I
only allowed photos of my last procedure and maked the rest out, nothing was said
to me about it, the most flack I got was over the technical resources because
something or someone may need to work on the equipment. I asked her how often
that happens, she responded NEVER?

Not sure what any of your situations are but has anyone ever went to any outpatient
facilities? They don’t practice the way hospitals do as far as the extensive preps
that have been described here, heck I even asked if they put a foley in a male for an
appendectomy, they told me ‘not that often.’ They never shave, just use an electric
razor and I have never had someone so much as remove my gown during my
procedures. I know this for a fact because I always had some betadine on my gown
and it was always the same gown (I signed my name on it!). I’m sure you couldn’t
do this in an emergency sitation but most elective procedures can be done at these
facilities. Again, only a suggestion.


Dr.Bernstein, from looking at some of your other blogs, this one and naked had
been pretty popular. Can you share with us what you have learned through this and
what if any comments have come from your class on this subject? Do you feel that
your students that have read this have gained anything from it? I know and
appreciate you being open and trying to explain this to those that have trouble
dealing with it. I’ve learned quite a bit and it has helped me to a small degree,
especially figuring out how to approach this subject with providers. Jimmy
Saturday, February 16, 2008 1:02:00 AM

Maurice Bernstein, M.D. said...
Jimmy, actually I learned a lot from the responses on the subject of modesty and I
have written about this previously. What I learned was that there was a definite
portion of the population of patients who had strong feelings about how their issues
regarding physical modesty was unknown, misunderstood or simply ignored by the
medical profession.
To what magnitude of the total patient population these feelings exist is impossible
to tell from simply the postings on my blog. However, since the doctor-patient
relationship deals with one doctor interreaction with one patient, what goes on in
that relationship trumps any statistical information regarding the extent of modesty
issues in the general population.

As I have noted previously, I was impressed by the degrees and extent of the
concern. I have been teaching medical students how a perform a physical
examination for a number of years and I have always reminded them of the
importance of considering patient modesty in all their interactions with their
patients. However, since the blog commentaries, I have reemphasized the need to
attend to modesty applying some of the nuanced concerns written by my visitors of
which I had not considered previously and also encouraged them to read the
reponses on my blog. But this represents only my 6 students each year. There needs
to be a wider broadcasting of patient concerns.

I hope, beyond this blog, to participate in this regard bringing more awareness of
modesty in medical student education. ..Maurice.
Saturday, February 16, 2008 12:50:00 PM

Anonymous said...
I would like to call the attention of this blog's readers
and posters to the following url:

http://www.drlaw.com/MEDICAL-NWSLTR-Medical-Chaperones.pdf

"The Medical Newsletter" found
here demands chaperones for doctors without the slightest concern for patients. It
implys that this dictate should not be made known to patients in
advance but that they should be refused service if they do not agree to whatever
level of humiliation the doctor finds necessary for his possible legal defense. Real in
your face medical arrogance.
-- CHUCK McP
Saturday, February 16, 2008 6:12:00 PM

Anonymous said...
Hey Jimmy,
I have had several operations and teriminal cancer and spent a lifetime in the
doctors office and hospitals. I have had my share and more of exsposure I qualify to
join in on any conversation. YOU NEED TO GET OFF THAT BOX BECAUSE SOMEONE
ELSE MAY NEED THE SOAP.
I understand what you folks are saying but when does the word informed end? Most
of us go on the internet and research the cars we are going to buy and ask several
questions at the dealership. HOW DOES THE SURGICAL TEAM KNOW WHAT BOTHERS
A PATIENT (AND THEIR SPOUSE) IF WE DO NOT INFORM THE SURGICAL TEAM. My
question is when does the question of the INFORMED END?
We are not informed about what kind of plastic is used to keep things sterile.
We are not informed how waste is removed?
We are not informed how many times the surgeon was married.
We are not informed that one team member it is there first day on the surgical
team.
We are not informed how many people died having that operation.
We are not informed if someone on that surgical staff is racist.
We are not informed on many things and if a surgical team would bring up out of
the clear blue what THEY THINK COULD BOTHER US, NO ONE WOULD EVER BE
GETTING OPERATED ON.
Some patient do not mind that parts of their body are exsposed during an operation
some do. Some patients would be more upset about having that facility not recycle.
Some patients would mind if their doctor did not like gay patients.
See most of my questions mentioned above I could care less with because it has
nothing to do with how my operation will turn out or will the amount of exsposure
of my body determine the outcome of my operation.
SO I GUESS TE BIG NEW QUESTIONS FROM YOU FOLKS WHO HAD LESS OPERATIONS
THEN JIMMY IS-WHAT IS NECCASARY NUDITY "VS" NON NECCASARY NUDITY?
WHAT IS NECCASARY TOUCHING "VS" NON NECCASSARY TOUCHING?
As patients we are all a little selfish and worry only with what bothers us and never
considered what may bother the next patient!

Jake
Sunday, February 17, 2008 6:08:00 AM

Anonymous said...
#1- all nurses .com is a good sight but as people were saying to me as being
uninformed, anyone can sigm up at all nurses.com, you do not have to be a nurse.
Even on allnurses there is rumor that poeople could be signing up and telling a story
of living out a fetish. Granted if that is the case I can not imagine it happens all the
time but I do not believe everything I read. I try to take what I can and leave the
rest.
#2 In my personal expierence I have had several situations in my medical situations
that I believe could have been handled different when I thought my modesty was
comprimised.
#3 No it is not rape when a man has a foley inserted during an operations. Maybe
the doctor thought for what ever reasons during the operations lets go ahead and
caythe. this guy. Maybe what they were operating on was worst and the doctor
thought and maybe for many reasons did not want this patient moving to much or
trying to get out of bed for the first 48hrs. after surgery.
#4 I agree with maybee 90% of the post on here but we keep hearing the same story
over and over. Bloggers are saying that some of these situations made there blood
boil, but you never hear they took a list of "what excatly would upset the patient" I
hear some have asked questions.
#5-Most medical proffesion have went to school for a long time and our educated
but we as the patient are not educated in "how to be a patient". This biggest
problem I find is here in the United States every nurse,doctor hospital,surgeon,aide
and out patient facility not two of them do the exact same thing at the exact same
time, or do not do something all together. Unless it is an emergency or 60 Minuntes
breaks a huge story about this "We must re-train our doctors and nurses the best we
can and make sure we can have any questions before, during and after a procedure
are address.
There are some jerks in the medical field like in any industry but majority of them
want to helps us and try to makes us feel as comfotable as possible, so maybe they
are not and it is our job to inform them, and get the procedure and move on to a
healthy recovery.

Jake
Sunday, February 17, 2008 8:03:00 AM

Maurice Bernstein, M.D. said...
Chuck, this article in 2000 was obviously written by lawyers whose interests are for
their physician clients. These lawyers are directed to preservation of doctors and
not for any humanistic concerns for patients. They are the lawyers who for years
(generations)have been advising physicians not to admit, apologize or make any
comments regarding any errors or injuries sustained by patients under medical care.
It is only in the recent few years that there is a beginning change in the advice
some lawyers are giving towards the value of admitting and apologizing for errors.
Maybe some changes in attitude towards chaperone use and gender will also take
place. ..Maurice.
Sunday, February 17, 2008 8:19:00 AM

Anonymous said...
Jake

I think if anything this does show the wide disparity of feelings of people, even
among those on this blog who are have similar concerns about modesty in the
medical setting. I personally agree with Jake, while I am a very modest person by
nature, I have had several procedures which required exposure, and to be honest I
didn't want to know what they were going to do or see anyone that was involved. It
made it a lot easier for me to have the anonmity. While my preference would be
same gender providers, I know this isn't reasonable in a surgery setting so I
concentrate on what I can to make it more comfortable. There was no way to avoid
exposure on these procedures. Next best thing for me...don't tell who is doing what
other than the mechanics of the procedure itself (risks, side effects, what to expect
from the procedure etc). While I have some mild discomfort knowing, or guessing,
for me it would be worse if I knew the extent of the exposure and to who and how
many. On the other hand as a result of this blog I have started making reasonable
requests before the procedures, ie male tech for ultra sound, requested a female NP
in training step out for hernia/prostate exam with my PCP. And, I am getting ready
for a lens implant for my eyes, it is in a surgery theater and I intend to make sure
to arrange with my surgeon prior that I can keep my underwear on since I have to
wear those ridiculous gowns...so for each his own, but I agree with Jake on this
one, not the ideal, but reasonable and something I can live with.

