MISSING COMMENTS FROM PATIENT MODESTY THREAD (A)

HERE ARE THE FIRST HALF OF THE MISSING COMMENTS FROM THE "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 IT WILL NOT BE PUBLISHED.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.



Anonymous said...
CLF
Have you had friends who came from a non-nudist upbringing that have adopted the
nudist life style. I would be interested in what it was that allowed them to
overcome the the norms they were brought up with. Was it a peer pressure (in a
positive way), was it the fact that they were around other nude people that allowed
them to make the transition? I wonder if that has any relationsihp to how they feel
when they are nude and others are not, i.e. in medical situations. Not sure there is
a correlation between that and the medical setting or not. Seems being comfortable
with others would lessen the situation in other scenerios such as medical...but
wasn't sure.....dg
Tuesday, February 27, 2007 2:11:00 PM

Anonymous said...
dg,
Yes, most of my nudist friends were not brought up as nudists. I guess that their
families had a relaxed attitude about nudity, but didn't do it in a public
environment. It is a bit of a hassle, for example, to get to a clothing-optional beach
- you usually have to walk farther, beyond the more conventional areas. Regarding
peer pressure, I think so - before I was married I used to bring my girlfriends to my
favorite nude beach (Lighthouse on Fire Island in NY) and some of them would
gradually take off their top, then the bottom, etc. Others would be so delighted by
the freedom that they instantly pulled their clothes off and sprinted into the waves
and stayed nude the whole day. Again, I'm not sure how this relates to the medical
situations, although I don't know for sure if, like me, when they're in a hospital
worrying about who sees what is not high on the agenda. I notice that you are seem
to be interested in nudism -- let me know if I or my wife can help in any way. This
is also for anyone else reading this, since it was the doctor who brought this subject
up in the first place!
-- CLF
Thursday, March 01, 2007 8:48:00 PM

Anonymous said...
CLF I appreciate the response, I was just curious as some of the posters seem
compfortable with nudity in the medical environment and others struggle with it. I
was curious if the factors that allow some to be comfortable are similar to those
that allow nudist to be comfortable with their nudity
Friday, March 02, 2007 4:16:00 AM

Anonymous said...
For me it's not the "being seen" part of nudity that makes me uncomfortable in a
medical setting. Rather, it is the differential in power. To an extent a patient is
vulnerable to whatever the Dr. thinks is necessary. Being more exposed than is
absolutely necessary is a very visual and tangible reminder that you are at their
mercy.

Here's the best way I can describe it - if I was at a nude beach and my Dr. and I
were nude I wouldn't have a problem. (Mind you I've never been to a nude beach but
I am just saying that I wouldn't have a major issue). However, me being
unnecessarily exposed for a second longer than necessary as part of a medical exam
in front of that same Dr. - makes me extremely uncomfortable.

For me it's the power thing being sexualized by the nudity.
Friday, March 02, 2007 8:31:00 AM

Anonymous said...
I agree with the power dynamics as playing part of it, I think that is part of the
embaressment side. The other thing that strikes me usually after its all over is
anger or anomosity that the medical community continues to ignore the desires of
their patients. The know patients hate the open back gowns but continue to use
them even when there is real need, they know a majority would feel more
comfortable with same sex providers but make little to no attempt to provide when
they can do so with a little effort. This is where resentment comes on my end. Once
again the question becomes, if they know, and they can, and they don't....what
does that say about the caregiver to the patient?
Friday, March 02, 2007 1:08:00 PM

Anonymous said...
I agree that there is a growing sense of patient anger toward medicine and doctors
in general. I think that the resentment that he or she identified is very valid, but
that there are a number of other factors at play. To me the largest factor is the
simple fact that the doctor/patient relationship must be based on trust to work
properly (it is obvious that each patient must trust their doctor in numerous ways),
but too often doctors will misuse that trust by withholding information from their
patients or even by telling flat-out lies. One common lie that sets a poor example
for medical students is to introduce the students to patients as “Dr. so-and-so”
(many recent studies have shown that this is a common practice). The effect of this
lie is to make the patient believe that the student is part of the medical team,
when they are really there for their own educational purposes. This is especially
relevant if the student performs part of the exam or procedure. I do not see how
such a lie can be ethically justified, although I have often seen it rationalized in
ways that disrespect the patient’s trust.

Many patients are becoming well informed and want to work with their doctor in a
collaborative way regarding their own health. These patients will feel justifiably
angry if they discover that their doctor has withheld relevant information from
them.
Saturday, March 03, 2007 8:34:00 AM

Maurice Bernstein, M.D. said...
I agree that the introduction of a medical student as "doctor" is misleading, unfair
and plain wrong. In the medical school where I teach, the student's name tag uses
the term "Student Doctor". I disagree with that designation. I introduce my medical
student to the patient as a "medical student" and nothing more. The "doctor" title
must be earned prior to graduation and for society to have the trust and respect of
that title after graduation, the title must be preserved with the doctor's best
professional behavior. ..Maurice
Saturday, March 03, 2007 10:02:00 AM

js md said...
I suspect that all hospitals require IDs to be worn by employees which would include
doctors, residents, nurses and aides. It's often just ignored or sometimes the IDs are
too small to be easily read. I personally have no problem with the 'student doctor'
designation. I think the meaning is clear. But I agree that they should always be
identified when personally dealing with a patient.

The other side to the story is that I often don't know whom I'm dealing with either,
the patient's nurse, aide, or a passing therapist, dietitian etc. I wish everyone
would wear clearly identifiable tags. It was easier decades ago when everyone wore
fairly distinctive uniforms.

In a hospital setting, you just have to be prepared to ask who you're dealing with.
And of course in a teaching hospital, this is of even more concern than small private
hospitals.
Saturday, March 03, 2007 10:29:00 AM

Anonymous said...
I agree with Maurice that "student doctor" is a confusing title that should be
avoided. "Doctor" should be reserved for people who have completed medical school
and earned the title. I strongly disagree with the idea that the meaning of "student
doctor" is clear to patients. On the contrary I know that it is very confusing to many
patinets, and have wondered if that is the intention of using the title. Thanks you
Maurice for clearly identying students to your patients. I think that you are setting a
great example for the students.
Saturday, March 03, 2007 12:29:00 PM

Anonymous said...
I also agree that thename tags are generally difficult to read, often turned over,
etc. Therefore it is the verbal introduction that the patients notice. It is too easy to
learn off the word "student" and simply introduce the student as "doctor" and that is
exactly what I have observed a majority of the time.
Saturday, March 03, 2007 12:47:00 PM

js md said...
The use of the term 'student doctor' is analogous to that of student driver, i.e.
someone who is not licensed except to practice under supervision.
Don't think it's an important point, but I have no objection to saying medical
student either. (My institutions don't have medical students so I have no personal
stake in this.)
Saturday, March 03, 2007 12:56:00 PM

Anonymous said...
A medical student is certainly not licensed to practice medicine under supervision;
in fact, they are not licensed at all. In addition, the title “doctor” is much more
specific and authoritative than the title “driver”. I would say that your analogy
breaks down quickly. The “student doctor” is actually is a medical student who may
someday become a doctor. To call them “doctor” with any modifying word in front
of the title is potentially misleading.
Saturday, March 03, 2007 1:14:00 PM

js md said...
I didn't say a medical student was licensed (anymore than a student driver is), but I
don't think the point is worth pursuing.
If a medical student is introduced as a student doctor there is no intent to deceive.
That is very different from introducing them as a doctor which is a deception.
I only wish that the use of the term 'student doctor' was one of the bigger problems
in American health care.
Saturday, March 03, 2007 2:37:00 PM

Maurice Bernstein, M.D. said...
John Lennon, in defense of widespread criticism of the full frontal nudity of himself
and Yoko Ono on the cover of his music album, he stated: “The main hangup in the
world today is hypocrisy and insecurity. If people can’t face up to the fact of other
people being naked or smoking pot, or whatever they want to do, then we’re never
going to get anywhere. People have got to become aware that it’s none of their
business and that being nude is not obscene. Being ourselves is what’s important. If
everyone practiced being themselves instead of pretending to be what they aren’t,
there would be peace.”

For the historical look at “John Lennon and Nudity” go to Absolute Elsewhere.

Do you think that Lennon would have any qualms about being examined or having a
procedure done by any medical professional of either gender? Do you think that
taking his attitude of “being ourselves” will make everyone feel more comfortable
and minimize the modesty issue? ..Maurice.
Saturday, March 03, 2007 2:59:00 PM

Anonymous said...
I’m sorry js md, I guess I missed your point. I thought that you were saying that a
student driver was licensed to drive under supervision (they are in my state) and
that a “student doctor” was analogous. I am glad that we are in agreement that it
is wrong to identify a medical student as a doctor, and that is my main point (a
2000 study found that happens more than half of the time, let me know if you want
the reference). I agree that identifying them as a “student doctor” is better, I just
think that it is still potentially misleading to patients and should be avoided. I come
from a medical family, and I wouldn’t know if a “student doctor” referred to a
resident, a medical student, or even a pre-med undergraduate student. Medicine
plays such an important role in society that precise titles to communicate clearly to
the patients are indeed important in my opinion.
Saturday, March 03, 2007 3:20:00 PM

js md said...
For clarification, a resident is nearly always referred to as a doctor as they are
legally doctors. That doesn't always mean they are necessarily knowledgeable or
competent. They are still in training. Of course we are all still learning.
The euphemism 'student doctor' should be reserved for medical students. An
undergraduate should never be referred to as a doctor. And of course there are a
few non medical PhDs around in hospitals who can also be called doctors, but usually
aren't.
Saturday, March 03, 2007 6:40:00 PM

Anonymous said...
Thanks, js md, for the clarification. You bring up the interesting point that
residents are granted the title “doctor” when they are licensed to practice medicine
only under supervision (I know that is the case in my state, and assume that it is
generally true). The residents are not granted an unqualified license to practice
medicine until after the residency, when they are board certified. Many patients
assume that all of the medical professionals with the title “doctor” have the same
qualifications, so I think that the practice of calling residents “doctor” is confusing
to patients. I have had a number of residents involved in the care for me or my
family, and I can say that some were clearly not yet competent (I hope they were
first year residents!) while others were as good or better than any doctor.
Sunday, March 04, 2007 11:49:00 AM

js md said...
Most states still only require one year post medical school (used to be called
internship) to be licensed.
You can look up your state here:
http://www.fsmb.org/usmle_eliinitial.html

They are legally doctors having an MD degree but cannot yet practice independently
until they spend an additional year and pass a test. Licensing boards are usually
behind the custom as most doctors take 3 to 8 years of additional training.
But physicians have more rigorous standards than lawyers for instance. Once lawyers
pass the bar test, they can practice any subspecialty of law, even ones they have no
experience in (at least in my state). Our phone book even carries the warning that
the listing of a lawyer's specialties implies no special competence. Imagine a
physician saying that in the phone book!
But I'm getting far off topic.
Sunday, March 04, 2007 1:06:00 PM

Anonymous said...
Dr. Bernstein, since societal norms are many times ingrained in us, and become
who we are. Often modest is who we are and is "being ourselves", and perhaps that
is really the crux of the problem. If being modest is who we are, and it is
disregarded, dismissed, or just plain violated, we exhibit the same approach as
Lennon's saying that his nudity is who he is and he is comfortable with that. I don't
think he felt everyone should adopt his feelings, quite the opposite. He was standing
up for his individual rights when he felt others were trying to dictate what he should
feel or think....sort of the reverse of "you should feel comfortable with this since I
do this all the time and I am a professional who knows whats proper. I think the
main text Question Authority, both cases, determine what is right for you, don't let
someone else define it.
Monday, March 05, 2007 8:25:00 AM

Anonymous said...
I would presume that nudists would be comfortable with their nudity in a medical
setting, unless, like me, the anxiety of the situation precludes comfort. The fact
that they would be nude while others are not; I don't think that is a factor, since
many nudists have worked as models in art schools (I have) and have been in other
situations in which they were nude in the presence of others without a problem. --
CLF
Monday, March 05, 2007 2:18:00 PM

Anonymous said...
CLF any thought on what has allowed them to feel comfortable with nudity when
they were not raised that way?
Tuesday, March 06, 2007 12:37:00 PM

js md said...
Just as a follow up, The New England Journal of Medicine had a recent leading
editorial about the difficulties of teaching students to do pelvics and how many
institutions had let medical students do them under anesthesia. I don't think I can
reprint the article here without violating copyright.
In essence, the article said that most institutions have gone to getting specific
permissions from the patients both for surgery and in the clinic setting.
Interestingly, they said it works better if a nurse asks for the permission. Other
institutions use paid patients. The problem is a real one though. The next
generation of doctors has to learn physical exams. The article did not mention
whether the gender of the medical student made any difference.
Wednesday, March 07, 2007 7:46:00 PM

Anonymous said...
I really have no idea why some people are comfortable with nudity despite not being
raised that way. Do you have any theories?
- CLF
Wednesday, March 07, 2007 8:23:00 PM

Anonymous said...
js md Has there ever been any attempt to use free clinics with medical students
with a supervisor? I know there are a lot of people out there without medical
insurance or the means to pay for them. A free clinic would help that situation and
assuming proper supervision, provide quality health care to people not getting care
now due to financial reasons. There should be alot of agencies for referrals. With
many social agencies struggling with buldging budgets for health care....now I
realize some will say it victimizes the less fortunate, but it also provides them an
option for care they might not have, and there are those folks out there that are
comfortable with the procedure and just don't want to pay for it.
Thursday, March 08, 2007 4:33:00 AM

js md said...
Every large public hospital that I'm aware of has a large teaching service as well.
Traditionally these hospitals have been very favorable places for doctors to train,
though I don't think it's as true today as it was in decades past. Not that the
patients there have any fewer rights than anyone else, but as most don't have their
own doctors, they are more accepting of any physician, resident or student who
comes in.
So large public hospitals have always had an important role in teaching. Most are so
overburdened and under financed though that the quality of care suffers.
Thursday, March 08, 2007 11:10:00 AM

Maurice Bernstein, M.D. said...
At the medical school where I teach, there is no such "free clinic" learning
experience as established and run by the school. However, in the past few years,
2nd year med students have attempted to develop their own free clinic with
physician supervision. Remember, that the students are not physicians and are
unlicensed to do anything much more than take a history and perform a physical
exam on their own. They are yet not adequately educated to be capable of selecting
pharmacologic agents and they certainly can't write a prescription. But relating and
connecting to the patient and understanding their problems and providing a basis
for workup under the supervision of a licenced physician is valuable for them and a
start to treatment for the patient. But, as I indicated, this is not an established
function of our school and I am not sure that the clinic is operational this year.
Thursday, March 08, 2007 9:07:00 PM

amr said...
To Dr. M and Dr. JS- and everyone else

Please read the article about Abdominoplasty (follow link) and comment upon the
appropriateness of the patient photo on page 5. Is there anything wrong with the
photo?

http://www.perspectivesinnursing.org/pdfs/Perspectives22.pdf
Saturday, March 17, 2007 10:30:00 PM

Maurice Bernstein, M.D. said...
To amr:you write "..comment upon the appropriateness of the patient photo on
page 5. Is there anything wrong with the photo?" If the patient or model gave
approval for the picture and since the patient is not identified nor identifiable and
since the inclusion of such a picture is warrented in the educational description of
the procedure within a journal which is specifically directed to and intended for
professionals who need to understand the procedure in order to properly carry out
followup care, I see nothing inappropriate or wrong with the photo. The picture
properly orients the viewer to the anatomical landmarks and there is no unneeded
exposure of the patient's body. For example, if the breasts were fully exposed, I
would consider that unnecessary for anatomical orientation. To do away with
photographs of patients or models and use cartoon drawings may deny the viewer
realistic education. One doesn't operate on cartoons. Read the publisher's
information below. The publication was not intended to be a "men's magazine".
..Maurice.