Dr. Bernstein, this blog is reaching out to more than the people on this thread.
Everyone that now makes thier wants and needs known...is touching someone else.
Its not where we need to be, not as wide spread as it needs to be, but its a start.
You are having an effect. JD
Sunday, February 17, 2008 8:32:00 AM

Maurice Bernstein, M.D. said...
Now I am going to tell you something personal and hopefully will provide another
dimension to this modesty discussion.

Two days ago, my wife underwent major cardio-vascular surgery involving widely
opening her anterior chest. Thank God, the operation was satisfactorily completed
and today she is recovering without complications. The surgery was complex and
delicate and substantial risks of all sorts were present including death.

I want you all to know that at no point leading up to the surgery or since the
surgery was the issue of modesty in my wife's or my own attention or consideration
or concern. During surgery, I and my family had no thoughts or discussion about my
wife's body being viewed by anyone. Her concern and my concern prior to the
surgery was that she would survive with no complications, especially kidney failure
or stroke and in the immediate post-operative period in the intensive care unit she
was attended by a male nurse whose special nursing skills were what we observed
and not his gender or the fact he had to view my wife's body.

Now of course, one could say that this was major surgery with a real death risk and
was not equivalent to some of the lesser risky surgeries or procedures related on
this thread by my visitors and it was natural that modesty would not be the major
concern. What I want to emphasize as I think I have previously written, that that
our attention to the skills of the surgeon and others in the operating team and the
anticipated good results without complications should trump any worries about
personal modesty. This doesn't mean that the surgeon, as team leader, should
ingnore patient or family's modesty concerns. Indeed, if concerns are expressed to
the surgeon, the surgeon should be able to take the time to listen, be attentive,
understanding and then communicate what the issue means in the context of the
surgery and how, if possible, the issue can be mitigated. Ignoring the patient's or
family's concerns whether it is about modesty, outcome, complications or mortality
would not represent the best of a surgeon's humanistic responsibility as a
professional. ..Maurice.
Sunday, February 17, 2008 6:03:00 PM

TT said...
Maurice,

Sorry to hear about your wife. I'm glad the procedure was successful, and you both
have my wishes and prayers for her rapid and complete recovery.

TT
Sunday, February 17, 2008 7:01:00 PM

Maurice Bernstein, M.D. said...
TT, thanks for your wishes and prayers and to any other visitor thinking about my
family, a pre-emptive thanks, too.

The reason I published my personal experience was not to get sympathy but to make
a limited, perhaps a very limited, point. In some circumstances, modesty is really
not the issue. ..Maurice.
Sunday, February 17, 2008 8:15:00 PM

Chris said...
I'm glad your wife is doing well. I will pray she has a quick nd full recovery.

Your point is a good one. I feel the same way.
Sunday, February 17, 2008 9:15:00 PM

Anonymous said...
CLW, Thanks for the invitation. I'll consider it.

Dr. Bernstein, Thanks for sharing, and I'm glad that your wife got through the
surgery and is recovering. I'm sure that, both of you being familiar with medical
procedures, you did not feel "left in the dark" on anything, and that's good. I wish all
of us had that benefit. I'm still making my way through this very long blog, and I
appreciate that you have made it available to us.

Jake, I see what you're saying that doctors can't always predict what will upset a
patient, but let's be realistic. What patient expects the doctor to volunteer
information on what type of plastic is used? If a patient is concerned about
recycling, would they really assume that the doctor would bring that up?

On the other hand, when it deals with the way a patient's body will be handled, this
is altogether different. The surgeon comes in and offers details of how the patient's
body will be cut, and the patient signs a consent form for it. I presume this is
because inflicting "injury" without express consent is legally considered battery.
However, offensive contact without consent also falls under battery, and most
reasonable people would call genital handling by a stranger offensive contact. Just
as most people will submit to the surgeon's knife for their greater health, most will
also submit to genital handling for their greater health. But by the same token,
express consent should be obtained for genital handling just as it is for surgery
itself. How can you really argue with that logic?

As far as feeling uncomfortable knowing the details, there are also patients with
"weak stomachs" who get lightheaded listening to the details of surgery, so that is
no excuse. If a patient feels better not knowing, they always have the option of
signing off a consent form without knowing the details. It should be the same with
genital procedures.

Also, I didn't state that my husband was raped, only that it feels that way only in a
much smaller measure. How would you feel if your wife (or other close female) were
one of the unlucky women subjected to the unconsented pelvic examinations under
anesthesia?

I have to concur with Jimmy when he says that finding out about unconsented
genital handling after the fact can be more traumatic than being informed before.

Other spouses, I want to say that I did feel better after asking my husband for all
the details he could remember. I was at least comforted to know that the few
female nurses there were kind and considerate to him while awake, and that there
didn't seem to be a lot of people coming in and out. You may find some comfort in
finding out all the details you can. For many of us, it is the not knowing that is the
worst part. Nevertheless, since it is after the fact, I still consider it only "damage
control," and I still plan to complain to the hospital about their policy of keeping us
in the dark.

- Dismayed Wife
Sunday, February 17, 2008 10:07:00 PM

Anonymous said...
D.Wife
My point was also misunderstood and maybe I left out an important phrase. If
doctors are going to keep us uninformed I think your husband got the better of two
evils. As Jimmey said very rudely if I have read the blogs, well I actually posted my
expierence's a month ago what it was like for an first time 18 yr. old man to go
through the motions of a very long and hard 14 day stay at the hospital. I was in a
horrible state with my parents so they were no help. At the time some of my
situations at the hospital was extremely embarassing and I was always ambushed by
the nurses and never told anything up front. I HONESTLY FOUND COMFORT IN THE
OPERATIONS ROOM BECAUSE NOT KNOWING AT THAT AGE WHAT QUESTIONS TO
ASK, I DID TRUELY UNDERSTAND I WOULD BE EXSPOSED ON THAT TABLE. So for
being so uniformed I wished more would have been done there and spared some
more extremely awkward moments. I truely do feel sorry for you and your husband
went through this. Dr. B shortly after my post and Retired Nurses was posting then
about a situation then he said something like (he nevers hears also that the patient
fully recovers and he hopes most people are not putting modesty in front of healing
and what lies ahead for the patient) that is just what I remember and you will have
to go back a month an re-read if you like. It made me think a little, as today I can
take care of myself in a medical situation much better then I could then. I will be
honest my surgeon was a ASS when it came to bedside manner but I am alive and he
was the one that kept me most uniformed but when I woke up it my room after
post-op I was in an incredible amount of pain but the pain that brought me to the
hospital was gone, I could feel that within seconds. I do wish you and your husband
and all people on this thread to find some peace in these situations for me I just try
to educate myself via-internet because you can read about most any procedure from
a doctors point of view and many times from the patients point of view usually two
different places on the internet. Yes, being a MALE I feel there is a DOUBLE
STANDARD in the medical world for male patients and yes, I feel there is a huge DO
NOT ASK/DO NOT TELL POLICY but just think our stories are going to help someone
else not go through what we did or someones love one. For me I had to flip the coin
try to look at the other side and then put the coin down and let go of some of my
feelings because I really think my nursing staff/surgeon was trying to do what they
thought was best even thow I did not agree at the time or agree today. This may
seem very elementary but it is like our parents may have made a lot of poor
descions for us/about us growing up but at the time they thought and problay still
do think that but they did it because they care and they never meant to harm us
even thow they may have.
Jake
Monday, February 18, 2008 3:33:00 AM

Anonymous said...
Dr. B, our prayers are with you and your wife. I am glad to hear of her successful
surgey. After seeing 60 min Sunday evening and the segment on Bayers drug used in
heart surgery, I immediately thought of your wife. Seems the drug should have been
pulled from the market after studies showed very dangerous risks, eg kidney failure
and death.

To the dismayed wife, I would like to say that my feelings were exactly as how you
reacted. It was the last thing my husband and I expected to happen, as he asked
prior about the prep. He was told a male would be doing it. We learned after that a
female nurse did it all. The prep is just as bad as the shave and cath. You must
insist on a male or an all male room staff if possible. Go to the link listed in this
blog that Dr. B listed(sometime in January '08)...OR-live. You can see a full prep for
yourself.

I must agree wholehearted with Dr. B, his wife's situation was life threatening and
very different from the other surgeries that have been referenced here. With heart
surgery, the entire body is scrubbed, from the neck to the toes including the vagina
and anus.

The other piece of advice I would offer to anyone having a surgical procedure is to
obtain your medical file after the surgery. It is important, for several reasons. You
will then have the record to take to another surgeon if the need arises afterwards.
Facilites usually only keep records for 7-10 yrs and then they are destroyed. You
should have a record of what was done.

Ambulatory Surgery Centers (ASC) in our opinion and from our experience firsthand
are not particularly better than a hospital. An ASC is where we had the bad
experience. They also usually have limited numbers of OR staff (due to the smaller
size) and therefore you may not be able to have a preference of gender in the OR
room.
Monday, February 18, 2008 3:12:00 PM

Anonymous said...
Okay Everyone,
Ladies what your husband experienced is the double standard that Jake mention.
Males have been going through for years (decades) and your husbands were not
singled out and your rage is not healthy for anyone foremost your husbands
recovery. Instead of fueling your rage here and arguing with people that may seem
to come across as blah because they may have experienced this themselves.
As for the comparison "a Foley and rape" that is way out of line. The Foley and
shave fall under prepping the patient. Prepping is part of the procedure and pelvic
exam is just that an exam. A procedure is a procedure and a exam is an exam.
Now that I said that you do have every right to be upset but I doubt you ever go to
the surgeon directly (maybe making an appt.) and directly face to face ask him why
this happened the way it did. Letters usually do nothing because the facility actually
legally did nothing wrong. Yes, they did something morally wrong but did nothing
really wrong. Letters are responded with a generic safe letter that has been written
by lawyers.
If you and others are as mad as you claim to be take that anger and help others not
go through this. Think of the much bigger picture and take yourself out of the
equation and put your fellow brothers and sisters in the equation.


Dennis...
Monday, February 18, 2008 7:06:00 PM

Anonymous said...
You said-"I must agree wholehearted with Dr. B, his wife's situation was life
threatening and very different from the other surgeries that have been referenced
here. With heart surgery, the entire body is scrubbed, from the neck to the toes
including the vagina and anus."
You have no idea what kind of surgery people had on these thread maybe your
husbands was not life threatning, so you had every opprotunity to research the
procedure.

When my situations are not considered life threating I reasearch the surgeon and
get feedback from other doctors. Once you have a good surgeon in place I think you
are very foolish to start seperating his/her team for gender issues and modesty
issues. Most people who work in a team and work well together is when you will
most likely get a flawless expierence. A good surgeon is a good surgeon for many
reasons and within that realm I trust that he works with the best people he can
find.
Yes we can push for a all same gender team but how do we then know we are
getting the best surgical expierence, that female nurse we just bumped could be
one of the best nurses in that facility, or maybe not but if you have a good surgeon
trust me he/she is going to want the best people around.
If we are trusting a surgeon to put a knife to our skin I think it is best to let them
decided what is best while I am out.
Also for the person saying about their husband gentila handled without consent,
trust me they scrubbed his entire area so his gentila's were handled regaurdless.
To the person scratching things out on the consent form you are aloud to do what
ever you like, but some of those consents are there for a reason, like the techinical
person. It may not happen much but a good friend of my father had the machine
break down that pumps the the blood in and out of the body. Yes, a techinical
person was present but the failure of the machine was out to long. They sued but he
is basically a vegatable. Machine do break and for someone who may or may not see
my penis I rather live a full heathly life.
I do have modesty issues but when it comes to surgery I let the people with the
medical degrees do there job and when I am healthy I will do my job.
Tuesday, February 19, 2008 5:09:00 AM

gve said...
Anonymous of 5.09 today, good for you that you feel that way. A thing that is
special about humans is that we are all different.

I would rather run whatever risks having an all male team would present. I do not
care what cosy relationships there may be in an OR, I am only interested in my own
perspective (aren't we all?).

The smug attitude of OR staff that they know best and are all "professionals" makes
no impact on me whatsoever. I want what I want and in future, I will get it or not
be operated upon.
Tuesday, February 19, 2008 12:28:00 PM

Anonymous said...
I never said the OR staff knows best, or did I say all OR staff's are "professionals".
What I did say was wants I research a surgeon and research the procedure, it is time
for me to let go and trust the surgeon I picked to do the job I am paying him to do.
You are right we our all different but it seems my attitude towards this will get me
operated on in a timely matter so the situation does not progress.
Wednesday, February 20, 2008 5:09:00 AM

Anonymous said...
The essence of not being informed of these ethical issues (prep, shaving, cath, etc)
boil down to one statement that can pertain to any situation if life.

"ANGER OCCURS WHEN EXPECTATIONS ARE VIOLATED."
Wednesday, February 20, 2008 5:20:00 AM

Anonymous said...
Pre-operative preparations (eg hair shaving, cleanse/scrub, caths, etc) can be
performed by other individuals and certainly do not need the expertise of a degreed
person such as an RN. A bachelors or masters degree is not needed to do these
procedures. There are student nurses in the OR for the first time in their OR
rotation that are told to do this task. Many preps are done by OR Techs. Techs are
not degreed or licensed.

Only about 5% of licensed RN's work in the OR. Many nurses never have this kind of
intimate contact with patients. Psychiatric nursing, peds, risk management,
administration, research, legal nurse consulting, clinic nursing, and so forth.

Nurses in the OR are responsible to know how to work and operate machinery that
is in use. They are originally trained by the company supplying the equipment but
vendor techs are not there on a regular basis. It is the role and responsibilty of the
hospital staff to be proficient in the equipment used in the OR.
Wednesday, February 20, 2008 5:36:00 PM

Maurice Bernstein, M.D. said...
Let me remind again all Anonymous posters to end the comment with some sort of
pseudonym or initials so we can following along the view of the writer through
subsequent postings. ..Maurice.
Wednesday, February 20, 2008 8:58:00 PM

Anonymous said...
I have a question for anyone who would like to answer and please more than one
person can answer. I have been reading this part of the blog carefully and I am
seeing very good thoughts and strong feelings on ths matter of oppisite sex in the
OR from all sides. So this is making me think more about my personal views. I will
ask people, try not to be rude in the answer because I am also reading some
tempers are started to rise.

question # 1-People here have said and not all that they would request/demand an
all same sex staff in the OR next time they had an operation. They also say except
in an extreme life and death situattion. Except for the death part why is it okay
then for someone so modest or wanting their request made on a less of a extreme
situation. Meaning on a everyday basis we get in our cars and risk the chance of a
car accident which can land someone in the ER getting there clothes cut off by
someone, examend by anyone and rushed off to the OR and operated on by anyone. I
think most of us would agree and formost our families "We are grateful that the
hospital moved so quickly and we are alive" How come most do not feel that
grateful feeling on a less extreme operations (Please remember my question is for
me to provke my thought and understand better, and no one is right or wrong
here).
#2- What does everyone considered an emergegency to allowing the oppisite sex to
participate in their hopital care. If you went to the doctor and he ran some test and
called you the same day and says he wants you to show up at the hospital the next
morning and he has schedule surgery 36 hrs. later do we go with it or do we try to
start requesting our wishes. What happens if the OR can fill our wishes 75% all same
sex is that enough for us to go ahead and get our surgery. Or do we check out and
find a facility that can do it?
#3- I had a strange thought the other day regaurding peoples wishes on this matter I
bet one day there will be a bracelet people can wear saying "request same sex if at
all possible in an medical emergency".
Thanks in advanced and remember Febuary is national HEART month, stay healthy
everyone.
Danny.
Thursday, February 21, 2008 3:46:00 AM

Anonymous said...
Danny,
From our personal perspective with this issue..
Unless someone has the knowledge through either an experience or from reading
something like this blog, surgical patients have no idea what will happen and who
will be doing procedures in the OR. A patient is immediately sedated and given
anesthesia. Typically, the OR staff does not inform a patient either. Prior to any
touching the patient must be sedated. The anesthesiologist gives the OK to the
circulating nurse when the patient is sedated. The prep is then started.

If you went to a doctors office and was asked to completely disrobe in an exam
room, and then a worker of the oppostie sex walked through the door and started to
shave your pubic hair, insert a foley cath and do a 10 minute scrub from your naval
down to your anus (including genitals) and to the table side to side...would this be
acceptable and comfortable? I think most people would have a problem with this.