Perspectives, a quarterly newsletter focusing
on postoperative recovery strategies, is distributed
free-of-charge to health professionals.
Perspectives is published by Saxe Healthcare
Communications and is funded through an educational
grant from Dale Medical Products Inc.
The newsletter’s objective is to provide nurses
and other health professionals with timely and
relevant information on postoperative recovery
strategies, focusing on the continuum of care
from operating room to recovery room, ward,
or home.
The opinions expressed in Perspectives are those
of the authors and not necessarily of the editorial
staff, or Dale Medical Products Inc. The publisher,
and Dale Medical Corp. disclaim any responsibility
or liability for such material.
Sunday, March 18, 2007 7:15:00 PM

js md said...
I would certainly concur. The picture is completely appropriate assuming informed
consent was obtained.
My wife who's an artist has old books showing nude figure studies which are far
more explicit than this.
I note that once upon a time medical photos were limited to medical books and
journals. Now that everything is freely available on the internet it's a different
scene. I realized with some surprise that several institutions have physical diagnosis
videos available on the net. Some 'patients' are identifiable. Some may be paid,
others perhaps volunteers. Is there anything wrong with this? Not at all. Would I
want to do it, probably not but it serves important educational purposes. But any
volunteer or patient should realize that the availability of these pictures far
surpasses what it used to be and they need to understand if they will be identifiable
or not.
Monday, March 19, 2007 8:49:00 AM

Anonymous said...
Am I the only one missing it ? This is an article on hysterectomy. What purpose does
it serve to have her breasts (nipples) exposed ? Also, why is her face partially
exposed ?
Tuesday, March 20, 2007 3:21:00 AM

Anonymous said...
While I would never in my life be able to consent to this, I would agree with js md
that if the patient fully understands the use and extent there isn't a problem. Some
people are much more comfortable with it and I would imagine that is the case
here. I have seen the videos of the physical exams and the patients (male and
female) make no effort what so ever to conceal their identity, they have no cover
on their faces and have pelvic, rectal, and gentital exams. I say good for them. My
brother had cancer surgery, they shaved from the knees to the neck for the
abdominal surgery so I would imagine they expose a wide area before draping for
the cutting...I had surgery and they asked me to sign the consent to video, freaked
me out, the nurse said it was only done on rare occasions and for legal reasons. I
had to take her word for it. I would imagine the patient agreed to the content give
our litiginous society i doubt the provider would take a chance. Still no response
from medical providers, js md, what do you feel when you are working with a
patient who is obviously stressed over the modesty part...do you feel one way or the
other, have you heard conversations from providers on it...sympathy, indifference,
don't understand why its an issue?
Tuesday, March 20, 2007 8:55:00 AM

Anonymous said...
Dr. Bernstein,

On March 8 you wrote:

"At the medical school where I teach, there is no such 'free clinic' learning
experience as established and run by the school. However, in the past few years,
2nd year med students have attempted to develop their own free clinic with
physician supervision. Remember, that the students are not physicians and are
unlicensed to do anything much more than take a history and perform a physical
exam on their own."

In a recent news story from Australia
http://www.news.com.au/story/0,23599,21411991-421,00.html

a man was convicted of sexual assault for doing essentially what your students are
doing, the only difference being, this man was a handyman and bodyshop worker
(not a physician, not licensed) but still working under the supervision of his brother,
who was a licensed physician.
Tuesday, March 20, 2007 9:52:00 AM

Anonymous said...
I agree with anonymous from earlier today. Do doctors really need to use a woman's
nipples as "anatomical landmarks" to know which end of her is up?

As for "cartoons" medical textbooks, from which surgeons learn, are full of just such
diagrams!
Tuesday, March 20, 2007 9:59:00 AM

amr said...
To Anonymous 3/20/07 3:21am: There are two articles in this publication. The
picture in questions pertains to the article on abdominoplasty or tummy tuck which
starts on page 1 and is continued on page 5. With this in mind, does that change
your perspective or questions?
Tuesday, March 20, 2007 10:42:00 AM

amr said...
Drs. M, JS

Before I ask the next a follow-up question (in a separate post) about your responses
about the picture, I want to tell you how much this, the “naked” blog, and some of
your other blogs have personally helped me through a very emotional time.
Hopefully, this background will orient you to my perspective and that my questions
and discussions here are meant to challenge precepts and not an attack on you
personally. (More on that later.) I believe in the public service you are providing
here. If institutional change is to occur, it is going to do so only by teaching and
acting upon the teaching of the entire next generation of health care professionals.
And it starts with Doc like you. But in order to have an effect, ALL health care
providers must be taught. Unfortunately, this is difficult and there are economic
forces that tend not to inure to the benefit of patient modesty and privacy.

Sorry in advance for what will be a long entry. However I’ll summarize my
conclusions first:

1. Modesty is triggered by an event or situation that makes someone uncomfortable
or feeling vulnerable. The emotion happens; you have no control over it. How each
person handles the emotion however, and how strong the emotion is, varies from
person to person, and event to event.

2. In a medical setting, lack of privacy when a patient is not comfortable, can
trigger a modesty response. This can get in the way of focusing on doing what is
necessary to be well. Pain, fear, and lack of sleep doesn’t help either.

I have been following the blogs since December 2006 when my wife underwent a
skin sparing mastectomy and attempted diep reconstruction which was unsuccessful.
If the reconstruction had been successful, I would not be writing you here today.
However, the surgery’s failure, triggered a modesty response in me (for my wife),
that overcame me like a wave. These feelings were so strong, and so difficult to
master that they got in the way of important communications between myself and
my wife about her condition and decisions to be made for the 2nd surgery. And her
not wanting to face certain decisions was extremely frustrating to me. (Equate here
Protection of my wife and needed medical decisions to be made, with the Modesty
emotion.)

But I get ahead of myself.

She is now cancer free and the doc has subsequently performed a definitive
reconstruction subsequent to a tram flap delay in the 1st surgery. Her recovery goes
well. For us the experience has brought us even closer together than we were
before.

My wife comes from a medical family, wherein her father was a surgeon (ret) at the
large teaching hospital where she had her surgery, and her brother and his wife are
now assistant proffs at that hospital. She is well aware of hospital practices (as I
am) from the “inside”.

Modesty in the medical setting “was” not an issue for either of us. Both of us have
been in the hospital before for various surgeries / ailments / birth of children, and
are aware that surgery by its very nature makes maintaining the modesty of the
patient difficult.

Now that I have had time to reflect upon my feelings, I want to systematically
deconstruct what happened to me as best as I can intellectualize it, and have it be
another forum for understanding patient and family emotions as they relate to
illness and modesty. Hopefully, telling my story in detail will help the process of
better patient care as well as maybe help someone else.

What I’m going to describe is the series of events that contributed to my very
strong modesty response – including sleep depravation and general anxiety about my
wife medical / cosmetic outcome.

I kissed my wife goodbye in preop at 7:35am. Her biggest fear was the anesthesia.
She told me to take good care of myself and our boys just in case. Since it is a long
surgery (6-8 hrs), I went to her parents house to sleep since we had been up at 4am
and had only 4 hours sleep.

Event 1: I had just gotten into deep sleep when I got a call from the plastic surgeon,
about 1 hour into the actual surgery. I battled my way to consciousness. He was
saying something about venous compromise and had anyone told us about this
possibility. He stopped and asked me if I was close by the hospital. He needed to
meet with me. I got back to the hospital in 25 minutes. To my surprise, he was
waiting from me in the patient waiting area.

Event 2: Over a small piece of paper he began drawing diagrams and explaining the
problem to me and my sister’s brother. He was proposing to perform a delay
technique (what I now know demonstrated his maturity as a surgeon). I realized as
he spoke that my wife and I had not done our homework. I was being educated in
order for me to consent to a change in procedure WHILE the mastectomy portion of
the operation was being completed. This made me very uncomfortable. I was being
told that out of 250 such operations that this MD had performed, only 1 other had
exhibited this problem. And as it turned out, that patient elected to not attempt a
delay. So although the concept of vascular delay is well understood, doing it this
way had not ever been attempted by this surgeon – and there had been only about
15 cases that he knew of in the literature. Now the fact that the odds were so low
that not being informed is not the issue.

The issue was that I was caught off guard.

Event 3: I asked the Doc that I be present when my wife is told that the surgery did
not go as planned. I am acutely aware of the emotional importance of
reconstruction and really had no idea how she would react when she found out that
she had possibly been disfigured without a positive outcome. At the very least I
wanted it to be the Doc to tell her and not her overhearing it from someone else.
My brother-in-law told me that he wouldn’t be surprised if the Doc would not be
able to control this. As it turns out, my wife is one of those people who was able to
remember what she was told in PACU, and the Doc’s resident decided to tell her in
recovery. I was angry when I found out from my wife that she knew. Fortunately,
she knows this is surgery and things don’t always go according to plan, so it didn’t
immediately effect her emotionally. She just wanted to know more and had to wait
to find out.

Event 4: She does not admit to this, but my wife just now 51 yo, is 5 ft, 104 lbs,
and is drop dead gorgeous. She is model type beautiful so that “comments” about
her body in the OR would not have surprised either of us. (In fact, her general
surgeon who did the mastectomy, a woman for the record, commented to me after
the surgery how “thin” my wife was. Given the twinkle in her eye and body
language, there was no doubt in my mind what she was really saying.) To be fair,
this could have been an “in-family” compliment to me that might not have been
said but for the fact that our sister-in-law had referred us to her. However it was
said, and it reminded me that my wife had been pretty much naked throughout
surgery with 10+ people in the OR over the course of the 7 hrs she was on the table.
And many of these were young student docs.

Event 5: Visual: For this operation, the patient is lying on her back, arms stretched
out at about a 90 degree angle, her body exposed from the neck to the pubis. The
arms are covered in sterile drapes as are the legs. Normally the drape on the lower
extremity covers all of the vagina, though just barely. The pubic mound (and hair
that has not been trimmed) is exposed. There are periods in this surgery where the
patient is repositioned into a simi-sitting position.

Ok….

So I started to visualize my wife not really on the operating room table, but
suspended in mid-air, upright, legs bent, arms outstretched, naked, being remotely
manipulated by the surgeon. My beautiful bride, unnecessarily disfigured – with all
the young residents gawking at her. With sleep depravation – this was not turning
into a pretty picture.

Event 6: On the way to lunch, I quizzed my brother-in-law about the practices at
the hospital regarding patient modesty in the OR. (My wife at this point is still in
the OR). At this hospital’s OR, generally, patient modesty is simply not a priority.
The patient is treated like a piece of meat. (This is a large, very well known
institution where he also did his residency.)

Event 7: After she got to her room from recovery, our Doc followed through on
calling me to the room so that we could both tell her the details. This caused a
strong emotion of appreciation. It also heightened my strong growing feelings about
my wife, naked in surgery -- and that I needed to somehow protect her from her
surgical result. These feelings are all juxtaposed with the equally strong rational
knowledge that she had in fact been well treated, she had a caring Doc, her vitals
were stable, she would probably be SSI free, and she was in relative comfort.

I was going down the rabbit hole.

What struck me was that my growing irrational emotions were taking on a life of
their own and I seemed powerless to stop them. Over the next few days, I found
myself crying uncontrollably. This was very new territory to me.

Event 8: I began to notice how much respect our Doc showed my wife in the hospital
(and I noticed at subsequent visits to the office.) Whenever he examined her he was
always careful to only expose what he needed to. And, he has never called her by
her first name. This brought tears to my eyes.

Event 9: We came home with really only 2.5 days in the hospital. As my wife
convalesces, I begin to do web research about what happened to her. I really didn’t
want to be caught flat footed again for the next surgery. In my research, I came
across the controversy about non-consensual pelvic and rectal exams done in OR’s.
AND, OH MY GOD -- our hospital was one of the hospitals that was defending the
practice. Obviously, my mind went there. Not only did she have a failed outcome,
but students might have been practicing pelvic exams on her without her consent.
(This is all about trust issues and medicine as an institution respecting its clients. If
we don’t feel safe and cared for, then all sorts of issues come up including modesty
issue transference for the “real issues”.)

These blogs of yours, and subsequent web research reinforced my feelings about how
patients’ modesty is widely not respected in the hospital.

This led me off into the weeds. Instead of doing the research about the surgery, I
started looking into modesty issues and hospitals. My wife and I had some big
arguments about the non-consensual pelvic exams. My emotions regarding her
modesty and protecting her were in full swing. As it turns out, when we did talk to
our Doc about this issue, he was shocked – he actually turned white and was taken
aback. He fell silent and said after a moment…. “Well you know Mr. R, the nurse
did put a foley in.” He wanted to disclose that to make sure we understood the
extent of vaginal involvement. (Of course we knew she had a foley placed…duh.)

The point is that I thought that every doc knew about the practice. I was wrong. He
said that he had never heard of the practice, and that he practiced on dummies.
Being in plastics, I now understand that in order to be successful, you really develop
a genuine report with your client because of the emotions involved, the thought of
this practice would be antithetical to the discipline.

My wife was very concerned that this modesty issue was consuming me – and it was.
When I intellectually forced myself to stop, it took quite a while to climb back out
of my hole and to rehabilitate myself in her eyes.

Event 10: It turns out that this surgery actually interopertively has an extensive
algorithm – meaning that the Doc has various decisions to make during surgery
depending upon the anatomy of the patient. The first surgery, we consented to a
potentially more invasive procedure that we were aware could happen. Finding this
out in my studies “pissed me off.” We had been managed. In retrospect, it was for
the good of the patient. At the time however, it fueled more “protection /
modesty” emotions. These decisions are all cosmetic and/or involving the extent of
muscle loss the patient will endure to achieve the cosmetic result. They should be
choices the patient makes. My wife did not want to face these choices – this was
the source of many arguments about how much of the algorithm to authorize.

Event 11: After several consults with the Doc, we were able to understand that he
was following the prescribed algorithm as I had learned about. We were able to
write down the perioperative plan completely on the consent form. We became even
more comfortable with him.

What he told us was that this a gruesome operation and patients just really don’t
want to know the details. He has “learned” not to say too much. They just want to
be made whole again. Unfortunately, I believe him. It thus makes it really hard to
solicit the patient as team member in their own care. And when patients like “us”
come along, we don’t get the info we want and need to make decisions that will
effect us for the rest of our lives (good or bad).

He was surprised to learn just how extensive my research had been, including
purchasing videos of the actual operation. (You really can get anything on the net.)

Event 12: I wrote the doc the following email prior to the 2nd surgery:

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.

And, at preop, when my wife’s body was exposed, being marked up for surgery, the
young anesthesiologist, briefly looked at her, looked at me, then literally turned his
body (and eyes) away from what her doc was doing. Now, our doc could have clued
him into my modesty concerns, or he could have looked at my body language and
did this on his own. I would like to think that it was a little of both, but I have no
evidence. It did however make me feel that she was going to be respected. (Mind
you, he was going to see her naked in just a few minutes anyway.)

Event 11: The Thursday before surgery, we went to pre-admissions to sign up and
pay our money. The form for the hospital states that the patient pre-authorizes the
institution and the doctor to take pictures and video. I FREAKED OUT! (For the 1st
surgery, I remember reading that and shrugging it off.) I paged the doctor, knowing
that he would return the call almost immediately (for real thing!). Just as the
admissions manager was telling me in one ear that the consent form will not be
changed and that signing it was a condition of treatment (more on THIS in another
post), the doc was telling me in the other ear to not worry, he can’t change the
form, but he will NOT take pictures. Meanwhile, my wife is wondering if she was
going to get her second operation. (This wasn’t a pretty moment.) The doc said
quietly. “Hang in there.” It calmed me down.

Event 12: The second surgery: “What a difference success makes.”

All of the issues of no privacy still existed in her room. More so because her chest
needed to be monitored every hour for the first 24 hours. And not to mention
monitoring her drains and tummy scar which generally exposes her lower body.

My wife never had any medical modesty issues throughout this process. And now,
neither did I.

Epilogue: When we went to the Dr office to have her chest drain removed, the
nurses that normally do this were not available, as was the plan because her Doc we
knew would be in surgery. Who showed up but the Resident from the first surgery
that had inappropriately spilled the beans in Recovery. As the gown was opened to
expose the breast mound, it also started to fall open to expose her remaining
breast. She quickly grabbed the gown on that side to hold it closed. If it had been
the nurses or her own Doc I doubt that she would have even noticed.

My theory about modesty and being uncomfortable seems to be holding….

Showing respect for a patient’s personal space and “potential” modesty issues is the
quickest way to establish and maintain doctor patient relations.

And as a final note: On the 2nd day of the 2nd surgery, I remember her Doc coming
in to check up on her. After a brief Q&A, he asked her if it was alright if he
examined her chest. My wife said: “Of course”, with a quizzical look on her face.
(Mind you, this the surgeon who had been inside her body – twice.)

Thank you for reading this LONG post.

--- amr
Tuesday, March 20, 2007 12:20:00 PM

amr said...
Dr. M and JS,

Thank you for your initial response regarding the picture showing a female patient
prior to a tummy tuck procedure. I frankly never considered that it could have been
a model and not an actual patient. It took me a little while to process in my mind if
that made a difference to me. It does not. Actually, since the “patient” does not
have a hair bonnet on, you could be right, this could be a model and not a patient. I
saw the picture as the “real deal”.

The photo was is supposed to, however, represent an accurate representation of a
patient about to undergo a tummy tuck procedure. It is meant for a medical
professional to understand the operation. It therefor has relevance.

This is a Rorschach test:

Is this the proper draping and placement for the given operation? With respect, if
you haven’t actually witnessed the operation, or one like it (aka tram flap breast
reconstruction), please ask one of the plastic surgeon proffs at your school rather
than saying that you do not know.

Thank you in advance.

Respectfully,

amr
Tuesday, March 20, 2007 2:39:00 PM

Maurice Bernstein, M.D. said...
amr, I don't want to sound callous or uninterested in your concerns about modesty in
the operating room but all patients and families must consider that being operated
upon is going to require exposure of the body and to do a proper antiseptic
preparation of the skin and proper draping to prevent contamination, parts of the
body which is usually covered by clothing is going to be bared. Modesty, when the
patient is conscious in the doctor's office should be a significant consideration.
Modesty, when the patient is unconscious in the operating room and is unaware is a
moot issue. The goal is one of performing a safe and effective surgery. Although I
am not a surgeon, I understand clearly what goes on in operating rooms and while
there might be wild exceptions (that could be publicized), there is a highly
developed protocol to assure safe and hopefully effective surgery.

To get an idea of the details with pictures of preping and performing abdominal
surgery go to: this Google Link
In my career, I have seen patients draped prior to surgery and then the drapes
removed after the surgery was completed. I never have seen any behavior by the
operating room workers that would be considered voyeurism or sexually
provocative. I have seen that the genital areas and female breast areas kept
covered if not being prepared for surgery. The patient is transfered to and from the
operating table covered and if a covering accidently falls away, the patient is
quickly recovered.
I have written about this a number of times here on my blog in the past.

I have no doubts that my observations and understanding of the process of operating
room behavior is exactly what I have described. ..Maurice.
Tuesday, March 20, 2007 4:52:00 PM

Anonymous said...
>>Modesty, when the patient is unconscious in the operating room and is unaware is
a moot issue

BALONEY ! At what point do you think a patients modesty is EVER not a concern ? It
is exactly this attitude that scares the heck out of me - that I would be unconcious
and the people in the room woulf think that my modesty is "moot" just because I am
unconcious. I cannot believe that a M.D. actually wrote this ! My safety, my privacy
and my modesty are ALWAYS a concern to me.
Tuesday, March 20, 2007 7:33:00 PM

amr said...
To Anonymous said... 3/20/07 at 7:33pm

Dr. M is really one of the good guys. I meant sincerely my complement to him in my
long entry. In that entry I also said that I wished to challenge precepts in the
medical community and NOT attack him personally.

Reactions to my posts (and Dr. M responses) are getting some strong responses. I
understand where you are coming from in your comments. This IS the place though
for these strong emotions; they serve to inform the doctor that some, and maybe a
lot, of patients concerns about privacy, modesty, and control of their bodies does
not “stop” at the entrance to the operating suite.

With respect to your not believing an MD would say this…. I am not surprised. This
is the widely held belief in the medical community; but it is actually beginning to
change. There already is much that I would like to comment upon from these brief
responses – but I do have a job….. so I can’t right away.

Dr. M has shown himself in these blogs to be struggling with these issues. That is to
his credit. I believe his opening statement at the top of the blog.

Removing a rather large parenthetical statement in Dr. M’s response to me actually
syntactically reads: amr, I don't want to sound callous or uninterested in your
concerns about modesty in the operating room but …. Modesty, when the patient is
unconscious in the operating room and is unaware is a moot issue.

And the doctor is absolutely correct…. medically…… but he is off the mark with
respect to the emotional well being of the patient. I believe I can make a case for
this contention from not only entries in this and the “naked” blog, but also other
blogs as well.

However, at the crux of the argument is actually contained in something Dr. M
wrote: “..all patients and families must consider that being operated upon is going
to require exposure of the body and to do a proper antiseptic preparation of the
skin and proper draping to prevent contamination, parts of the body which is usually
covered by clothing is going to be bared.”

The fact is…. patients do not think these things through. Often they do not know,
what they do not know, to think these things through. Therefore when an
observation after surgery makes them uncomfortable, the modesty trigger is pulled,
and absent support, the mind goes racing.

Example: My wife had all sorts of small puncture marks all over her chest and upper
arm. Before she could even ask about them, her Doc told her that she may notice
scabs in weird places – it’s “normal” for this operation – just ignore them – they will
quickly heal. She was OK with that explanation. She was told what to expect.

Dr. M did good when he provided the link showing an operation. Demystification is
the key – and communication with the patient is critical. It is well understood that
pain management is easier when the patient is part of the team and understands
what is going to happen; for some patients knowing what is going to happen in the
OR helps them emotionally cope as well. Most probably don’t know and don’t care
to know… until the dreaded… observation.
Wednesday, March 21, 2007 1:08:00 AM

Anonymous said...
AMR, this is not what I meant. I meant exactly what I said.

Necessary exposure is what it is, necessary. However, if Dr's think that unnecessary
exposure, or carelessness, or even anything but the utmost respect for my modesty
is "moot" once I am unconcious, then I am still dumbfounded.

I expect EXACTLY the same amount of respect in all manners, including modesty,
whether I am concious or not.
Wednesday, March 21, 2007 4:55:00 AM

Anonymous said...
Dr. M I have read this blog and others of yours, they are great. In my mind in the
OR after a patient is out modesty becomes less of an issue, but it does not become
no issue. All I would expect is that staff give reasonable respect to my modesty,
cover me when exposure isn't required, limit the people in the room to relevant
providers, and be professional. As the previous post indicates a patient often does
have a little OMG I wonder who...this is especially true in smaller community
hospitals. I go into the operating rooms expecting this and I have no problem, a
little apprehension after, but nothing tramatic. If I felt the attitude of the staff was
going to be he's out let the party begin, or even he is out who cares lay him out
buck naked for all to see and don't worry about it, I would really have some anxiety
afterward. I really assumed modesty concerns are reduced when the patient is out,
that is natural, but it shouldn't be totally disregarded, that is disrespectful. I have
had some surgeries that absolutely required expsoure (removal of a cyst from a
testicle, colonoscopy, and the dreaded hemmroid surgery), the stress going in was
far worse than concern for what happened during the surgery. The least stressful,
when you go out in the prep room before any preping and wake up back there,
never saw any of the OR staff other than the anesthiologist and the Doc. That was
really easy for me, So, for me it isn't an issue if I assume the staff is simply
respectful, I realize its nesecary, but if I felt it was totally disregarded, I would be
upset and disappointed. I watch discovery health channel, I think a good (or bad)
example of our concern as a patient, if you watch stories of the ER often patients
are brought in, clothes cut away, laying there naked as people work on their
heads....it is obvious the staff is engrossed in what is going on physically and they
should, but come on, would it be to much to ask to lay a towel across the guys
privates until they are down to that area, emt's, cops, etc are all standing around
and this guy is laying there naked often consious or semi consious,,,,respect not
just the task at hand...its part of compassion....dj
Wednesday, March 21, 2007 5:19:00 AM

Maurice Bernstein, M.D. said...
To Anonymous of 4:55am today:
Maybe we really should come to a consensus what we mean by modesty. I checked
the definition in Answers that relates to what we are discussing and modesty is
defined as: "The condition of being chaste: chastity, decency, innocence, purity,
virginity, virtue, virtuousness." I like the term "innocence" as related to modesty
since I think that is what the concern is all about. The patient wants the physician
or other healthcare providers to be "innocent" or better "unknowing" about the
patient's "private parts" and to accomplish this desire, those parts must not be
revealed and "known" to the observer. If this is the real intent of modesty on the
part of the patient then you are absolutely correct--modesty is denied even if the
patient is fully unconscious and unaware, if the healthcare providers simply observe
the "private parts".

But serious and potentially dangerous work has yet to be performed by the
healthcare providers. A decision must be made regarding the degree of attention to
the patient's personal modesty should be given while the patient is under anesthesia
versus the requirements of ending up with a safe and effective operation. This is
especially difficult if the patient has not expressed before surgery their own desires
about how this balance should be weighed. It may be that the operation might not
even be able to be performed at all if the patient insisted on "innocence of the
private parts" on the part of the healthcare providers. So this is the dilemma: how
to provide modesty for the patient vs how to do a good job. In most operations and
for most patients, there is no problem, efficacy and safety trumps innocence any
day. But for some operations and some patients including some of those writing to
this blog, the problem is enormous and emotionally upsetting. If nothing else, I am
glad I am providing a hopefully "safe" environment for those who want anonymously
to ventilate their views and feelings and perhaps get some support from others.
..Maurice.
Wednesday, March 21, 2007 8:18:00 AM

Joel said...
I have already weighed in on this issue previously and my opinion is the same.
Modesty is a secondary issue during surgery and I personally would not want to
interfere with normal operative routine. And please note I have had surgery in my
hospital, been exposed during surgery, and post op and had no complaints about it.
What's necessary is unavoidable.
The only thing that would bother me is if I knew that staff were discussing it
elsewhere. I'm sure this is rare, would be a violation of privacy and grounds for
dismissal. I certainly don't worry about it. If there was something unusual about my
body, maybe I'd be more concerned.
But what amr did is correct. If your concerns about modesty are great, talk it over
with the doctor and personnel first and see if they can accommodate you.
I by the way would not sign a blanket permission for pictures or video being taken
unless it explicitly said my identity would be protected. But having said that, I
admit that I did not bother to read whatever I signed before surgery. I was just far
more concerned about the surgery itself.
Wednesday, March 21, 2007 10:56:00 AM

js md said...
joel = js md
Wednesday, March 21, 2007 11:00:00 AM

Anonymous said...
My point is this - treat me the same when I am unconcious as you would if I was
concious and alert. If you need to expose something - do it. If you don't need to,
then don't assume its a non issue because I won't remember it.

I REQUIRE that I am treated with respect when I am unconcious. Period. It scares
the heck out of me to give control of my body to someone who would have anything
but an absolute respect for me as a human being. Modesty may even be more
important to me if I am out. I say this because I am not there to protect myself and
my own interests. I am delegating this responsibility. The person I delegate it to
(Dr.) has to be 110% worried about me, down to the issue of not exposing anything
that isn't required. I do not want to think that my delegate considers me a piece of
meat without human dignity.
Wednesday, March 21, 2007 2:08:00 PM

Anonymous said...
Have to disagree for once Dr. M...I have to agree with the last post, as I said, I
have had several surgerys and exams, knew I was going to be exposed for surgery,
while I had/have some fleeting moments of concern afterward, I would have to say I
was pleasantly surprised that the experience was far more positive than I thought it
would be going in, very little concern or issue with the way I was treated, but that
is because I was treated with respect preop and assumed I was getting same
treatment when I was out. Dr. M I think you are a reading a bit more in this than
intended. I absolutely do not expect the same level of effort to protect my modesty
when I am out, but I do expect respect, leaving someone laid out naked for
extended periods without reason isn't respect. Nearly everyone here has said they
can accept compromising modesty in nesecity, that isn't what most are talking
about. On the DHC mentioned earlier, these people are brought in seriously and
sometimes critically injured, of course that is priority one, two, and three, they
have to be completely examined for unseen injuries, no problem, but what you see
even when the camera's are rolling is someones clothes cut completely away and
they are just left lying like that sometime consious and communicating, is it really
asking to much to have some one place a towel over their gentitles until they are
examining that area, would take what all of 5 seconds...they took the time to cut
the clothes off, can reach over for a towel...same with surgery, of course we are
going to be exposed to be preped, etc. but afterwards is it really asking to much to
be covered after the prep. Perhaps the proper term should be "respect for our
modesty", I personally do not expect to not be exposed on the OR or during some
types of exams, but I do expect to be respected. If every provider treated a patient
like it was one of their loved ones it would not be an issue. If your wife was in for
surgery, and was left naked or exposed after prep rather than being covered, with
all sorts of providers milling around would you feel that was reasonable or would you
feel the need to cover her? Not saying never and no,but would you want her
covered......thats what I am saying. The worst experince I had I don't think I was
exposed to anyone, went for an endoscopy (tube down the throat for non meds), 4-5
of us were lead back (both genders), the nurse turns to the group and says grab a
stall and strip, everything off, gowns on. Private curtained areas, but no
respect...dj
Wednesday, March 21, 2007 7:02:00 PM

Maurice Bernstein, M.D. said...
I have been awaiting surgeons or operating room nursing professionals to write
something on this topic here but it seems that it remains a long wait. I do want my
visitors to read an extensive discussion on this very topic of modesty in the
operating room written by nurses who do the job and have been patients
themselves. Therefore I direct my visitors to the following website: All nurses.com.
Let me know what you think about the comments there. ..Maurice.
Wednesday, March 21, 2007 8:31:00 PM

Anonymous said...
Thanks Dr. Bernstein, that was very comforting. While I assumed the staff was
acting in such a professional matter, I got sucked into the voy blog and the people
posing as professional nurses are really frieghtening. To me what these real nurses
and professionals express is respecting modesty to the highest degree. They can only
do so much, but if they do what they can, they are great. I would think the other
side is the exception. One person downplays the importance to the patient and 10
defend the patient. I feel better.
Thursday, March 22, 2007 4:50:00 AM

amr said...
Dr. M,

Thanks for publishing the allnurses modesty blog. You actually beat me to it. Here is
the link referenced in the Modesty thread: allnurses.com Naked in Surgery.

(My focus here is care for the dignity and privacy of the patient, NOT the needed
and necessary exposure for a safe surgery. And again, I’m here to challenge
precepts, not attack anyone individually.)

Excerpts from All Nurses links seen above and in a previous entry that supports the
subtext:
Patient Modesty: CNORSUE: For those of you who have no qualms about "ripping off
the covers & gowns" of your pts. to make it easier to place monitor patches,
grounding pads, etc. shame on you-maybe NURSING (think about what that means)
is not for you. Would you like that done to you or a loved one? Think about that
every time you CARE for a pt.