An emergency situation is an immediate life or death care of medical needs. STAT
as they call it. Anything else is referred to as elective surgery. You plan the surgical
procedure, get the appropriate tests (eg. blood work, chest xray, etc.).
You go in at your schedule under your terms and go to the surgeon and facility of
your selection. That's the difference --ELECTIVE vs. EMERGENCY.

RN- Retired
Thursday, February 21, 2008 4:00:00 PM

gve said...
RN retired,

I might suprise you here.

I don't care if it is emergency or elective. I planon having my medical notes show
that I do NOT want to be treated by opposite gender staff when nakedness is called
for , period. No exceptions, no "its different if my life is at risk", no female staff in
OR if I am to be naked, end of story.

And yes, I would rather die than compromise. I know you don;t know me but anyone
who does would know I am not kidding or posturing, I mean it!
Thursday, February 21, 2008 6:37:00 PM

Anonymous said...
To retired nurse,
I have had several operations more then I care to admitt even at a very young age
have had a foiey and been prepped for an operation always by a female, I have to be
honest as a retired nurse have you not been outraged by this most of your working
yrs. where men have usually no option in who participated in there healthcare
where gender was concerned. Times are changing I will admitt that but married
men are not the only men that expierence this kind of care I guess people call it
"the double standered" I was not married when my illness started and I had no one
to talk to how embarrassing this was, I also lived in a very large city I never notice
a male ever come into my room except for the doctor, so all gender care did not
exsit in this hospital. Men have always been treated this way not just in the
operating room.
Thursday, February 21, 2008 7:36:00 PM

Anonymous said...
RN RETIRED-I also have had a couple of operations and I am aware of the scrub
procedure so I think you can stop posting the same thing over and over. I do
personaly feel the prep and scrub down is pretty awful. I do not actually think that a
female nurse as yourself enjoys or looks forward to performing or degrading a male
patient in the operating room. My mother is a retired nurse who worked in the OR
for twenty five yrs. To this day she has nevered shared one story of her expierences
in the OR with my three brothers or myself, and trust me we always grilled her just
out of curiosity, even growing up some of our friends would try to ask her questions
and she always said "would you like it if you were in my operating room and I told
people stories of your operations". She is the most loving mother and raised four
boys and loved her job because she is truely a caring person. I know to my innercore
she treated every patient male or female with dignity and respect. I also think she
is not the only nurse male or female that went into the medical field because they
wanted to help people and stayed very true to that principal. I do not understand
where your anger is coming from being a retired nurse?

AbCd.
Thursday, February 21, 2008 9:53:00 PM

Anonymous said...
I am sorry retired nurse let me shorten my question because I am well aware what
happens in the OR and am well aware the difference in "elective vs emergency
surgery".

Why are people not more grateful in elective surgery that there are people in place
to make any operation a success, no matter what anyone sex is?

How much pain does someone need to be in to change their mind on allowing the
oppisite sex to participate in their operation?

As gve said there is no pain cap it is all or none I cannot say I agree but WOW this
guy is clear on that?
Again thanks in advance,
Danny
Friday, February 22, 2008 3:39:00 AM

Anonymous said...
As a working nurse my background never was in the OR. I did med/surg for 3 yrs,
renal dialysis for 1 yr, 4 yrs in the health department clinics (which included
immunizations (travel and childhood), peds, ob/gyn/ vd/ tb, general, alcohol &
drug). For 8 yrs I was a manufacturer sales rep and then a detail sales rep for a
distributing company selling to surgi-centers, hospitals, clinics, doctor offices, etc.

Years ago there were few male nurses. When I graduated there were 2 males out of
32 students. I believe now the stats are about 10%males in nursing.

Men in nursing tend to promote to admin positions many times. They make on
average $3,000 more per yr than female nurses.

As a head nurse on the med/surg floor I always had a male tech do a cath on a male
patient. I thought the man should have some respect and it was unnecessary for me
to do it.

There used to be mostly men physicians and surgeons. Now people also have a
choice.

RN -Retired
Friday, February 22, 2008 4:53:00 AM

Anonymous said...
To Mr. AbCd,
You obviously had not read my initial post. My anger and my husbands anger comes
from the fact that he had a surgical procedure and he specifically ask about the pre-
op prep (he was not cathed) as it was an issue with us as to who would be doing it.
He was misled and lied simply for their convenience. Never having witnessed a prep
in the OR and never having worked the OR I was not aware of the extensive cleanse.
We learned all of this after the fact just as the "dismayed wife" learned.

Thus our anger
Friday, February 22, 2008 2:21:00 PM

Anonymous said...
Dr. Bernstein

Let me first off add my prayers for your wife's speedy and complete recovery.


The diversity of feelings on these issues is one that will never be one that allows
universal agreement. I as I have stated am a very modest person. I have had several
procedures, and while I would have preferred an all male staff, would have been
more comfortable, I never asked as I felt that would be asking for a little to much
for them to provide. Now given the different points of view, I think there is
something in common in the difference between accepting opposite gender in
emergency and nonemergency elective situations. One is control, we have the
ability to make choices, to request, and to go elsewhere for elective procedures,
staff has the option and the time to bring in people to meet those request if they
choose, the thing is there is choice. In an emergency situation I and others
understand, there is not that ability even if they wanted to, time and severity
dictate. In the OR, many people understand we may not be able to choose, in life
threatening situations such as heart surgery, some of our modesty becomes over
shadowed by the concern for our lives. In most procedures, it is not life or death so
we are more focused on other issues, while we are still the same person, with the
same modesty, our priorities naturally change so the gender of our providers can
move up the ladder of importance. My wife always made sure my daughters were
freshly bathed and clothed in new clean clothes for their Dr. visit, but when one
broke her leg in a fall we went hell bent for the Dr.'s office with her wearing raggy
play clothes covered in mud....priorities change in the with the
circumstances....same goes with our modesty. Most of the anger her still comes
down to when they can reasonable provide, but do not. The choice, and in some
cases the honesty makes a ton of difference. JD
Friday, February 22, 2008 3:09:00 PM

Anonymous said...
JD's post of 3:09 P.M., today, is
right on the money. MOST patients with modesty concerns understand that the
needs of the emergency or the operating room will often make same gender
requests impossible. To appear sane and to point up the double-standard concerning
men, I think we need to focus on regularly scheduled procedures. The point
is that medical staff wouldn't expect to offer the same choices to women. If the
problem extends from an imbalance in staffing then the favored side of this
imbalance needs to do more to serve justice regarding the modesty issues involved.
Frankly, we need affirmative action to quickly remove women from their
overabundance in nursing and medical support roles.
If men were actually being paid more to join up, they would be enrolled in nursing
programs. Most male nurses don't move into administration at superior pay.
The truth is they drop out of nursing twice as fast as females because of what can
only be described as the "bitch" factor involved in dealing with a female
dominated profession. As a male, let me say that I have never received bad attitude
from a male
nurse or technician, it is always the sisterhood which is in your face when modesty
concerns are raised. BJB
Friday, February 22, 2008 8:57:00 PM

Anonymous said...
Jake,

I’ll try to clarify my last post and answer some of your questions.

You said:

SO I GUESS TE BIG NEW QUESTIONS FROM YOU FOLKS WHO HAD LESS OPERATIONS
THEN JIMMY IS-WHAT IS NECCASARY NUDITY "VS" NON NECCASARY NUDITY?
WHAT IS NECCASARY TOUCHING "VS" NON NECCASSARY TOUCHING?
As patients we are all a little selfish and worry only with what bothers us and never
considered what may bother the next patient!

This is actually simple, if it’s not getting operated on, leave it covered! As far as
my surgeries are concerned, had I had them in a hospital setting I would’ve been
fully exposed….unnecessarily! Getting the SAME TREATMENT elsewhere without the
exposure PROVES IT CAN BE DONE!!!!

I don’t get your last statement. If I’m in the hospital, I’m worried about myself and
I’d hope everyone would be. Most of the time I don’t know who the next patient is
and what I approve of in a hospital setting has no barren on the next patient. If
people are comfortable exposing themselves, so be it. It’s not for me to judge those
people but when it comes to me, that’s a whole different story. My whole problem
is with this don’t bother attitude that most display. There’s a lot that can be done
to improve this (as has been posted here) but their attitude of not caring just fires
me up. There’s no excuse for not trying!