(amr comment: Normally these tasks are performed after the pt is asleep.)

Naked in surgery: zacarias: I was observing in an OR during school and and was
horrified by the following event: A woman was bare-breasted as they were doing a
biopsy on several discrete areas of the breast. That part I can understand. Except,
then comes in this doctor with a mask who says to the surgeon, "Hey, did you tape
'24' last night? Oh man, you have to see it!!", they exchange a couple sentences and
then he leaves the OR. I know for sure he saw the patient's breasts; He had NO
REASON to be there.

Naked in surgery: penguin2: One of my pet peeves is we go to great lengths to
preserve a person's modesty in pre-op & then they come out of the OR w/their gown
off or down around their waist, betadine on everthing- blankets in a jumble-- and
they're waking up exposed!! It seems the OR crew doesn't have to be in THAT much
of a hurry & so worried about turnover times.

(amr comment: This means that the patient is transported out of the OR, down the
common corridor connecting all of the OR’s into the recovery room into a stall. The
pt would then be cleaned up and draped. Whoever walks by the pt during this
process would see them exposed. Normally, post op cleanup takes a little while, so
that “time” is turffed to PACU so that the OR can be more quickly turned around for
the next case. They might save 10 minutes a case. One cost study of OR utilization I
saw on the net placed the charge rate (to the patient) of running an OR at $2500
per hour. Just showing a quick example of a revenue benefit analysis: If a given
institution has 15 ORs saves 30 minutes average per day per OR, turfing patients to
PACU “early” – would mean $18,750 per day or about $4,700,000.00 more revenue
per year. )

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

Dr. M, I believe that your description of what happens in surgery is accurate, is
generally true from all that I know and have studied, and is backed up by many of
the AllNurses entries. (As I understand it though, draping of a patient is more for
the purposes of the creating sterile field than it is meant for the modesty of the
patient.)

However…. these entries ALSO show the grittier side of medicine and the OR, which
is less idealized than what you described. There is a subtext in these threads that
indicates that indeed, there is a class of OR personnel and hospitals that do not
respect the modesty (or privacy) of a patient – which includes by the way – the
doctors. Also, the money side of medicine seems to bump into the respect for the
modesty and privacy of the patient, in order to turn an OR for the next case. (Time
is money.)

Since OR personnel are drawn from the same pool of people as the rest of the
hospital, (and for surgical technicians the qualifications and education is less) it
makes no sense to me that the frequency of “modesty / privacy” violations in the
OR suite WOULD BE ANY LESS than what occurs on wards. And we all know how
frequently modesty / privacy violations occurs there. I believe I can make a case
that there are more violations in the OR suite and will do so in future entries.

Do these violations effect the standard of care, I would say no.

Do these violations normally go unnoticed by the patient because they are asleep?
Well… yeah.

Is it then sort of considered: “No harm not fowl.”? I believe that is what my
brother-in-law was saying to me (see my long post) and part of what Dr. M was
saying when he wrote above: “Modesty, when the patient is unconscious in the
operating room and is unaware is a moot issue.” He was also saying that safety for
the patient in the OR trumps modesty…

My sister-in-law (also a MD) – simply puts it this way…. Hospitals are the pits.

There are 40 million surgeries and procedures per year in the US, or about 110,000
surgeries / procedures a day. If 10% of those surgeries have a nurse Crached, 11,000
patients have their modesty / privacy violated each and every day in the OR suite.

When my wife was in the hospital, only ONE of her nurses (out of at least 3) asked if
it was ok to check my wife (expose her) with guests in the room. The others just
went ahead and exposed her. (And this is with her awake…….) If those statistics
hold, the numbers would be more like 33,000 per day.

My point is that until this comes into public view and society demands a change, the
medical community will continue proceed with business as usual.
Thursday, March 22, 2007 5:33:00 PM

Anonymous said...
This is such a individualistic issue. What bother one is nothing to someone else. For
me personally, what goes on in the OR when I am out really doesn't stress me as
much as long as I feel going in the staff is going to be respectful of my modesty and
do what they can to protect my modesty. I have had several surgeries and
proceedures, all of the issues I have had came before I was out. In the settings
where they made a concious effort to protect my modesty and be respectful prior, I
came out of the OR with only minor discomfort, several time almost exhilarated
becasue it was over and I wasn't publically humiliated. One poster on allnurse said
"treat them like they were your loved one"....can't ask for much more than that. We
realize the providers, esp. surgeons get a little insensitive to this, and as the above
post stated, its up to us to remind them rather than stay silent. Given we can't do
this when we are out. One of the big pushes is colonoscopies now, I normally go out
of town for procedures as I live in a very small community. For the colonoscopie I
went with my PCP, told him I wanted to be completly out and didn't want to
remember any of it. The did the IV in the little curtained area, the nurses rolled me
in the room, and started the drip, as started to get hazy the nurses (2) plus a
female anesteheologist told me to turn on my side, when I didn't respond one took
ahold of my shoulders and started pushing me onto my side, when I rolled over i
could see they left the door open, the other said stick this pillow between your
knees, and again when I was slow to react grabbed my knees and proceeded, about
that time I went out...I know they were backed up from conversations I heard
earlier. After about a week of stewing over it I sent a letter to the hospital
supervisor. I was surprised when he called me at my office, we talked in length
about it. He apologized, within a few days I recieved a letter from the hospital
thanking me for the letter, they listed the steps they were taking to remediate the
problem including coaching the staff on letting the patient go out before starting
any processes, making sure the doors were closed and secured, etc. and again
apologized and stated the issue would be addressed and stated I would see an
improvement on any further visits due to my efforts to inform them. I was floored, I
have sense made it a point to make my mentality known upfront. I woud agree with
the above post, speak up don't just take it, it will help and you'll feel better. dj
Friday, March 23, 2007 5:12:00 AM

js md said...
Today I saw an article relating that a Massachusetts legislator has proposed a law
that would mandate that all surgeries be videotaped and kept for 3 years to be used
as evidence if needed.
Anyone have an opinion? A violation of privacy or a good way to keep tabs on OR
mistakes?
Monday, April 23, 2007 5:23:00 PM

amr said...
It is both. But just like in sports replay, the camera angle is important. But what
about also audio like an airplane black box?

Do you have a link to the MASS article?

-- amr
Tuesday, April 24, 2007 9:30:00 AM

Anonymous said...
I personally am pretty modest, but I would not have a problem if several things were
assured. 1. I was told upfront 2. I was offered a complete copy 3.There was strict
assurance it would be protectd from viewing only as per its purpose of a law suit not
for teaching or other unauthorized usage. I think it would benefit the patient in
that if the staff new it was being taped they would be more concious of draping etc.
if they knew the patient had access to it.
Tuesday, April 24, 2007 2:28:00 PM

js md said...
"Do you have a link to the MASS article?"

http://www.ama-assn.org/amednews/2007/04/23/prsb0423.htm

The article cannot be fully read online without subscribing. As I recall, the rest of
the article spelled out some of the difficulties with the idea, such as videotaping is
technically not so easy. Surgeons often work in very small fields which would not be
visible to a fixed camera without special maneuvering, not something that could be
done easily. One standard mounted video camera couldn't get much. And having a
professional videographer taping every operation would be very expensive.
An interesting idea, but as so often the case with legislative proposals it is far more
complicated than the bill's author likely imagined, even apart from the privacy
issue.
Wednesday, April 25, 2007 4:07:00 PM

Anonymous said...
"Modesty,
when the patient is unconscious in the operating room and is unaware is a moot
issue."

As others have said, this is totally offensive and really shows that medical
professionals in general do not have
care and respect for their patients' needs, both physically and mentally. An
unconscious body
deserves just as much respect and modesty as a conscious one. That body is a
person, and
the care s(he) receives and respect of bodily privacy should not change because of
that.

It reinforces what this very long subject and debate does; this is a serious issue that
providers in general
are not taking seriously enough. It has nothing to do with how the *provider*
interprets the situation. It is the
patient being exposed and he is the one who is being disrespected.
I don't understand what is so difficult about keeping
private parts covered all the time. This is so little to ask and does not interfere in
the least
with 99.9% of surgeries. It is nothing less than dispicable how commonly surgery
patients are treated as
"meat," needlessly exposed, as though their bodies mean nothing. Ironic how there
is such focus on
the physical importance of survival of the body, but it is simultaneously treated as
worthless, not even deserving
of the slightest dignity.
Monday, May 14, 2007 8:33:00 AM

Anonymous said...
wow that was good, very well put. There are many opportunities to make the
patient feel more comfortable, clothing and considerations that are not provided
becasue the providers do not see the need for it. access to the body for an
emergency could be provided with a garment that covers ones private parts isn't
reasonable or possible? G-string, thong type covering not possible, placing or having
the patient a covering not reasonable. While I think we as patients often do not
realize the reason for somethings as per the other blog, I think it is still rather
obvious the medical community does not give us the concern or consideration we
desire becasue THEY THINK...well put
Monday, May 14, 2007 5:23:00 PM

Anonymous said...
It seems that in some cases males are raised with little concept of modesty. I
remember that as high school baseball players, a friend of mine and I stopped at his
house after practice. My friend undressed for a shower, and his mom came into his
bedroom with towels. After my friend was done, he made no effort to cover up; his
mother apparently saw nothing unusual in the fact that he was naked.
Saturday, May 19, 2007 7:54:00 PM

Maurice Bernstein, M.D. said...
Gosh.. it is quiet here for the past month. Do you think that everything that needed
to be said about patient modesty has already been said? ..Maurice.
Monday, June 25, 2007 4:22:00 PM

amr said...
A combination of a long post and perhaps your comments, that might be perceived
as a put down to your bloggers, may be contributory. I have been researching the
issue of nudity in the OR. The OR is becoming a very public place, and patients as a
whole have no idea how much they are exposed to potentially 100’s if not 1000’s of
people world wide – potentially in perpetuity.

-- amr
Monday, July 02, 2007 2:01:00 PM

Maurice Bernstein, M.D. said...
amr, I hope I am not putting down my blog visitors. I simply try to write of what I
am aware but I certainly want to encourage open, rational and civil discussion here
on that topic. ..Maurice.
Monday, July 02, 2007 3:30:00 PM

js md said...
AMR,
Why don't you share your research with us.
I can't imagine how OR patients could be exposed to 1000's worldwide unless they
had consented to be videotaped.
Monday, July 02, 2007 7:48:00 PM

amr said...
js md

I will be – sorry, I forgot to mention in my last post that it was my intention to do
so. Simply put, the very high speed internet has begun to invade the OR. It is called
“telemedicine” There are multi-national companies and very well organized medical
industrial “K” street lobbies pushing the technology. Almost without fail, every
release that a patient signs for surgery carries with it a clause that allows videos of
them to be taken. (I will be more specific about this later). And, it is the case that
hospitals make the taking of videos a condition of treatment. (As you know, this I
know from personal experience). Thus the “operating theater” is now becoming
“virtual” and projected onto the world wide web. Couple that with the ability to
capture the entire procedure on disc from the time the patient enters the OR to the
time they leave, from up to 8 different cameras (remotely controlled), the OR is no
longer a “private” place. The surgery can be called up and replayed. The
information about telemedicine is readily available on the web – I will be presenting
links to representative sites. Mind you, this invasion of patient privacy is
downplayed for the “benefits” to the patient (which are considerable) and the
institution – but there is no mechanism for the patient to opt out – like opting out
of a unnecessary pelvic exam or opting out of an industry rep being in the OR. In
the telemedicine world (and medical community), this invasion of privacy is being
justified as “necessary”, very similar to how teaching pelvic exams in the OR with
the patient is asleep without the patients true informed consent was justified as
“necessary”. To be very clear, many if not most patients are fully undraped when
they are brought into the OR in order to be positioned, have a foley placed, prepped
and draped for the surgery. And the reverse occurs at the end of the surgery. Often
times the undrapped positioning of the patient would be considered very undignified
by the general public. If patients knew that this was being record or viewed often
times by a convention room full of people, I’m pretty sure that patients would want
to have a say in how their visit to the OR was being used by the medical
community. It is not possible to fully discuss my findings in a few words in “this”
post. However, this technology is being reported upon in various sectors, in major
news papers and technical magazines. The problem that I have is that the patient
privacy issue is not being brought to light yet, because the general public still has
no idea what goes on in the OR after the patient is asleep. After all, Dr. M’s
comment that patient modesty in the OR is a moot point, is in fact, a widely held
belief in the medical industry. If it was a moot point before cameras in the OR,
with the OR being open to observers, rationalizing that it is “still” a moot point
with cameras in the room is exactly what is being done. One argument is “patient
safety”. The cameras reduce the possibility of SSI (surgical site infection). Thus,
they are a “good” thing for the patient.

After some considerable thought, I believe that regulations should be put into place
to protect the patient’s modesty / exposure / privacy and allow patients to opt out
of the process. This is going to take some deep thought, because as I mentioned
earlier, there is some fantastic benefit to the patient with this technology. How to
balance patient benefit and patient privacy will not be an easy issue.

I’m writing this late at night, so I hope this is somewhat coherent.

-- amr
Tuesday, July 03, 2007 2:14:00 AM

js md said...
Thanks amr,
A few questions and comments. I share your concern for the overall way medicine is
going in terms of privacy. Most of this is not due to your personal physicians, but to
corporate interests who see a way of making a profit in this all digital world. Drug
companies seem to have access to personal patient drug records as one example.
Insurance companies are bound by HIPPA, but have so many affiliated companies
that I don't know if it means much.
I've already said that I wouldn't sign a release for video if it didn't say that my
identity was protected. But it needs to be in bold print. It's not foremost on most
people's mind when they're checking in for surgery. My guess is that very few
hospitals have the videotaping arrangements which you describe and make them
available for wider distribution. Hopefully none ever show faces or identifying
pictures without express approval. And no one would need to rebroadcast videos of a
patient being prepped, draped, or catheterized. 'Teaching' videos of that just aren't
needed; there are already lots available. I fully believe that patients could easily sue
and win if their privacy was violated, and I don't think a general consent would be
enough.
So in conclusion, I would think that the present day problem is minimal, but
certainly cause for concern.
Tuesday, July 03, 2007 10:48:00 AM

Anonymous said...
Take a good link at this medical video and see if you would like to be in this
position or your spouse with onlookers. Through the glass or on video the way this
lady is uncovered for no apparent reason for such a long period of time is just
wrong.

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


Folks have enough to worry about when faced with sickness, their modesty should be
one thing that they should not have to think about.

Great topic and I'm glad to see that you as a medical person are taking an intrest in
it.

Good reading.
Tuesday, July 03, 2007 2:44:00 PM

Maurice Bernstein, M.D. said...
This same link was posted by Mike on the Naked thread. I viewed the video and
wrote a comment there which I would like to reproduce for my visitors on this
thread. ..Maurice.

At Wednesday, May 10, 2006 2:05:00 PM, Maurice Bernstein, M.D. said...
Mike,thanks for the referral to the Hartford Hospital video website and, of course, I
witnessed what you did. I have some important comments to make about what was
done by the surgeon and hospital and also what you observed.

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

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

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

Now whether the production was legal and ethical. If the patient was fully informed
about the details of the live and later web-cast production, its effect on the surgical
procedure itself, that her genitalia would be visible but she would remain
anonymous then I think that the production was ethical and could meet legal
standards. The question of whether surgeries should be presented to the public for
publicity or advertising beyond purely educational intent is another matter. What
did others think about the Hartford Hospital production? ..Maurice.
Tuesday, July 03, 2007 3:59:00 PM

js md said...
I find the commercial aspects of the video disturbing, but not the medical aspects.
Hospitals feel the need to compete and commercialize their 'message' in our unique
health care 'system.' I don't like it, but there's not much I can do about it.
Medically there's nothing improper about it. I don't think that the majority of
patients want to know the details of their surgery in that much detail. But a few
do, and there's no reason why they shouldn't be accommodated. Almost certainly the
patient agreed to the video knowing full well what was involved and what would
happen with the video. Not everyone cares about modesty issues and there is
medical value to films like this.
Tuesday, July 03, 2007 6:05:00 PM

Anonymous said...
I would think that that paticular procedure was set up in advance with the
knowledge it was going to be used for promotion. Even with the camera rolling as
someone pointed out at one point the patient was left exposed as staff walked
around. Her identity was never shown so that much was preerved. I think it is an
indication of how the staff becomes oblvious to the nudity and how they loose
concern for what the patient might feel. I have had a couple minor surgeries and
posted my experience with such a consent. The problem is when a patient is in a
gown stressing over what is to come, there are a zillion things running through
their minds...not the time for clear thinking yet that is when the consent is 1st
presented. You have reached the point of no return...I am sure if it went to court
that would not be lost. It is a process that needs review and procedure set. It is an
example that patients accept a lot of things that aren't needed becasue of the
vulnerable position they are in.
Thursday, July 05, 2007 5:55:00 AM

Anonymous said...
While we often focus on problems and issues here, and I have posted several
concerns and experiences I had, I would like to put this forward. A little over a
week ago my father passed away in the hospital after a brief illness. Our family was
with him 24-7 the last 10 days of his life and I must say the nurses I saw were just
exceptional in not only the care they gave him, but the compassion they showed,
and this included maintaining his dignity as much as they possibly could. Even in his
final days when they were changing his gown and he was under heavy sedation and
did not appear to know what was going on, they folded down the top of his gown,
laid the new one over and pulled the old one out from underneath never exposing
him in the process. A day or so before he passed he was incoherent and would
struggle throwing the covers off and fighting, they continually adjusted his gown to
cover him. While I still feel there is a issue here that needs to be addressed, I think
we need to keep in mind it isn't universal. Sorry to get off the video track,,,just
thought I would toss it out there
Friday, July 06, 2007 5:36:00 AM

Anonymous said...
I'm sorry for your loss.

I'm impressed with the way you father's dignity was maintained in his final hours.
Thank you for sharing!
Tuesday, July 10, 2007 12:36:00 PM

Anonymous said...
I just got back from a physical, the nurse told me my GP had a NP in training with
him would I mind if she observed. I told them it would be fine but when it came to
the prostrate exam I really did not feel compfortable with someone there for that.
She came in with him and when it came time to go down to the underwear he
stepped out as ususal and returned without her. After the hernia & prostrate exam
he told me to go ahead and get dressed, returned with her and finished. Anyone
else had experience like that?
Tuesday, July 10, 2007 1:09:00 PM

Anonymous said...
A follow up to my post above, when I was at the desk paying for the visit the NP
came up, she was early 20's and started talking about her boyfriend who I knew, she
proceeded to tell me she recognized me from my business, started talking about
knowing my nephew and yada yada, all the time I was thinking, I am so glad you
were not there for the prostrate/hernia exam. After I talked to the nurse I had
thought I should have let the NP observe the whole exam for experience and almost
told my Dr. so. Her mannerism was not the maturity level I am used to with my Dr.
(in his late 60's) nor did it make me feel comfortable with her talking about all the
mutual acquaintances, esp knowing these two young men are big partiers. Just not
the professional approach I am used to. Dr. M, JSmd, do you have any concerns or
observations as NP become more common with this. The years it takes to become a
MD lend to maturity and professionalism, whereas many NP were nurses with
extended years of experience, it appears a newer trend is nurses going right from
RN into NP.....this was my first experience with a NP and was not very reassuring.
Don't think I will be open to a NP in the future
Wednesday, July 11, 2007 4:56:00 AM

js md said...
Anonymous from July 11th, any NP must have 5-6 years of training at least. One
would think that is sufficient to act professionally. Can't make any further
generalizations, but I would have no special concerns.
But if you think any given professional acts young and immature, that is sufficient
reason to go elsewhere. Some people are naturally chatty, especially if you have
friends in common. I don't think you can assume anything further, but not liking her
friends is a valid observation.
Wednesday, July 11, 2007 3:57:00 PM

Maurice Bernstein, M.D. said...
I would agree with jsmd. I can't criticize any responses that Anonymous from today
described as his responses to the presence or behavior of the nurse practitioner. If
you were anticipating being uncomfortable with her presence during the genital
exam, then requesting her to leave was a reasonable request especially since she
was not responsible to perform the exam. Being concerned about her conversations
regarding non-professional topics was also appropriate. The only suggestion I would
make would be to reconsider your comment about not being "open to a NP in the
future." You shouldn't reject all NPs or all physicians simply by their professional
duties. You will probably find more and more nurse practitioners in the medical
care system and you may have to reconsider your rejection of their participation in
your health care. ..Maurice.
Wednesday, July 11, 2007 7:49:00 PM

Anonymous said...
What exactly are NP allowed to do compared to a MD?. Given the extensive
training, internships, etc MD's go through, how does it compare to NP. I realize this
was a single person, she might have been nervous, etc. not indicative of all NP's.
However when we lay people think of the training MD's go through, and how
selective medical schools are, we would hope there would be similar expectations of
NP's who are going to be assuming some of those duties. This young lady I later
learned was in my my daughters class. Is there a screening - qualifying process for
NP's? Acceptance to Medical school screens out some, and I am sure there are other
hurdles to cross that continue to reduce the number who CAN be a MD. My daughter
graduated 4 years ago, if this young lady got her BS in 4 years and is now in study
for her NP certification......doesn't appear to have those same screening,
experience, or challenges that make the MD such an achievement worthy of trust
that we don't normally give to others.
Thursday, July 12, 2007 4:38:00 AM

js md said...
Anonymous from today, there is no answer to your question. Every state is different
and the regulations are in constant flux in many states and an ongoing source of
contention between the various competing interests. There is a big variation as to
how independent of physicians the NPs are and how much they can prescribe. You'd
have to look at your own state. Most NPs work for specific practices with narrow
responsibilities and are quite competent in what they do. They may also serve a
screening function for the physicians they work for, taking care mainly of the minor
problems. I personally would not go to a stand alone NP clinic for any but a minor,
common or transient problem, but that might just be me. But remember that no
one is competent in everything, no matter their degree or training.
I have no first hand knowledge as to the admitting standards of schools that grant
NP degrees. I imagine that they too vary, but on the whole are nowhere near as
stingent as US medical schools.
Thursday, July 12, 2007 10:16:00 AM

Anonymous said...
js md, you touched on a couple of my concerns. I know from my own experience I
get a little stage frieght in the medical setting. I am pretty comfortable with my
MD of 25 years, but still sometimes for reasons even I can't explain I fall into a if he
doesn't ask I'm not going to bring it up mode...going to a NP for a physical would
not give me the level of comfort as my MD. Sometimes it is the things he asks or
sees that I wasn't there for that are the most important. I want someone with the
most training and experience doing everything from physicals up. Now if I need a
couple stiches, a NP would be fine. I guess I just always assumed all NP's had to have
years of practical experience in addition to training. One thing I did notice, I have
had the NP and another time I had a male intern shadowing a dermotologist I went
to, and felt both times the Dr. seemed more focused on them than me as the
patient, his conversations etc was with them vs with me as the patient. Just an
observation, and I understand they have to get experience somewhere. JR.
Thursday, July 12, 2007 1:46:00 PM

Anonymous said...
The above posts while a little off the subject do have relevance to the topic. To a
large degree how we handle nudity in the medical community depends on our
comfort/trust of the provider. If we don't feel comfortable with the provider it is
more of an issue. And as Dr. M alluded, while one provider is not indicative of all,
we tend to lump medical experiences as a whole. I can tell you for certain if I had a
NP like above involved not only in an exam/procedure involving exposure, but
video, I would have been extremely upset and uncomfortable. Something the
medical community needs to be aware of and think through. Everyone in the
procedure is going to be judged by the experience even if on one NP was the
unprofessional one.
Monday, July 16, 2007 6:12:00 AM

James A said...
After reading a good bit of the comments above, I would like to offer my basic
opinions about the whole physical exam experience. The benefits package where I
work includes provisions for an annual physical exam. I had been seeing a doctor for
several years for this physical and his office became more and more inefficient. The
last couple of years I would make the appointment well in advance, show up at the
appropriate time, then wait for up to three hours to see the doctor. I expressed my
discontent and the doctor said, "sorry, things come up sometimes".

My wife and three kids had been seeing a new doctor in town and said that her
office was very efficient with very little wait time. She suggested I switch since I
was dissatisfied with my previous doc. Now I have been seeing the new doc for
about three years and I have to say everything has gone pretty well. She seems
genuinely concerned with any issues I ask about.

The exam itself starts with a consultation with the doc where she asks questions
and where I have the opportunity to express any concerns. I usually write everything
down in advance so nothing is forgotten. I try to have the blood work done a week
before so that the results are in the file during the exam. I have several large moles
and SKs so a full skin exam is included.

After the consultation she provides a gown, says to undress and she will return in a
moment. In a few minutes she returns with the nurse (also female) and the exam
begins. She starts with the typical eyes, nose and ears then continues with lungs,
heart etc down to the waist. The gown is lowered for this part. The skin exam is
performed concurrently with the other procedures. She next starts with the bottoms
of my feet and proceeds upward raising the gown as the exam continues.

Lastly I am asked to stand, the gown is now removed and the DRE and TE is
performed. The last part of the skin exam is also done at this time. All during the
exam she is commenting on exactly what she is checking for and remarks on any
concerns. At the conclusion, I am instructed to dress and she will return shortly.
After I am dressed and she returns, we discuss anything that was found, and any
changes to my overall health program. This is done without the nurse present.

So, overall the whole experience is very professional and efficient. Of course I am
completely nude some of the time but I have never felt uncomfortable or
embarrassed. Maybe I'm in the minority of guys with female doctors but it really
doesn't bother me to be exposed to these two medical professionals even if they are
female.

I believe that it is important to take an active role in one's health and be proactive
in taking care of any issues before they become serious if at all possible. Some years
ago one of the moles on my foot was found to be a benign tumor and it was
suggested that I see a dermatologist annually as well. During those visits there is a
good bit more exposure with the doctor and nurse but that is another story.

I sympathize with those who have had bad experiences with opposite gender doctors
but I am completely at ease with my health care providers. It just doesn't bother me
to be seen, touched, poked, probed and squeezed when the intent is my continued
good health. If anyone has more questions, feel free to ask. Maybe I can help
provide positive experiences to the discussion.
Tuesday, July 17, 2007 8:24:00 PM

Anonymous said...
james, I think you hit on many points that this thread has brought to the surface.
Take an active role in your care, my brother recently underwent cancer surgery, his
PCP, and referral both said he was fine, he didn't agree and the 3rd doctor he went
to on his own discovered kidney and testicular cancer....he appears to be fine but
he took charge of his care. The other thing that comes to bear is we need to feel
comfortable with our providers in order to have honest communication with them.
My PCP is male and I am never totally nude for his physical, I have had other
physicals and for the DRE and TE either the gown is left on and moved as needed or
I am down to underwear which is lowered to perform the exam. Also, my PCP does
the exam without the nurse. I think many patients would feel uncomfortable with
two members of the opposite sex there for the exam be they male or female. The
nurse is there for the Dr's comfort or convenience, they really are not a have to. The
long and short is we all are different we need to do what we are comfortable with,
ask for accomidation to that end and find someone who will provide it if we don't. A
patient who is uncomfortable or embaressed will tend to not be open with the
provider, thus things that should be addressed aren't. The problem is most providers
don't ask and most patients, esp. males don't feel comfortable or think they can ask.
Wednesday, July 18, 2007 4:21:00 AM

James A said...
Yes, we agree. Your brother was very smart to continue until he was satisfied with
the results. It more than likely saved his life.

In my case I ended up seeing three different dermatologist because of dissatisfaction
with the first two. The first one removed the little benign tumor and, in my opinion
did a very poor job with the incision, stitches and pain management. I had a pretty
nasty scar for quite a while.

The second dermatologist did a good job with the exam but the attending nurse, in
my opinion, was somewhat unprofessional. After being escorted to the exam room
by the nurse, she asked the reason for my visit (first time patient). When I replied
it was for a complete skin exam with the moles etc, she says that I should go ahead
and get undressed and she would document my family and medical history. So I
remove shirt, pants, socks and shoes and am down to the boxers and I ask if I should
remove "everything". She says since it's a complete skin exam yes, everything, and
have a seat on the exam table. I comply, thinking I would receive a cover but to my
surprise, after I am seated she proceeds with the medical history questions. After
about ten minutes of questions she starts to leave and then provides a two foot
square cover. The exam is performed with just the male doctor, who, did a very
good job. There again, I'm the type that really doesn't mind being exposed in a
medical situation but this is really beyond what I was comfortable with and I think
she was probably taking advantage of the situation for who knows what reason.

I then asked my regular doc to recommend a dermatologist and she suggested a
physician in a nearby town who was one of her instructors in medical school. She
was also a female doc and female nurse to help. My GP said she was very
professional and was sure I would be treated with respect.

When I arrived for the appointment I was taken to the exam room at my scheduled
time by the nurse, my medical and family history were collected while I was still
clothed, then the nurse provided a gown, said to leave it untied in the back and
that the doc would be in shortly. When the doc came in with the nurse, she went
over several items including my history, the use of sun screen and described exactly
the process she would be using during the exam.

She also made it clear that for a complete skin exam that, while they would try to
keep things covered as much as possible, she and the nurse would see "everything"
and was I ok with that? I was.

The exam started with the scalp, then slowly moved down to the chest and with the
gown lowered followed by the bottom of the feet then up to the mid thigh, much
like the procedure used by my GP. She then said to spread my legs so the inside of
my legs could be examined. In this position it was obvious that the gown was mainly
for my benefit because from their angle, it really wasn't doing much to cover the
male parts.

Next I was asked to lay on my stomach so they could examine all the places on my
back side. The gown is now between me and the exam table. They documented
every mole and SK on the chart by position, size, shape and color. The doc then said
that this next part was necessary and apologized but that I should now roll over so
the front side and groin could be examined. This part of the exam was completed
very quickly but included a through inspection of ALL the parts and places. I was
then instructed to dress and the doc would be back for the follow-up.

Turns out everything was ok with only a couple of spots that special attention should
be given to. It was recommended that an annual exam be done each year. I agreed.

So, what was the difference between the second experience and the third? Patient
respect, comfort and modesty. Obviously I will go back next year for the exam. I
have no way of knowing that the motivation of the nurse was who let me sit in my
birthday suite for ten minutes but I had a choice. Keep in mind that I'm just an
average guy, not tall or short, average build and definitely nothing to write home
about in the manhood department but maybe she just wanted to get a good look.
Was it unprofessional, yes, was I permanently scared? Nope. Anyway, I chose to
change doctors.