My apologizes if I came across rude, that wasn’t my attention.

Jimmy
Friday, February 22, 2008 10:25:00 PM

Anonymous said...
Anonymous February 22 @ 3:39

You said: ‘Why are people not more grateful in elective surgery that there are
people in place to make any operation a success, no matter what anyone sex is?’

If I’m paying for this service, I should have the choice of who does what to me. I
would also guess (for my case) that having an elective procedure means that you
could live your life, just with some discomfort. It all depends on the patient’s pain
threshold. For me, I wouldn’t have had any of the procedures that I had done unless
I found a surgeon that would work with me. He did his job with his staff and got
paid while I had a speedy recovery and kept my dignity. Was a good trade off overall
and I’m grateful that I found a surgeon and staff that would use a little common
sense. Jimmy
Friday, February 22, 2008 10:52:00 PM

Anonymous said...
Anonymous February 19 @ 5:09 AM

‘To the person scratching things out on the consent form you are aloud to do what
ever you like, but some of those consents are there for a reason, like the techinical
person. It may not happen much but a good friend of my father had the machine
break down that pumps the the blood in and out of the body. Yes, a techinical
person was present but the failure of the machine was out to long.’

They wouldn’t be on the form if it was critical that they be present. For my form,
this would’ve also gave any salesman a right to be in the room during my procedure
and that wasn’t acceptable to me. This is really the only control that I have over my
body after I’m out, if the argument is made that a patient can’t mark something
out; Get rid of the form. As long as you have to sign and agree to it, there should
be no questions. It works both ways. Jimmy
Friday, February 22, 2008 11:23:00 PM

Anonymous said...
With regard to males in nursing the latest info published in the bi-monthly journal,
"Advance for Nurses" [May 14, 2007]states 10.4% males vs. 89.6% female. "The
majority of men surveyed work in critical care segments of medicine: ED, intensive
care, cardiac care and med/surg." According to this survey they do not find
integration in a female dominated field complicated. Equally, the gender
domination had no effect on their job satisfaction. If anything, these men said they
have experienced a warm wlecome form colleagues, patients and hospital
administration. More than 72% found no gender-based discrimination, and 93%
never experienced belittlement by co-workers, patients or families."

I did not state males were hired in with a $3000 higher rate than female nurses.
Male nurses on average earn $3000 more annually than females nationwide. That
was stated in the latest edition of Advance for Nurses.

I totally agree with the modest factor being rudely addressed by female nurses and
the "bitch" factor. I left hospital nursing because of the "bitch" factor. It was just
like the high school b.s.

I might add from my own perspective when salaries increased in the field of nursing
so did the number of males.

"In the 70's rate of pay was around $8.00 per hours now averages are around $60.00
per hour." (Advance for Nurses)

RN -retired
Saturday, February 23, 2008 6:05:00 AM

Anonymous said...
To RN Retired,
I am well aware of your original post because I have read every post here on Naked
and Modesty 2. I was trying to be polite previously because your original post does
not make a lot of sense to me.
The system that you claim screwed you and your husband, you were part of that
system at one time. I am not saying you miss treated a patient but the bottom line
you worked in part of the system.
I am also very aware you do not live or have you lived in the United States. Our
health care system is very different compared to Australia. Several males since your
original post have shared with you there experiences or explained to you how
"Dismay Wife" husband was treated is a big way how male patients are treated and
have been treated in the United States for a very long time. I have not seen where
you said a single word to them and some have sent you a direct post. I get a strong
feeling you only seem concerned for yourself and dismay wife. I will be honest again
I do not even see a a lot of similarities in her case and yours except for a spouse
being upset and that just makes me think you want to start a "wives club" instead of
acknowledging there is a huge problem in the way male patients are treated vs.
female patients or adding any ideas on how to help fix the problem, as a caring
nurse would.

Male nurses are not paid more in the United States then females.

I will agree on the 1 in 10 of male nurses vs. female nurses, lets do a small break
down on that.
A large hospital may have 100 nurses working a shift so for every ten female nurses
there is 1 male nurse working. I would have to say that is a lot of work for that guy
nurse to attend to every male patient on that floor or do you think some of the guy
patients fall under the woes care?
Here in the United States doctors do not prep patients (BOTTOM LINE)!!!
I also think the doctor in your case said he will take care of the prep, meaning not
to do the shave at home and his team will take care of it.
That is why I do not understand where your angers is coming from?

AbCd.
Saturday, February 23, 2008 7:59:00 AM

Maurice Bernstein, M.D. said...
For those interested in reading and writing about physician modesty in terms of
behavior and appearance, I created a new thread on the subject titled: Is Being A
Modest Doctor a Virtue and a Benefit for Their Patients? ..Maurice.
Saturday, February 23, 2008 8:42:00 AM

Anonymous said...
Mr AbCd,
I do live in the U.S. and am licensed in two states. If you don't understand where I
am coming from, well, what can I say. I put "our" feelings down on this blog as
others have. My husband did not at all expect to be prepped by a female nurse. That
is the bottom line. He asked ahead of time and was told a male would be doing it in
the OR. He learned afterwards that he was lied to. However you personally want to
disect and analize this is your choice. Yes, I am not denying there is a double
standard. I think most are in agreement with that.

Just because I was a part of a system at one time does not mean that my husband
and I cannot or should not be upset with the process that he encoutered. What does
that have to do with anything? Does that mean a doctor is never going to undergo
an unpleasant medical experience from another physician? Or a restaruant owner is
never going to get a bad meal in another restaurant? Or an attorney is never going
to have a bad experience with legal counsel? To be honest the experience was even
that much more upsetting because I had been a part of the system. It became much
more personal.

Patients should have the honest information given to them and they should have a
preference if it concerns them. This was the same exact circumstance others have
stated here.

RN -retired
Saturday, February 23, 2008 11:47:00 AM

Chris said...
A lot of the bad feelings and miscommunication would be avoided if surgeons made
it clear that the request couldn't be guaranteed. They should tell patients they will
try and have their needs met, but make it clear that there is a decent chance that
opposite sex personnel will be involved in their care in the OR and in recovery. This
is the most honest and accurate way to handle it.
Saturday, February 23, 2008 2:43:00 PM

Anonymous said...
Hey Everyone,
Does anyone want to share a success story on requesting a all same gender OR
team, from prep to recovery? Was it recieved open minded or did you get some
slack.

I myself have read the 1 in 10 male vs. female nurses so I would imagine it would be
hard to get an all male team. With the huge rise in female doctors but not such
such a rise in male nurses I think we are seeing way more female presents
everywhere. Even with speciality doctors using nurses and chaparones during an
exam. I do not mind a female doctor but forget the idea of disrobing for a full body
skin exam with a female doctor and a female nurse. I just turned forty and my
regular doctors wanted me to go to the Urologist (sp) and looking for one was hard
because I know some of the test they run can be embarrassing. The chances they
have female asst. are very high, actually I was getting tired of looking because my
regular doctor even recomened his uroligist "he said the team of urologist is the
best in the city" and I asked do they have any male asst. he said he has never saw
one nor has he had a female asst.
I had a nagging question in the back of my mind.
DO I GO TO THE SPECIALIST MY DOCTOR GOES TO AND TRUST, OR DO I KEEP
LOOKING AND SAEARCHING TO MEET MY MODESTY ISSUES?
So I called the specialist and they have no males but the doctors working and they
actually they have a female doctor working there also. I was assured patient
modesty is a big concern for all the doctors. I asked the person who answered the
phone "why do they not hire male nures and asst. at this urologist office" she said "
because the doctors do interview male nurses and asst. but to date the females that
applied have much better expierence then the males did" and she said it is a very
hard balance to considered modesty over expierence for their patients. She also told
me doctors work closely with their nurses and and work well together to make sure
the dignity of the patient is the same before, during and after the appt. She also
told to get an appt. at this office is very hard and to take some time to think about
it and she would get me appt. as quickly as possible.
So I decided to make an appt. and I new everything up front, what made me decide
to go was how upfront the person who I spoke to on the phone, she spoke to me in a
caring and honest way, so I was hoping that was the tone of the office and it was.
Yes there was some embarrassing moments but I would have been just as
embarrassed with a male asst./nurse present. When I left I felt very intact in BODY,
MIND and SOUL.
Rick.
Sunday, February 24, 2008 4:34:00 AM

Anonymous said...
Jimmy
I also and not being rude but 9 chances out of 10, your also going to pay for both
surgerys. Elective and Emergency, and in an Emergency the bill is much higher
because of ER., and others things when cost is not issue in an EMERGENCY
sitiuation.
Sunday, February 24, 2008 5:21:00 AM

Anonymous said...
Responding to the question about the success of requesting gender for treatments I
can say that we have researched this area by calling dozens of facilities. You will
have more success with a larger hospital that has both male and female staff.