The bottom line is that if you're unhappy with a health care professional, go
elsewhere until you are satisfied. Like the brother of the person who posted above,
it could save your life. Sorry for being so long winded. Maybe the moderator of the
blog could comment if I did the right thing...
Wednesday, July 18, 2007 11:53:00 AM

Maurice Bernstein, M.D. said...
James A, you did the right thing. Changing physicians is your right as a patient if
you find you are uncomfortable with the doctor and/or the others in the office.
Although some have recommended a preliminary sit down with the new doctor
before deciding whether to keep the doctor for ongoing professional care. This may
give an idea about the office and doctor but still you may not get a complete
evaluation unless you also experience what goes on during a physical exam.
..Maurice.
Wednesday, July 18, 2007 9:30:00 PM

js md said...
James, a few personal observations. Your first experience with the nurse was
unjustifiable. For a provider or nurse to stay in the room while a patient is totally
undressing is considered inappropriate or outright sexual misconduct everywhere
(unless the patient needs assistance). To interview you in the nude is outrageous. I
would have complained immediately.
I would not have enjoyed the second situation either, in that I would not like an
observer in the room while I was being examined, both for modesty and privacy
reasons. However the doctor was up front about it and undoubtedly makes it her
routine. She gave you the chance to opt out. I might still prefer to go elsewhere,
but there was nothing inappropriate about the second physicians conduct.
You have different feelings Dr. B? In a teaching situation such as yours this probably
happens all the time, but is less common in private practice.
Friday, July 20, 2007 9:12:00 AM

Maurice Bernstein, M.D. said...
First of all, I fully agree that there is something pathologic or pathetic in office
protocol for any patient to be sitting naked for interview or examination. I have
written about this previously on this blog. History taking is directed to obtaining
the medical history of a patient and to also observe the patient's body language,
speech and thinking process during the history-taking. There is nothing in clinical
practice that requires a complete surface anatomical exam while taking a history.
It is important to keep the patient from chilling and to keep the patient from
unproductive and unnecessary stress. The patient should remain clothed during the
history. Not allowing time for the patient to partially undress in private represents
a defect in the office protocol.

On performing a physical exam, there is no need at all to have the patient fully
naked. I have written here before, it may be wiser and more productive, while
doing a full body dermatologic skin exam to examine the skin systematically in
small uncovered areas rather than try to having no areas covered, the patient
simply be examined fully nude. This process, as pointed out by the head of
Dermatlogy at our med school, is not just for the comfort and modesty most
patients would desire but also because, particularly, small lesions may be identified
when small areas are being examined but missed when there are no boundaries to
the exam area.

Finally, my experience teaching first and second year med students during their
experience with real patients is that the patients understand and give consent for
the students to examine them. The student is considered the primary examiner. I
am only the observer and I identify myself to the patient as the student's teacher. If
there is some noteworthy physical finding that would be of value for the remaining
5 students in our group to observe, both the initial examining student and myself
get permission from the patient before the remainder of the group appears at
bedside.

Again, sitting or standing naked in front of a nurse or doctor as part of a physical
(except momentary dropping of shorts during a genitalia or rectal exam in males or
in the case of fully body dermatologic exam by some practitioners) should make
anyone suspicious of motivations. And more particularly if requested at the time of
the history taking. ..Maurice.
Friday, July 20, 2007 11:03:00 AM

Anonymous said...
Dr. M-JSmd Have either of you noticed a difference in the attitude or acceptance of
patients in accepting students based on gender, i.e. male patient accepting a
female student, or female accepting female student. Personally as a male I would
feel more comfortable with a male Dr. and male student than male Dr. an female
student, and the least comfort with female Dr. & female student when exposure is
required.
Monday, July 23, 2007 10:54:00 AM

Maurice Bernstein, M.D. said...
To Anonymous from today: Since the student-patient interaction is very important
for a host of different teachable reasons, one of my responsibilities while
supervising a student-patient history or physical exam is watching and noting what
is going on in the student-patient relationship in addition to how satisfactory the
history and physical is being performed. Once the patient accepts the student's
request for permission for the exam, I find no difference in further acceptance of
the student regardless of the gender of either party. When a patient rejects a
student's request to participate, I have no idea what is the main basis for the
rejection. Patients usually say they are "tired" or uncomfortable and don't want to
be bothered or that another student interviewed and examined them recently or
just appear sleeping and don't respond at all. I have never heard a patient reject a
student or even me based on a gender argument, instead I have heard one of the
above excuses.
Nevertheless, despite the excuses, each patient has their own right to select an
examiner based on gender preferences, if students of the opposite gender are
available. I would try to accommodate--but this issue has never come up! ..Maurice.
Monday, July 23, 2007 2:58:00 PM

Anonymous said...
Thanks, I guess I never thought it would be difficult to determine why they would
not agree. I am not comfortable with that is pretty general. I was curious, from this
an other threads the modesty issue is pretty much opposite gender, and several
have expressed multiple providers of the opposite gender intensified that problem.
Not sure what they express at the time or in the medical setting, we tend to just
bitch after the fact.
Tuesday, July 24, 2007 5:08:00 AM

Anonymous said...
on another site there is a discussion on the Discovery Health Channel's Trauma in
the ER shows. Basically they film an ER with bringing people in and treating them
through the ER to follow-up. A couple of issues are bign brought up frequently. As
could be imagined some of these people are in pretty bad shape when they come in,
the question is the crew is filming them as they are brought in and treated, their
privates are pixeled out but their faces are viewable, the assumption is they were
filmed and signed a consent for it to be publsihed, but the concern was one would
have to assume that some or all of the filming was conducted before consent due to
the fact that some come in unconcious, unresponsive, in duress, and sometimes
drunk or drugged, so consent would be difficult or impossible. The question of
allowing people in the ER during treatment and paticularly exposure without
consent of the patient. Does a hospitial have the right to allow whoever in for
whatever reason they choose? I would imagine if the patient declined to sign the
permission slip they could not show it, but by then they would have still been
exposed to people who had nothing to do with thier care. One facility mentioned
was Sunnybrook Womens in Houston I believe. The other issue was one discussed
here, the double standard on modesty, while males are often left naked and
uncovered for a long period, females are often given extra care such as cutting or
removing clothes under a sheet rather than cutting them off and leaving them
exposed....Dr. M,,,,jmsmd....any thoughts on any of this, realizing it is TV I would
still think medical care would not....should not be compromised for TV...JD p.s. I
would be really mad if I woke up and found out they let a camera crew to film my
care for a purpose like DHC
Friday, July 27, 2007 8:37:00 AM

Maurice Bernstein, M.D. said...
To the best of my understanding, a hospital emergency room is unlike other public
places such as parks and football stadiums and that patients within emergency
rooms have the same opportunity for privacy of their person and their illness as any
other patient under the current HIPAA federal regulations. If anyone knows
otherwise, please speak up. ..Maurice.
Friday, July 27, 2007 10:37:00 AM

js md said...
I'm sure HIPAA laws apply. It's hard to believe though that a Houston Hospital
wouldn't know that and leave themselves exposed to lawsuits. If a patient is
unconscious, I assume a family member can give permission, at least temporarily.
My guess is that's what happens. They undoubedtly offer to pay the patient if they
use the footage to get them to agree.
I certainly don't think any of this is appropriate. It's more show biz than medicine.
And situations like this should not be mistaken for 'reality.' They are played to the
camera I'm sure (I've never seen one of these shows.)
If there is a double standard, it's likely more related to the consent process than
indicative of their usual practices. How many women patients would agree to have
lots of cameras and camera men filming them when they are exposed, whether or
not it is pixelated out later?
Friday, July 27, 2007 11:27:00 AM

Anonymous said...
While we are on the topic of TV showes. A couple of seasons back I was watching
ER. During the story one Dr. says to the other. "I see that you (tubed) that pretty
young blond." (tubed) being the slang for totaly unnessary breast exam. While I do
know that this is made for TV, it has to have some basic rooted in truth. I'll bet my
bottom dollar that this is a slang term that is really used among young doctors in
the ER when they (tube) a patient.
Sunday, July 29, 2007 6:11:00 PM

Maurice Bernstein, M.D. said...
I would caution Anonymous from today against extrapolating behavior in emergency
rooms with what was seen on the TV program ER or the others TV dramas. First, if
you haven't noticed there is a tendency to incorporate sexually interesting behaviors
into these programs to stimulate viewer interest and viewership. Further, none of
those young ER doctors on the TV program are subject to be involved in malpractice
suits or have their licenses taken away because of unethical, illegal or poor or
unprofessional behaviors.

Do you know something, except for an occasional monitoring of those medical
dramas to see if there is any improvement in presenting reality, I can say that I am
not part of the regular viewership.
..Maurice.
Sunday, July 29, 2007 6:51:00 PM

js md said...
Anonymous from today July 29 11:00 PM, I don't qualify as a young doctor, but I've
never heard of the term tubed applied to a breast exam. In 40 years of practice I've
also never heard any doctors discussing doing unnecessary breast exams. If a real
doctor was doing that, he'd be unlikely to be discussing it openly I assure you.
In short, as Dr B says, what you see on TV is just that, entertainment, not medicine
and that includes the 'reality' shows. Don't take them seriously. I once tried to watch
one of the ER dramas, but couldn't take it for more than 5 minutes, it was so
ludicrous.
Sunday, July 29, 2007 7:52:00 PM

Anonymous said...
Thanks, after considering what you posted it seems rather obvious, the Hippa
implications of letting a film crew in without patient permission never crossed my
mind. When you watch the DHC life in the ER with all sorts of people standing
around...I thought it was big city vs small town from my actual
experience....makes sense its reality tv, scripted for tv
Monday, July 30, 2007 6:53:00 PM

js md said...
I don't claim to be an expert at HIPAA laws. Maybe someone with full knowledge can
comment. But I believe the thrust of HIPAA is concerned with medical records,
written or electronic, and not with direct patient interactions or audiovisual
restrictions. And I don't think physicians or medical entities can be sued for
malpractice by patients under HIPAA. The penalties are restricted to government
imposed fines.
Nonetheless providers can be sued by patients for privacy violations directly, HIPAA
laws aren't required. Most states have separate laws requiring that privacy be
respected.
Tuesday, July 31, 2007 4:10:00 PM

Maurice Bernstein, M.D. said...
With regard to HIPAA regulations revolving around photographs or photography of
patients in or outside of emergency rooms, I looked at the Complete Text of the
Final Rule of HIPAA located at this link and couldn't find any pertinent regulations.
You might try and see if I missed them.
Though there may be other laws regarding such photography, one would think that
the purpose of HIPAA was to prevent unnecessary and unconsented identification of
individuals even as only patients (that is, outsiders might infer that individuals who
are being attended medically are sick and this knowledge would be a violation of
privacy as described in the following Summary from the HIPAA.) ..Maurice.

SUMMARY: This rule includes standards to protect the privacy of
individually identifiable health information. The rules below, which
apply to health plans, health care clearinghouses, and certain health
care providers, present standards with respect to the rights of
individuals who are the subjects of this information, procedures for
the exercise of those rights, and the authorized and required uses and
disclosures of this information.
The use of these standards will improve the efficiency and
effectiveness of public and private health programs and health care
services by providing enhanced protections for individually
identifiable health information. These protections will begin to
address growing public concerns that advances in electronic technology
and evolution in the health care industry are resulting, or may result,
in a substantial erosion of the privacy surrounding individually
identifiable health information maintained by health care providers,
health plans and their administrative contractors. This rule implements
the privacy requirements of the Administrative Simplification subtitle
of the Health Insurance Portability and Accountability Act of 1996.
Tuesday, July 31, 2007 5:47:00 PM

Anonymous said...
My wife worked at an eye care center, they were really diligent and perhaps went
over board but they reconfigured their office so conversations between the
receptionist an patients could not be overheard in the waiting room. Likewise when
I had a screening proceedure at our loccal hospital they have the typical counter
with a small devider for multiple intake, the intake person was very careful to only
refer to it as "the procedure" and when she wanted to address specifics she would
turn the form to me and say, we will be doing this, and point to it....whether by
law or practice the limited experience I had with it indicated they were concerned
with people who were not directly involved in patient care over hearing what was
happening.
Wednesday, August 01, 2007 8:19:00 AM

js md said...
Anonymous from today, I would hope your wife's experience is typical. Most
practices have to be very concerned about these issues, though obviously some
practices deal in more sensitive conditions such as VD and AIDS than others. This
topic was greatly stressed during the early years of the AIDS epidemic when it was a
virtual death sentence and fears of patients being ostracized were great. Most
states I would think have laws or regulations governing this.
I just don't think that the federal HIPAA laws per se govern most of these situations
except as it concerns the confidentiality of patient records.
Wednesday, August 01, 2007 7:46:00 PM

Anonymous said...
One would think that even if the original intent was aimed at records, it would be a
small jump for an attorney to take the intent to protect privacy to extend to
allowing unauthorized or unneeded people in the OR where they would be privy to
private medical information, any medicince they are taking, illnesses, as well as
what is happening at the time.
The other thing I see, is why would a medical facility allow this to happen. I
personally would be very angry if my hospital allowed this to happpen, we come
there for care in a stressed state, in a vulnerable position. Commercializing the
process lowers the respect for the patient and for the facility. One of the themes
that the medical profession holds out not only in this thread, but everyday, that
they is used to address nudity in the medical setting is "we are professionals". A
camera crew is not a group of professionals, they are media, media by an large
lives and dies by sensationalism. Even the DHC, if its factual and boring, nobody
watches. Bringing a camera crew in is self serving to the hospital and perhaps the
Dr. at the expense of the patient. I would think less, and likely not willfully go to a
hospital that allowed someone, or they themselves profited from someones tradgedy
and vulnerability. Even if they didn't use film from someone if they did not agree,
simply allowing the crew in would set me off, and maybe send me to an attorney.
Friday, August 03, 2007 4:58:00 AM

js md said...
Anonymous from today, I doubt that I can fully answer your questions. Some lawyer
may figure out how to use HIPAA as the basis for a state suit. I think someone has
tried. But federal law mostly stays out of physician patient relationships which are
mostly state regulated.
As I said I don't approve of filming TV in hospitals, and few due it for commercial
TV. Why do those few do it? Because hospitals are under great fiscal pressure in
general, especially if they have a large welfare population. Years ago no hospital
advertised. Nowadays they nearly all do because getting paying patients is a
competitive business. I guess they feel that having reality shows filmed there is
good business. They should know.
Health care is a business in the USA and these practices aren't going to change
unless the whole system changes. Go watch the movie SiCKO for contrast.
Friday, August 03, 2007 6:21:00 PM

Anonymous said...
I had some of those same thoughts after reviewing your posts. For awhile I as
addicted to these shows. One of the things I have noticed is there seems to be a lot
of lower income patients, a lot of stab and gunshot wounds etc. I live in rural
midwest and tend to compare to the local smaller facilities. The one segment
featured a hospital in our state capital, that facility does in fact set in a poor part
of the city and handles a lot of poor clients...so you could be right on the income,
and larger facilities are probably more able to get the benefit vs the negative from
the show.
Saturday, August 04, 2007 7:40:00 AM

Anonymous said...
OK, since you and Dr. M have been so helpful and open onthis thread I will forego
my opinion of Micheal Moore and go see it. I have noticed something lately, there
have been very few segments on the trama in the ER which were supposed to be
actual events, but more "Untold Stories of the ER" which are recreations, the
recreations are pretty cheezy, perhaps that is what you saw...Good Dr's do not
make good actors. I also noticed the time slots where Trauma in the ER (the actual
event) were scheduled the title is there but the programing is different, perhaps
there was some push back.

Dr. M & JMS md...do you have concerns that the commercialization of health care
will have a negative effect on the view of the profession, and as related to the issue
of concerns for modesty, effect the way people view their interaction with
providers. If the view of the industry becomes more of a buisness could it, will it
lower the level people hold providers to?
Tuesday, August 07, 2007 6:55:00 AM

Maurice Bernstein, M.D. said...
The problem with commercialization of healthcare is that it can deminish the
profession in many ways. Pharmaceutical advertising to patients promotes the idea,
without knowing the actual person who watches, reads or hears the ad that "their"
drug will do the job and all you have to do to get it is to "talk to your doctor." That
commercialization action "simplifies treatment" doesn't it.