There is a wide variance of attitudes and response. Some facilities will absolutely
accommodate in the OR and other facilities respond with a smug and uncaring
attitude. It is easier for a female patient to receive an all female team in the OR,
simply due to the percentage of female vs male OR staff available. There are at
least 4 people in the OR suite other than the anesthesiologist and depending on the
complexity of the procedure.

If a male patient lets it be known that he wants male clinicians on his case, many
facilities are understanding and will accommodate. There is a high percentage of
male surgical techs. You also need to ask the surgeon who will be his assist. Talk to
the surgeon and let your wishes known and talk to the facility. The main thing is
you can find a facility that will be understanding if you look.

I have no use for the facilities that mock a person over this issue.


RN -retired
Monday, February 25, 2008 5:10:00 AM

Anonymous said...
A comment on Rick's post earlier regarding female assistants and doctor
appointments--
When setting up an app't a person can ask about the office procedure re: assistants
in the room. If you express that you are not comfortable with a female assistant
being in on the exam they ususally will accommodate your wishes. I do not see the
need for it. For a male he should certainly be able to be examined by just a male
physician. All you have to do is state that you don't want anyone else in the room.
Most urologists are males. We have found that many dermatologists in our area (at
least) have a female in the room to take notes. We never encoutered that
previously where we used to live. We are changing derm docs because we are not
comfortable having a young female assistant in the room. I don't think it saves a bit
of time, but that seems to be the reason the doctor has the assistnat in the room.
Again, you just need to SPEAK UP and chose a physician of the sex you are
comfortable with and let them know you do NOT want anyone else in the room
during your exam.

RN -retired
Monday, February 25, 2008 10:44:00 AM

Anonymous said...
As long as you aren't having a procedure done the doctor should accomodate a
patient's wish to have the exam without a chaperone/assistant. I'm male and have
yet to have a male doctor bring a chaperone into the room.

I wouldn't even call ahead on this one. No need to go through all that trouble. If the
doctor brings an assistant into the exam I would simply ask them to step outside the
room. If the doctor had a problem you could then leave.

My mother is female and never has a chaperone either. She's early 60's and grew up
in a time where it was just the doctor and patient. She likes it better this way. My
sister does the same. Her gyn told her she wasn't alone. They do get this request
about 15% of the time.
Monday, February 25, 2008 12:05:00 PM

js md said...
RN -retired,
You speak as if the request for same gender care was common. Yet a hospital I
asked denied that it ever occurred. How common was this request in your
experience, once a week or once in a blue moon?
Monday, February 25, 2008 2:52:00 PM

Maurice Bernstein, M.D. said...
Anonymous wrote the following Monday, February 25, 2008 11:23:00 AM:

I see a lot of female spouses talking about switching doctors and writing letters to
hospitals and I wonder where the patient is in all of this? If they are of sound mind
and conscious why aren't they writing the letters? It would carry a lot more weight
coming from the actual patient than the spouse.

I wonder if some of this has more to do with jealousy on the spouse's behalf and not
so much about patient modesty. Some spouses really don't want their spouse
touched by the opposite sex which is their feeling and they are entitled to it. I just
wonder how much of this is control and jealousy and how much of this is the actual
patient's modesty issue and feelings.

When the patient is telling the spouse he was treated with kindness and compassion
by the female staff maybe it should be left there. If they don't have a problem
maybe the spouse needs to work on theirs

And in the event like gve where he is the patient and clearly has very strong
modesty issues I truly understand. That to me is much different than a spouse whose
ticked and writing letters. Trust me if your spouse is outraged they will react. You
won't need to do it for them.

In the case of the RN I am surely throughout your career you have had to do genital
handing and bathing of males. I would bet you treated them with respect and
dignity. I'm sure your spouse was treated the same way.
Monday, February 25, 2008 10:30:00 PM

Anonymous said...
I'm a lawyer who has worked at hospitals in the past. I posed the question to some
nurses and support staff and they stated it's uncommon for them to get same sex
requests in bedside nursing or surgery. They all agreed they absolutely try and get a
same sex nurse when requested. They said it would be harder to meet the needs of
men due to a shortage of male nurses and techs.

This becomes harder in the OR because there aren't as many nurses (male or
female) working in this area so options are limited. They also said some men prefer
a female nurse and have made that clear. They were all nice when I inquired.

I also threw it out at some surgeons and they seemed a little surprised by the
question but unkind. They said they had never had this requested of them. Two said
they had been doing this for 30 years and it had never come up. All said they would
try and meet the patients need if they could. They said most of their patients are in
pain and their questions are geared towards the length of hospital stay and recovery
time.

I've never to date seen a complaint made in regards to modesty issues. I now work
in a private practice and have yet to see one here either.
Monday, February 25, 2008 11:37:00 PM

Maurice Bernstein, M.D. said...
The lawyer's posting regarding the experience of the surgeons simply corresponds to
my own experience, written to these threads previously, in internal medicine for 50
years during which time patients have never brought up their concerns about
modesty. Thoughout the past 20 years in first and second year med student
teaching, I have stressed the need for the students to be aware and proactively
protect their patient's modesty during the exam I had never really had any patient
express concerns within my practice. ..Maurice.
Tuesday, February 26, 2008 7:54:00 AM

js md said...
Anonymous from February 25, 2008 12:05:00 PM, I have commented before about
the use of chaperones both here and extensively on my blog.

I have gathered these guidelines for chaperones culled from many sources:
1.) They should be identified as such.
2.) They should be professional, i.e. nurses or trained assistants.
3.) They should be voluntary.
4.) Same gender chaperones should be made available.

Chaperones are really only necessary when male providers are doing genital exams
on women. They are optional in all other situations. Some states mandate that they
be offered to nearly all patients if a complete exam is contemplated. But patients
rarely request them and a good percentage don't want them. Their use frequently
implies that there is a lack of trust between patient and provider. Most chaperones
are used to protect the physician, not the patient.
These are my guidelines by the way. The AMA does not specifically support number
1, 2, and 3 above.
Tuesday, February 26, 2008 10:14:00 AM

gve said...
The recent postings have basically implied that the concerns expressed by most
people in this blog are groundless. Those expressing concerns are in a minority and
are probably cranks or wierdos.

The reason people have said so little has been espoused on many occasions in this
blog, people feel paralysed by the machinery of the healthcare system. It is assumed
that people have no feelings, will not object to what is being done to them, will be
compliant, do not have any grounds for complaint.

The reality is now quite different.
Some people are speaking out (racism used to be acceptable , as did sexual
discrimination against women) things are changing. It merely needs a few high
profile cases or publicised requests to start an avalanche. Most hospitals will
accommodate most same gender requests when pushed because they do NOT want it
to become public domain, advertised, get people thinking etc.

What the last few posts have described is what will soon be history, people will
become more active and more people will follow them etc etc
Tuesday, February 26, 2008 11:04:00 AM

Anonymous said...
With regard to Dr. Bersteins comments on the patient making the complaint vs. the
spouse I can say the patient did make all of the complaints both to the facility and
other appropriate agencies. My husband as most men is not one to sit and type a
letter or sit and type on this blog site but it did not or does not diminish his
thoughts or feelings on the matter of how his medical experience was.

It was not what he wanted, not what he EXPECTED, and something he would not
have consented to if he had been truthfully informed of their procedure and who
would be handling him. As I stated previously, if a patient was alert and would not
have consented to this why should it be any different just because they sedated the
patient. Most people are not complaining about this because they are not made
aware of it. They wake up and don't know what happened to them or who did what.
For those people that care, it becomes very upsetting. As a female I would not want
to be prepped vaginally by a male nurse in the OR while sedated and find out
afterwards. My husband would not be approving of that either. And, yes there are
males and females working in the OR with both the males doing gyn cases and
females doing cases on male prepping. This isn't discussed with patients because it
is the old we do it our way and just get the job done with no regard for the patients'
feelings. Just because this has been done for years doesn't make it right.