Then you have the commercial TV dramas that also simplifies and exaggerates
disease, diagnosis,treatment possibilities and results. Not only that, but it also
exaggerates the professionalism and also the non-professionalism of the doctors and
nurses for commercial (viewer interest) value. Do you really believe all that sexual
activity is going on in hospitals and emergency rooms? I won't deny that staff
personal attractions and perhaps some sexual acts of one sort or another might
occur but really are the dramas presenting the true state of these activities? And
yes, patients who watch these dramas as examples of reality are naturally going to
be more suspicious of what really goes on in hospitals, ERs and operating rooms
regarding sexual interest by the staff and their own modesty issues.

Exaggeration is part of commercialization and helps to sell the products but really it
truely hurts the medical profession. ..Maurice.
Tuesday, August 07, 2007 9:43:00 AM

Anonymous said...
I have just read through the blog.I live in Australia and find it is totally different
here. We go to the doctor when there is something wrong, we dont have anual
check ups. Women have a pap test for cervical cancer every 2 years, mamograms
over 50 years and men have prostate checks over 50. I and my husband are quite
able to check ourselves for lumps or sores or whatever. My husband had a lump on
his scrotum. Went to the doctor then had an ultrasound. Everything was fine. We
dont need someone telling us to strip so they can touch or see. My husband and I
check each other for skin melenomas etc. If we are worried about something then
we go to the doctor.
Wednesday, August 15, 2007 8:27:00 PM

Maurice Bernstein, M.D. said...
Personal self-examination is highly recommended since the patient or his or her
spouse will more readily identify changes than will a physician in an annual exam. If
the patient finds an unexpained change, prompt professional medical consultation is
advisable.

There is real controversy in the United States whether an annual physical exam on a
healthy adult is really necessary beyond some few screening tests which have been
found of value. Probably a better approach, and more economical from healthcare
cost viewpoint would be to seek medical attention when disturbing symptoms or
observation of a bodily change appears and do away with the annual exam. Patients
who have significant chronic illnesses, perhaps more complete annual exams in
addition to their brief interval visits would be of value. ..Maurice.
Wednesday, August 15, 2007 9:03:00 PM

Anonymous said...
My wife and I attend nearly every physician appointment together, including DREs
and pelvics. We specifically choose providers who will accommodate this. Obviously
patients who follow our example must not make a nuisance of themselves in the
exam room. Providers, in turn, need not be intimidated by the presence of a
spouse. If their exam is professional, they need not worry. If it is not, its good that
the other is there. We've never had an issue personally, but in my work in health
care I've encountered a few (less than 20) inappropriate practitioners - both docs
and nurses/techs. Rarely someone (usually the office nurse) is put off by our desire
to have the other present. When this occurs, we firmly insist that our partner
accompany us. There can be a case made for the nurse/MA or practitioner to have a
brief private chat with the patient. There is no reason, however to exclude a
properly behaved spouse from a physical exam (if its OK with the patient), or for
that matter from most office procedures.

Thanks to Dr. Bernstein for his willingness to endure a long and sometimes
contentious blog.
Thursday, August 16, 2007 7:54:00 PM

Anonymous said...
there is a blog on voy with a thread that addresses this specifically. The poster
stated there was more reluctance to allow the husband in for the exam when it
included a pelvic than allowing the wife in for DRE, etc for the husbands exam...any
such experience for you anonymous Aug 16?
Saturday, August 18, 2007 5:56:00 AM

Anonymous said...
I've been thrown out of pelvic exams with wife and girlfriend. Wife and girlfriend
have been welcome at when I'm examined by my urologist.
Sunday, August 19, 2007 7:23:00 PM

Anonymous said...
If a partner is being asked to leave for a pelvic or other exam I would ask why. Is
there something to hide? If my partner wasnt allowed in I would see someone else
that would allow this. My husband and I occasionally attend exams with the other.
This is not to catch the doctor doing something wrong or that we are suspicious of
the doctor (if we were we would go somewhere else) it is because its nice to have
someone to hold your hand or simply for support. On the rare occasion you are to
get bad nws you want your loved one with you.
Sunday, August 19, 2007 9:39:00 PM

Anonymous said...
My husband and I recently had a discussion about the different approach in
examining a female to a male patient. When I attend the doctor for a pelvic exam
the curtain around the exam table is drawn while I remove the clothing below the
waist then I cover myself with the sheet given to me by the doctor. When he returns
I feel as though I am covered even though technically I am not. When my husband
recently attended the doctor as he had a lump on his testicle the curtain was not
draw and the doctor simply said remove pants and jump up on the table while he
stood there. My husband is quite a modest person and felt very uncomfortable. The
doctor was to examine his testicle not his penis so why couldnt he have had the
curtain closed while he removed pants then covered penis with sheet leaving testicle
exposed before the doctor returned. On the next visit (we see the same doctor) he
asked why there was such a different approach to his examination compared to
mine. The doctor stated he didnt think men worried about that type of thing and if
he wanted a sheet he couldve asked. Yes I guess he could have asked but shouldnt it
have been offered. I think the medical profession just assume that men dont care
about modesty but some do, dont just assume everyone is the same.
Sunday, August 19, 2007 9:51:00 PM

Anonymous said...
I think you hit it on the head, it is an assumption that arises from a historical mode
of treatment and beliefs. It is up to us as the patient to educate the providers,
silence is taken as consent. In todays competitive environment providers are now
competing for patients, make the issue known to your Dr., if its an institution,
contact the patient advocate or director, its the only way it will change.
Monday, August 20, 2007 6:43:00 AM

Maurice Bernstein, M.D. said...
To Anonymous from today: I fully agree with what you wrote. The issue is how can
the doctor-patient relationship and interaction with the goal of accomplishing the
best examination and the best communication of information can be facilitated. It
can be facilitated by both parties recognizing there must be a level playing field
between the two despite what might seem to be unequal power on one side (the
physician). That means, the patient should feel free to express needs and desires
about how to run the examination and the doctor should listen to and consider and
not simply ignore. The patient, on the other hand, should be aware of limitations in
office practice and be willing to listen and be educated but together try to find a
common resolution for an effective but also emotionally comfortable examination.
..Maurice.
Monday, August 20, 2007 10:00:00 AM

js md said...
Anonymous, August 19, 2007 9:51:00 PM , I can see where your doctor is coming
from. The majority of older men who have been through military service and forced
communal showers in school (sometimes including nude swimming classes) have
little modesty in all male company. That is not to say that everyone is like that, but
it is certainly much more common than the greatly increased sense of modesty that
many younger men seem to have. But I agree that doctors shouldn't assume that
men are less modest than women. (Actually I know some GPs who think men are
more modest to begin with.) Men should be accorded the same courtesy as women.
I personally am more comfortable in just my shorts than I would be in a gown, but
that's just my preference. And I don't care about removing them when necessary. I'd
only get upset about unnecessary exposure which I believe is uncommon. Men must
feel free to speak up until practitioners realize that they need to extend the same
courtesies to all their patients.
Monday, August 20, 2007 3:21:00 PM

Anonymous said...
Anonymous Aug 16 here again. Only rarely do we encounter resistance to our desire
to visit the doc/PA/NP together. As I said, it is usually the assistant that has the
problem, and if the doc does, he/she covers it well. Personally, when I had to be
examined by a female PA for a urological issue, I was less embarrassed having my
wife there. We usually check to be sure that spouses are welcome anytime we see a
new provider, and if not, we see someone else. Being "thrown out" of a pelvic exam
(or a DRE) is solved by the patient simply and firmly stating that she (he) insists you
remain, and being willing to ask for a different provider if necessary. That way it is
clear that the patient wants you there, and that you are not forcing your way in
when she (he) doesn't really want you there. Neither of us has been asked to leave
once it has been clear that the patient wants the spouse there. Remember not to
interfere with the exam, or make improper comments because that interferes with
the care of your partner.

Since this thread is about modesty, I thought I would add that each of us are more
comfortable handing our clothing to our spouse than to have it on a chair, or
handed to a nurse. As far as nudity is concerned, we are rather familiar with how
each other looks naked; and we each know what are the components of an intimate
medical exam. We are both open with each other about our personal stuff, and have
no problem discussing anything with the doc with the spouse there. Emotional
modesty can be as important as physical modesty in some situations.

All health care providers and workers (myself included) would do well to remember
that modesty and privacy are the domain of the patient. My work only occasionally
requires me to intrude on someone's modesty, and when it is necessary, I try to
always explain why, and to make the intrusion as brief as possible.
Monday, August 20, 2007 5:19:00 PM

Maurice Bernstein, M.D. said...
Anonymous of August 16th, thanks for bringing up the concept of "emotional
modesty". This thread on modesty has concentrated on bodily modesty, nudity and
nakedness. Yet, the other elephant in the doctor's office or examining room could
well be emotional modesty: the fear of exposure, the need for control of historical
information which the physician requires in order to make a diagnosis. Perhaps the
patient finds it difficult to tell the doctor or respond to the doctor's question
because of embarassment. "What will the doctor think of me?" and so on. If another
person from the office is in the room or even the patient's spouse or other person
accompanying the patient is present, emotional modesty might be present, the
patient unwilling to expose a sensitive history to these people. One common
example would be if the physician found a traumatized vaginal vault and suspecting
foreign body insertion asked the patient if she masturbates and if so with what.
This question might precipitate an emotional modesty response--an unwanted
emotional undressing.

Obviously emotional modesty might well be related to other subjects besides those
of a sexual nature. As with bodily modesty, the physician and patient must come to
some agreement of how to continue a productive history and physical examination
despite the modesty issue. Again, Anonymous, thanks for reminding us about this as
yet undiscussed aspect of the thread. ..Maurice.
Monday, August 20, 2007 7:34:00 PM

js md said...
A related comment:
I don't do general exams, so modesty issues rarely enter into the picture. But
frequently spouses come into the exam room. They are always welcome. Usually
they are there because I asked the patient to return to discuss findings or because
the patient has increasing symptoms and the patient and spouse are very concerned.
If something serious is happening, I much prefer to have a spouse listen to the
discussion along with the patient.
I suspect having spouses in the room for routine general exams is much less
common, and likely some doctors are suspicious of the motives. But I see nothing
wrong with it if the spouse is there to be supportive in whatever way is needed. By
all means, if the doctor won't permit it, go somewhere else.
Monday, August 20, 2007 8:27:00 PM

Anonymous said...
Nude swimming classes???? Where did you go to school JSMD?
Tuesday, August 21, 2007 3:35:00 PM

Anonymous said...
Dr Bernstein re:Aug 20 comment
what limitatons are you refering to that would restrict a partner being present.

I find when I attend the doctor with my husband or he with me there are things the
partner may remember or contribute that the patient hasnt thought of in relation
to why the patient is attending the doctor in the first place. I think it can be
beneficial for the partner to attend so long as the patient agrees.
Tuesday, August 21, 2007 4:18:00 PM

Maurice Bernstein, M.D. said...
To the last Anonymous, I find no fault with the spouse or other partner present if
the patient desires and you are correct that the other person may help to provide a
more complete history. I was only writing about patients who may want to withhold
history from their partner where this may be described as "emotional modesty." The
partner may be aware of the patient's whole body but may not be aware of
everything the patient thinks about or does and this might be information the
patient does not want to share. ..Maurice.
Tuesday, August 21, 2007 5:14:00 PM

js md said...
"Nude swimming classes???? Where did you go to school JSMD?"

Well this is mostly off topic, only peripherally related. But since Dr B posted your
question, I'll amplify.
This was a common practice in this country up until the 60's to early 70's. Many
people can't believe it ever happened, but it is amply documented for those who
care to check. Many high schools scattered across the country had mandatory nude
swimming for boys. Don't ask me why. They never did it for girls. This was standard
in the Chicago public school system. It was also standard at many YMCA's around the
country. My YMCA had the policy until the Y went coed in the early 70's.
Nowadays this seems bizarre to many people and hard to believe. It is part of why
guys of my generation weren't modest with other guys. We survived and thought
nothing of it at the time. To us it just seemed normal. Times and social mores
change.
Tuesday, August 21, 2007 6:11:00 PM

Anonymous said...
"Traumatized vaginal vault"...what a poor example to use. You're just a few steps
away from sexual impropriety: "What do you masturbate with? Describe to me how
you do it", etc. Seems to me you are thinking of the female body more than you
realize. Why not an example using a male patient? Would a male patient be asked
about his masturbation habits? Why not use a non-sexual example? For instance,
some people are very reticent to discuss mental health history.
Tuesday, August 21, 2007 6:23:00 PM

Maurice Bernstein, M.D. said...
I would doubt "sexual impropriety" would be the right words for this example of not
rare occurance of vaginal injury for which information the patient might want to
withhold from the physician. These kinds of issues are of medical import to the
physician as any trauma or illness and do not represent something personally sexual.
Perhaps it might be the patient's erroneous evaluation of how the physician would
accept information about masturbation trauma that may prevent the patient from
full disclosure. I think that your description of my example is possibly a sign of the
public's underlying confusion of what is medically pertinent and appropriate
discussion and what is pornographic. That confusion could lead to the emotional
modesty issue we are discussing.

I do appreciate that you also noted that "mental health history" could be another
area where modesty might prevent the patient from disclosing to the physician. I
fully agree. In fact both patients of either gender should be aware of the importance
for their well-being regarding relating sexual or mental health history to their
doctor. ..Maurice.
Tuesday, August 21, 2007 7:59:00 PM

Anonymous said...
Doctors and nurses dont just stop being human because they put on thier doctors
badge in the morning. To say once youve seen 100 vaginas or penises you dont look
at the same way cant possibly be true and is why I am so terrified of any intimate
exam particularly with the opposite gender. The other issue I have is that some
believe its ok to be undressed in a medical scene (eg. ER or OR) and have both
genders look, touch etc with little regard to the patients feelings toward modesty.
(dont try and tell me when your out everone will take care to keep you covered, I
find that hard to belive and I'm sure this would take too much time!) If this
happened anywhere else it would be seen as assault. I realise it is a totally different
situation but for some mentally this can play on thier minds. That they were naked,
possibly unconcious with no contol over what was being done or seen and by who.
You only have to watch hospital documentaries and see the persons naked body
which they have blured but you get the idea.
Tuesday, August 21, 2007 8:26:00 PM

Anonymous said...
I think the past few posts are a perfect example of the diversity of feelings on the
subject. Some people don't care, some people are traumatized by it. I personally
have been really upset over a skrotal ultrasound when I was assinged a female tech,
when I found out a male was avialable. On the other hand I had only mild discomfort
with the thought of who was present in the OR for hemmroid surgery becasue I was
out when I left the prep room and out when I returned and never was exposed while
awake. For others this is very stressful. Which is why once again I stress it is up to
the patient to communicate this. The right answer would be for medical personell
to error on the side of modesty and do everything they can, or at a minimum
ask...at least for the near future, that isn't going to happen and and it falls on us to
promote change by stating our wants and needs and protest when we don't get it.

jms md, my brother in-law in his 60's told me about mandetory naked swimming at
school, I thought he was just blowing until I read it on other threads. It is related to
some degree to this thread as it is an indicator of not only why some handle the
medical nudity easier, but it also shows the double standard which is now starting
to be challenged.
Wednesday, August 22, 2007 4:50:00 AM

Anonymous said...
Anon Aug 16 here again. Sometimes I think we take it personally when patients
don't tell us everything. We certainly can all do our jobs better if we all know every
pertinent detail. I believe that some people don't want to disclose certain things
because that will make them true (did I read that elsewhere in this thread?). Mental
Health history never all comes out in one sitting. It usually requires a particular
degree of trust before the patient will go there. As we are discovering each patient
develops trust in different ways.
Wednesday, August 22, 2007 10:07:00 PM

Anonymous said...
Good point, as stated before disclosure of issue to providers is so critical. If a
patient is uncomfortable with a provider/tech due to modesty issues, there is going
to be less disclosure. Trust and being comfortable are closly related. It is hard to be
open to a provider when a patient is feeling intimidated, uncomfortable, or
questioning why they have to be exposed or exposed to the opposite gender....
Thursday, August 23, 2007 6:13:00 AM

Anonymous said...
Workplace supervised drug testing. Some of us have never taken drugs in our lives
yet can be subjected to supervised testing. Its hard lines when you cant urinate
without someone watching. Just the thought of a nurse watching me urinate makes
me feel ill. Does anyone know the procedure for this testing.
Saturday, August 25, 2007 4:28:00 PM

js md said...
Anonymous of yesterday. I don't think anyone can answer your question. The
procedure varies from company to company and by the reason for doing the test.
You won't necessarily be watched.
But if you will be watched, you can certainly request that it be done by a male if
that's what you want.
Sunday, August 26, 2007 7:30:00 AM

js md said...
Maybe it's time to ask a more basic question. What is modesty? Does it serve any
rational purpose? Or is it just the customs and mores we were raised with that
inhibit us for no purpose? I’ll state at once, I don’t know the answer. But modesty is
clearly not intrinsic to the human condition; many cultures have little or none.
As my prior post on swimming alludes to, our customs in the US have evolved over
the years. They are quite different from what they were at the turn of the prior
century. Then mostly all male nudity was fairly common and female modesty was
Victorian based. Nowadays women appear in almost invisible thongs and bikinis and
young men wear bathing suits to mid calf. What possible purpose does increased
male modesty serve? Is it caused by homophobia and a reaction to pedophilia which
was always around, but downplayed and ignored till recent decades? Would we be
better off with no modesty or would society turn into a Roman style orgy? Do
women still need modesty with today’s modern birth control methods, equal rights,
and gender neutral divorce codes?
Medical modesty is just the tip of the iceberg.
Sunday, August 26, 2007 10:58:00 AM

Maurice Bernstein, M.D. said...
Js md, a dictionary definition of modesty would be, as an example,

"1. The state or quality of being modest.
2. Reserve or propriety in speech, dress, or behavior.
3. Lack of pretentiousness; simplicity."