As a practicing nurse in the hospital setting I can say that I always treated all my
patients with respect and dignity and I never did a cath on a male. I had male
tech/nurses/orderlies do it. The few bed baths I did I kept the patient covered and
let the males do the genital areas themselves.

Yes, some men want women nurses, I have heard that. They are afraid of the
"homo" factor. That is a whole other topic for discussion.

It really is up to the patient and their feelings..it should not be up to the feelings of
nursing. We did contact an attorney and he was floored with our experience and
said he would be very upset in this circumstance. He said it was a "violation of
patient rights."

People are not basically aware of this and if they were made aware there would be
many more objections than what currently exists.

RN --retired
Tuesday, February 26, 2008 11:26:00 AM

Anonymous said...
I wanted to make a correction. The surgeons weren't unkind when asked. I left out
the word not. Sorry for the confusion.
Tuesday, February 26, 2008 11:28:00 AM

Anonymous said...
To js MD regarding requests and how often..I cannot give statistics of course, but I
can tell you many facilites I have discussed this with and other nurses in the OR that
gender requests are not uncommon at all. They receive them regularly. Many
facilites say they always accommodate the patient.

Legally facilites are suppose to accommodate special request for various reasons,
religious reasons for example. For whatever reason, if you read the "Patients Rights"
document on file at any healthcare facility they are by law to give a patient his/her
rights. It explicitly states all kinds of rights and information. Go to any hospital
website and on the search engine line type in Patients Rights. Read it carefully. It is
there and very specific.

RN -retired
Tuesday, February 26, 2008 11:38:00 AM

Anonymous said...
Dr. Bernstein and attending lawyer... You've never heard of such things until
hundreds of
posting hit this blog???

Of course, people don't usually run to lawyers with these request. Of course, nurses
and doctors deny there is an issue
at every turn. Especially to a lawyer.

I had a procedure in an LA hospital and after much discussion with the very
agreeable patient advocate (and no hospital issues presenting themselves in
advance) had my modesty request totally
dismissed.

I had given all reasons for it in advance, the patient advocate agreed with me. It
was no big deal. They would schedule alternate staff by gender.
I re-scheduled, twice, due to a last minute "vacation issue" ... and ended up being
rolled into a venogram where nothing that had been carefully arranged was in place.

The staff had gone to the doctor regarding my request. Even though his office and
the hospital both said he had no control over his venogram staff and that staff could
and did change regularly, he squashed my request. He then tried to cancel the
procedure after I was prepped! Perhaps he thought I was nuts? I refused the nursing
stations request to reschedule with an IV already in my arm.
I guess all were having second thoughs about the pending violation of my well-
planned
request.

The doctor came in and did the procedure(late) then quickly referred me to another
specialist.

I went to my medical plan and he
was dropped by them within 90 days
of this incident.

The reason I had made the modesty
request in the first place was because this same doctor had given me two intimate
exams in front of an office manager. I thought she was a nurse! She served no
function except to hold his celphone and a clipboard. Totally humiliating!

Point is -- it happens. You can
make a change if you protest. Expect trouble from the cohorts
protecting their jobs and entitlements. I should have sued the hospital for breach of
contract but I had not gotten their promise in writing. To this
day, 8 months later, I am still angry with PTS.
-- TODD
Tuesday, February 26, 2008 1:52:00 PM

Anonymous said...
Lawyer here again. Surgeons and hospitals should not be making guarantees that
they aren't 100% sure they can see through to fruition. When they do and then it
isn't carried out patients are very upset like we've seen here and rightfully so.

I bet none of you received the guarantee in writing which would hold some weight.
They won't do that because they can't always control it due to staffing, schedules,
emergencies, etc. If you start with same sex personnel and someone gets sick, has
to leave, etc. they will replace that person with the first qualified person they can
find. There are too many variables at play to make a written guarantee.

I would make a few suggestions to all of you. Read your consent form and be sure
you understand it before signing. Ask questions of your surgeon especially if you
would like a play-by-play.

The consent form usually includes a statement which reads all medical procedures
necessary to this surgery or something to this effect. That encompasses a whole lot
of things which can include sedation, prep, heart monitoring, foley, temperature
monitoring, shave, breathing tube, taping down eyes, IV, wound dressing, wipe
down, new gown, etc.

There will not be a different consent form for the genitals as all of you now know.
Some hospitals do include a separate consent form where a blood transfusion might
be necessary. I have seen that, but ut varies hospital to hospital.

You do have the right to cross out students, technicians, etc. If you are given a
problem you should ask to speak to the Administrator or HIPAA officer. Period. It
will never get that far. A supervisor should address it and rectify it immediately.

In the office tell the doctor you don't want an assistant or chaperone. That is your
right. I would also urge all of you when an assistant needs to be present for a
procedure in the office that you verify they are actual medical staff. The office
manager is completely and utterly inappropriate.

I have had someone walk into the room and took to the doctor during an exam. I
looked at the doctor who said nothing. I firmly stated, "Leave the room
immediately. This is an exam. Thank you." She and the doctor almost jumped out of
their skin. She apologized as did the doctor.

I wouldn't think anyone is crazy asking for same sex care. I wish everyone's
experience in the doctor's office and hospital was a good one for them.
Tuesday, February 26, 2008 2:45:00 PM

Anonymous said...
gve,

I'm the lawyer and I never said the concerns of those here are groundless. I said as a
lawyer for a hospital and in private practice for years I have never seen a complaint
where patient modesty is concerned. The surgeons I spoke to hadn't been
approached about it either. Dr. B says this has also been his experience. That
doesn't mean it doesn't exist as it clearly does.

I don't think you are a weirdo or a crank. These are your words not mine. I don't
view you in this way in the least.

Your modesty concerns do seem to be to the extreme from what I've read here. And
it does make me sad you would risk your life versus having a female see you nude in
the OR, but that's still your choice.
Tuesday, February 26, 2008 3:22:00 PM

js md said...
Thanks for your response RN -retired.
If same gender requests are common, most doctors never hear of them which is
perhaps what this thread is about.
You're right that all hospitals are supposed to have a brochure listing 'patients’
rights' as I understand it. On my blog from Feb 7th I copied the pertinent part of my
hospital's statement. It only says you have the right to have a chaperone present and
says nothing about same gender care requests. I don't know of any hospitals that are
willing to guarantee this, especially for men. I'm not against this, but I think you
are wrong in implying that patients have any legal right to same gender care.
Tuesday, February 26, 2008 3:25:00 PM

Anonymous said...
Dr. Bernstein, in response to your question about the patient vs. the spouse
speaking up:

I second what "RN Retired" had to say. In my case, my husband was humiliated at
the unexpected genital handling. He had no idea going in that he would even be
exposed. In fact, he chooses a male doctor when he has a choice, for the very
reason that he doesn't want another woman handling his privates. However, he is
very shy and fears being put on a "bad list" by the hospital in case he needs future
treatment. He is also not the type to sit and write a letter. I am not as paranoid,
and so I am taking it upon myself to speak up for him.

Perhaps you should withhold judgment on spouses being "jealous" or "controlling"
rather than protecting modesty. I, for one, do not have a problem with a female
nurse handling my husband's genitals for a medical procedure, PROVIDED that he is
informed beforehand and consents to it. (If I were "jealous," why would the kindness
of the nurses comfort me rather than concern me?) Despite my leniency (yes, I said
LENIENCY), I can completely understand the people who want only same-sex care,
as well as the spouses who want the same.

Also, different couples have different takes on outsiders intruding on the spouse's
body. Widely held religious beliefs consider the wife's body to "belong" to the
husband, and vice versa. In a few couples, this does play out as control. However,
the ideal is that each spouse would respect the other's wishes, and this is how my
husband and I view the issue. To us, it is only natural that an intrusion of one's
privacy is also an intrusion of the spouse's.

In other words, neither of us "controls" the other. Instead, I view my body as a
mutual possession of us both. Therefore, even though I go to a male OB/GYN (who I
went to before meeting my husband), I would willingly switch to a female in a
heartbeat if my husband asked me to. I have great regard for his comfort level,
which I know is not based on "jealousy," but on protecting the private intimacy that
only we share. In return, my husband views his body as a mutual possession, and will
honor any requests that I make as well.

I would say that one of the purposes of modesty is to protect the intimacy of the
marital relationship, when there is one. Therefore, when a spouse reacts as RN
Retired, Kim, and I have, we ARE reacting on behalf of modesty and its purposes.

For a doctor or nurse to assume that their medical standing gives them an
automatic right to view and handle a patient's genitals, no questions asked, is
arrogant beyond belief -- yet that is an attitude I have seen on the allnurses blog. It
is an attack on the patient's humanity and a direct intrusion on the marital
intimacy that they share with their spouse. I have GREAT RESPECT AND ADMIRATION
for "RN Retired" for understanding this -- which should be so obvious to everyone --
and making it a point to have males insert catheters for male patients.

What it boils down to is that my husband was violated without his consent while he
was unconscious and incapacitated. Do you honestly believe that he had no right to
be informed that his genitals would be seen and handled by a woman, just because
he was in a hospital? This issue is real. Don't try to downplay it by calling spouses
jealous and controlling.

- Dismayed Wife
Tuesday, February 26, 2008 4:08:00 PM

Anonymous said...
I am a little confused on yours. Did you make a request for same sex personnel? Was
there anything additional requested? I might be misunderstanding but it sounds like
everything was in place, but doctor nixed your plan and tried to cancel the
procedure after prep. He then agreed to do it after you didn't want to re-schedule.
That's odd. Do I have everything accurate or am I missing something?
Tuesday, February 26, 2008 4:24:00 PM

Anonymous said...
Dismayed Wife,

I made the comment not Dr. Bernstein. If the patient is of sound mind they should
complain. I'm telling you the truth when I say the letter will hold more weight from
the patient than if it comes from a spouse. If he isn't the type to sit and write a
letter about this trauma than he isn't as upset about it as you are.

If your husband signed a consent form it included something along the lines of
anything necessary to the medical procedure or something to that effect. Check
your consent form and you will see it. Ask questions before signing especially when
you are modest.

The consent doesn't break everything in the surgery down. It won't say oxygen,
sedation, foley in urethra, heart monitoring, breathing tube, IV, pain meds, shave,
dressing of the wound, etc. It won't include a consent for genital handling.
Everything is on one form. This is legal. The consent form has to meet many
standards and will do so to avoid lawsuits and liability. This does. The only thing
you might see a separate consent form for is if a blood transfusion is needed.

In signing the consent form you consent to all that is necessary to that surgery. Now
not all surgeries would require a catheter or pubic shave and scrub. Many don't, but
for those that do the staff is perfectly within their rights to touch the genitals and
do what is needed to keep the patient safe and healthy. That's their job.



Hospitals staff males and females and don't discriminate against them. They will put
qualified people of both sexes in the OR. The person trained to do the job will do it.
I'm glad he said the nurses were kind and compassionate. I bet they remained that
way througout.

Now if your husband stated no genital touching by females and they didn't have a
male to fill in he could have opted out of the surgery then and there. No one will
force him into the OR. Depending on his level of pain and his illness it might be
unwise but he could still opt out. That's his right in the OR, an exam room or a
hospital bed.
Tuesday, February 26, 2008 10:09:00 PM

Anonymous said...
THANK-YOU, EVERYONE!!!
I ,am 40 yrs. old amd have had a couple surgies and things throughout my life. I will
be honest I never read the consent forms for any procedures. Yesterday I had to go
to a eye specialist at a teaching hospital and I was asked to sign two consent forms,
they were rather long and I asked the person at the desk if I could sit and read the
forms and not lose my turn to see the docter, because it was getting busy and I did
not want to hold up the line behind me. The office person said "absolutely, I wish
more people took the time to read them". This was my practice run for the future
and I read everyone word on both consent forms just to start to get firmiliar with
them. In the future I will not be worry about holding up the line behind me eithier,
again this was my practice run. I learned about carefully reading the consent form
on this blog. THANK YOU DR. B. and everyone else.
Rick.
Wednesday, February 27, 2008 4:48:00 AM

Anonymous said...
Regarding the legal issue of "Do patients have a legal right to choose the sex of
their nurse?"

For one, go to the website "allnurses.com" an pull up the thread on "should male
nurses work the OB floor" then go to page 15 of the thread and # 141 by fagley. It is
long but pertinent to answer this question.

I do not have the time at his sitting to recite the "patients rights." I will do so soon.

RN -retired
Wednesday, February 27, 2008 7:37:00 AM

js md said...
RN -retired. I am familiar with those cases. I'm the one I believe who first brought
up the issue on this blog awhile ago re equal employment laws.
The one case upholding your view was in California, the other case in W. Virginia
did not uphold it but remanded it to the lower courts. These are case laws that
determine the outcome in one specific hospital only. Many hospitals have male ob
nurses. There is little national precedent.
I was going to reopen this topic on my blog shortly in any event.
Wednesday, February 27, 2008 12:51:00 PM

Anonymous said...
Patients do have the right to request same gender care. Hospitals are to try and
meet the patients needs. This however is a request not a guarantee.

The flip side is that patients also have the right to refuse medical treatment. If the
request for same sex care isn't met they can refuse exams, surgery, intimate care,
etc. That is completely their right. I'm sure when met with the decision it would be
weighed against their level of pain and discomfort.

Hospitals I have dealt with all have males OB nurses.
Wednesday, February 27, 2008 3:05:00 PM

Maurice Bernstein, M.D. said...
I am really interested in following the views or slants or opinions or whatever you
want to call it of each writer to this thread but I truely find it impossible (anyone
else finds it also?)when there is absolutely no identification of the Anonymous
writer's multiple postings. I just can't figure out which Anonymous wrote what and
actually for the reader to understand the writer's philosophy and approach to the
modesty problem, it is necessary to identify who wrote what. Please.. I say again..
if you want to be Anonymous, be anonymous in terms of your personal identity BUT
please end your message with some consistent initials or pseudonym so we can all
follow along. ..Maurice. p.s.- I think this is a fair, reasonable and important
request. I would like opinions as to whether I should reject publishing Anonymous
comments which fail to provide some identifying marker.
Wednesday, February 27, 2008 7:51:00 PM

Anonymous said...
Sorry Dr. Bernstein. I'm the lawyer who has been responding and mentioned that in
a few responses and then stopped. I am the Anonymous from 2/26 at 10:09 and the
Anonymous from 2/27 at 3:05 if you want to edit them pls feel free to do so. I will
remember to sign from now on.

-law
Wednesday, February 27, 2008 8:41:00 PM

Anonymous said...
HIPAA legislation released in 2000 defines a patients rights of privacy and the rights
of a patient to refuse treatment. The law says that a patient must give informed
consent of any care received. Even touching a patient against his/her will may
constitute battery. For a patient to be fully informed, they must receive a
description of the proposed treatment or procedure, and know the name and
qualification of the person who will perform the procedure. A patient has the right
to determine the course of treatment, the right to information about all aspects of
treatment, the right to privacy and the right to refuse treatment.

The JCAHO also affirms that patient's rights and personal dignity should be
respected and care should be based on individual needs. It also addresses the right
of the patient to make decisions affecting care.

The number one indicator of patient satisfaction involved staff concern for the
patients privacy.

The AHA has published a patient bill of rights based on the foundation of respect for
human beings as individuals and emphasizing active patient participation in
decisions about the care they will receive.

The Patient Bill of Rights hanging in facilities in California by the Dept of Health is
2 1/2 pages.

No. 5 on the list states:
Make decisions regareding medical care, and receive as much information about any
proposed treatment or procedure as you may need in order to give informed consent
or to refuse a course of treatment. Except in emergencies, this information shall
include a description of the procedure, the medically significant risks, and the name
of the person who will carry out the procedure or treatment.

RN -retired
Thursday, February 28, 2008 5:06:00 PM

Anonymous said...
Where I have worked most surgeries aren't taped. If you are completely against
pictures and videotape you should cross out this part of the consent form and initial
it. If given a problem ask for the HIPAA officer or Administrator.

If it is a more unusual surgery they might be more apt to want to film it. I know
they often film re-attachments. These are for educational purposes. It's still your
right to say no.

The consent form should state that you will not be identified. Most people take this
to mean their face, but it also includes any other identifiers such as a tattoo, scar
or birthmark.

Most people do consent. That could be because not everyone reads the form in its
entirety.

-law
Thursday, February 28, 2008 5:42:00 PM

DO NOT ATTEMPT TO MAKE A NEW COMMENT ON THIS MISSING COMMENT SITE. IT WILL NOT BE PUBLISHED. ..Maurice.