To me, I think we can define the word in another way. Perhaps a better way to look
at the word from the medical practice point of view. Modesty is a form of human
expression in which a person attempts to restrict disclosure of various aspects of
that person to others. Those aspects include one's body or physical appearance, one's
intellect and one's behavior.
In other words, modesty is a way of controlling how others see us by how we look,
how we think and express ourselves and how and what we do. Each aspect might
affect the medical evaluation from the physical exam to disclosure of medical
history to a restrained reaction to issues arising in the doctor-patient relationship.

Do any of my visitors have other ways of defining modesty? ..Maurice.
Sunday, August 26, 2007 8:19:00 PM

Anonymous said...
I really don't have a good way of defining modesty. It is a bit like defining love. It is
obvious the modesty we are speaking of is mainly physical, however you have
brough up the disclosure, or lack there of of information as modesty related and it
would apprear often that is the case. Simply put it is the desire to conceal or
prevent exposure of physical attributes or mental-emotional experiences, issues,
and or concerns. This is a tough one, I think jms md's question is a little clearer, I
think obviously modesty varies so from culture to culture it is socially derived and
imposed. Our culture is basically a spin off or has its roots in European Society, yet
while topless beaches etc are acceptable in Europe, they are only in rare occasions
acceptable here and where they are are not often used (topless) by many women in
our culture. The versions of modesty are countless and vary greatly but are pretty
universal within those cultures. Would we be better off with out it, in many cases I
think we would, the medical arena is perhaps the most obvious case, the question is
how would we ever effect change. While some have been able to practice when in
Rome when traveling abroad....a lot of people from this country don't feel
comfortable, can not over come what has been drilled into them since birth. Your
example of swimming, I was shocked when I first heard of it and thought how
terrible to force that upon young men, you never indicated if it bothered you at the
time or thought nothing of it, did you care, were you worried about what the others
would say...think, were you afraid the girls might accidently walk in or female
teachers be present..or was it just amother day at the office. Times have changed,
try that today and you can bet a legal challene would follow shortly....that was a
one generation change...as you stated what changed, is it modesty or males
starting to demand to be treated the same,,,or is it the pedophlilia or homophobic
concern?

On the Drug test, I drug test all of my drivers and management. We have used
several different drug companies over the years, none have requested to observe the
test being taken, your employer doesn't want to loose you, they gain nothing by
stressing you out, they want to address drug use, I would really doubt they will want
to have you watched, but as stated, if they do I would imagine requesting a male
instead of a female monitor would be accepted, a lot of people can't go with an
audience, don't stress, if it does arise ask for accomidation rather than refuse or be
tramatized
Monday, August 27, 2007 10:13:00 AM

js md said...
Yes Anonymous from today, I was of course speaking of physical modesty, though
you can generalize the subject.
I have conflicting emotions on the subject. On the one hand, I think we'd all be
better off if we had a lot less modesty in most situations, definitely including
medical encounters. Modesty accomplishes nothing in that situation; it only
complicates medical care. On the other hand maybe kids are more protected today
from sexual abuse than they were years ago. It would be nice to see some real
research on the subject. I don't know which way the pendulum should swing.
My moral codes were learned in the 50's and I am continually offended by the low
standards of our mass media culture. When I grew up, nudity, certainly all male
nudity was not synonymous with sex like it seems to be today. I think it was
healthier that way.
Since you asked, the forced nude swimming was completely matter of fact. It was
just the way things were and there was nothing sexual about it. We never sriously
questioned it or worried that a woman might accidentally see us, though I'm sure
we would have been embarrassed if it had happened. It was the innocent 50s.
Women weren't supposed to sexually covet men and we knew of homosexuality only
as an abstraction. Certainly wouldn't have been aware of it at our high school.
Due to this upbringing, I am just as modest as anyone in a mixed environment, but
not at all in an all male environment. In a medical environment as a patient, I still
have my modesty but easily accept any needed exposure and put it out of my mind.
Monday, August 27, 2007 4:24:00 PM

Anonymous said...
My husband and I are very modest people. I cant help it, I wish this wasnt the case
especially in a medical environment. The thought of either of us being exposed even
in an emergency room brings much anxiety. If I could change it I would as it is the
worst feeling. It doesnt help matters when you read some nurses blogs where they
talk about patients bodies and how they and thier collegues joked about it, or how
they have no time for modesty etc.
Monday, August 27, 2007 5:00:00 PM

Anonymous said...
I find it interesting it is assumed I am a male (drug testing) when I am actually a
female. All workplaces may conduct drug testing be it male dominated or female
dominated. It is quite common for these to be supervised according to friends that
have had them. I find it is an invasion of my privacy and as a modest person will
feel violated if this is the case. Why cant I have a blood test instead?
Monday, August 27, 2007 6:09:00 PM

js md said...
Re drug testing, an interesting question as to whether it has to be a urine test.
Most pre-employment tests are urine tests because they are easier to administer
and cheaper. Most are not monitored so that you're probably worrying needlessly.
But all kinds of tests are available including blood, saliva, hair and others. You can
ask but your employer may balk as most other tests are more expensive. Many
people would be more fearful of a blood test than giving a urine sample.
Unmonitored urine tests are subject to all kinds of problems, but most employers
aren't too worried about it to begin with.
I don't think I assumed much about your sex, saying "if that's what you want."
Complaints on this subject on the web are much more common from men who are
more exposed during urination than women to begin with, especially if witnessed by
a female nurse or tech. That is the usual complaint. The reverse is very rare, that a
man would monitor a woman. But it may be as pertinent that men post in larger
numbers on most blogs than women do. My guess is also that the majority of testing
is done on men, but I have seen no documentation on it.
Monday, August 27, 2007 8:08:00 PM

Anonymous said...
The reference to male vs female on the drugh test was probably mine jms md. My
apology, it comes from our practice, the people we drug test are almost exclusively
male. We test all of our drivers on a regular basis for safety reasons, while we say
management is also subject to random, we have not done so to point. The other
part of this is we have used several testing companies they have sent male and
females to collect samples (none observed). To jms md's point, I doubt women
would allow a male to obsrve collection, as stated before males have been forced
into the situation and have accepted it more in the past so are more likely to
accept it, even if they don't like it, though that seems to be changing some. This
comes through in many area's, we went to a major life insurance policy for key
employees. As a qualifier, they had to take a brief physical which included urine
sample, a EKG (they brought a portable to the office), etc by a nurse/paramedic.
The company the insurance company sent contacted me ahead of time and asked
me the gender of the applicants, when I questioned why, they said if you have
females we will send a NP (female), if not we will send a paramedic (male) or NP
which ever is available...they did not want to hassle with having a male do the EKG
etc on females....but did not see it as a problem the other way around, while I can
not say for certain, I would doubt they would send a male to observe a female
urinate, it would be inviting problems.

Modesty, I wish I did not have so much, as someone posted above, I have an
unreasonable amount of anxiety about it in medical settings. I know its
unreasonable and serves no purpose, and I struggle through it, but it is a struggle.
As stated above, it does not help to read the all nurse blogs etc and see that
providers suffer from the same issues, it makes it hard to believe its all in a days
work, I am a professional....
jms md, you pose an interesting question, is it the association with sex, pedophiles,
homosexuality, linking nudity to sex on tv that is causing a evolution, or is it
something else. Is modesty really that radically different to the conservative side, or
is it how we deal with it. Sticking to medicine, in the 50's the hospitals as I
understand them were staffed by female nurses, and male orderlies. Most if not all
of the intimate care was same gender so the conflict in the medical arena would
have been less frequent if at all. Now as medicine becomes more profit driven,
modesty was pushed back for efficiency of staff use, thus more opposite gender
exposure and more chance for issues. Nearly all of the issues on this and other blogs
were opposite gender related....could that be as much of the issue in medicine.
One would think with fashion trends we have become less modest, perhaps the
current younger generation is...but not the previous? It also could explain some of
the issues we have in a medical setting if the link to sex and nudity is strong, and I
think it is. Even without sexual conotation, exposure to the opposite gender is
condictioned from early on. We are taught exposure to same gender is acceptable in
certain situations, gyms, showers, high school physicals, public restrooms etc. but
we are never taught exposure to the opposite gender in any of cases is not
acceptable. A woman in our office recently walked out of her bathroom after a
shower to find the Culligan man bringing in salt, she was naked and just about lost
it becasue the older guy had seen her naked, no sexual issue there, just exposure to
the opposite gender. To expect people to loose what they have been taught since
they were young...tough jump even in medical situations. Last thought, at what
age are we told it is not appropriate to see our parent of the opposite gender
nude...pretty young there, no sexual conatation there...sorry about the long post jd
Tuesday, August 28, 2007 6:11:00 AM

js md said...
A further point, jd. The legality of drug testing has generally been upheld, but I
don't think the mandatory use of cross gender monitoring has. Applicants for
employment are not prisoners; they have lost no rights to their privacy. Anyone
subjected to it can certainly complain and insist that accommodation be made for
them. Why don't more men complain? Well some don't care, and in any event,
lodging complaints is not the best way to get a job. But anyone refused employment
because they refused monitoring would likely have a valid legal claim. I think you're
right though that the large majority of employers don't submit anyone to
monitoring, let alone cross gender monitoring.
Tuesday, August 28, 2007 10:38:00 AM

Anonymous said...
considering the change from same gender orderlies for males, more males going to
nursing, and the increase of opposite gender care, do you think patients have
become more modest, or do you think it is more the case of more reason for
conflict becasue of the change in how care is approached. Since most of the
complaints here were opposite gender issues...would it not follow that in itself is
more of the issue than changes in patient attitudes? jd
Wednesday, August 29, 2007 1:24:00 PM

Anonymous said...
I think these days people tend to say what bothers them more than they use to.
People are not of the thought that doctor knows best and just do what doctor says
no matter how you feel(or nurse). I think the issue was probably always there but
we dont just allow people to tell us what to do no questions asked.
Wednesday, August 29, 2007 4:12:00 PM

js md said...
I have difficulty being sure of the trends. There are less male orderlies, but more
male techs who take care of women as well. Men were always bathed by women at
most hospitals, though that may have varied from institution to institution. It is
true that men were never catheterized by women up until the 60s or 70s. I'm not
sure if the percentage of male nurses has consistently increased or not. Women may
come into contact with more male aides and techs, but also can choose female
physicians in a way that was not possible decades ago.
So I think the chance of cross gender exposure has always been high for both sexes.
What I am sure of is that the internet with blogs like this didn't exist until 10 years
ago so it is much easier to appreciate these concerns than it was ever before. I do
agree that it does seem to be a prominent concern based on the popularity of these
discussions on blogs, especially when contrasted to more 'serious' or philosophical
topics. But I never know how representative these blogs are of the average patient's
real concerns. I can tell you that the subject of modesty doesn't come up much at
the hospitals and settings I have worked at. Traditionally protecting a patient's
modesty has been a nursing concern, and not one taught much to physicians in the
past. Dr B says that it is now a topic with medical students, and that is a major
change from my training. I believe too that Dr B has expressed some surprise at
how much interest this topic generates. Is it a matter of the health industry missing
these concerns entirely or is it more that patients are just now making these
concerns known?
Wednesday, August 29, 2007 6:02:00 PM

Anonymous said...
you say the subject of modesty doesnt cme up. do you ask or just assume its not an
issue? I bet many patients go home as I have feeling violated at a doctor/nurses lack
of respecting my modesty.
Wednesday, August 29, 2007 10:15:00 PM

Anonymous said...
I think it is a combination of caregivers missing and patients keeping quiet. As the
above poster put it people are more open to questioning. People accepted this in
the past and did not feel they had the right to ask or question it. Society overall is
more questioning. Our silence was permission to conduct these activities even
though I have to feel the providers know it made the paitents uncomfortable. I say
this from a very basic point, 1st body language has to show this, and 2nd many
providers have stated how uncomfortable they are in these situations, so they have
to know it bothers the paitent. It made it easy to downplay this when everyone was
quiet, and it made the providers job easier if they didn't have to address it. The
question is should we attempt to change it and if so, how....even though I feel very
storngly about this and have taken steps in the past (ie requested a male for an
ultra sound), I am not so sure if I was in a hospital bed if I would say anything if I
had to be cathed for fear of what the nurses would say or how they would react if I
asked for a male....the answer if for the staff to ask if there is a concern, but I
have never known of this to happen
Thursday, August 30, 2007 5:28:00 AM

Anonymous said...
Wed anonymous is pretty well on target. While many people don't say anything, they
walk out with a lot of anxiety and bad feelings. While Dr. B has encouraged patients
to speak up prior, and they should, shouldn't that really fall on the provider? Are
they not the ones incharge and directing this. I honestly think they (the industry as
a whole) don't ask because they probably really know the answer and don't want to
have to deal with it or make accomidations. To thier defense they are probably over
loaded so some guy asking them if they could get him a male to do a cath when
they are right there with the tray casues them extra step and time....but, if they
are really focused on making medical visits/procedures as positive as possible for
the patient, they would/could do it in most cases. Most of us aren't going to say
anything for fear of being viewed negatively by the people we depend on for care,
and if they can't or won't accomodate now you have to deal with it and it makes you
even more embaressed, that is our shortcoming, on the other hand if the provider
would just ask, we wouldn't have to and it would be much easier for the paitent to
express their preference....
Thursday, August 30, 2007 9:25:00 AM

Anonymous said...
A agree with anonymour Aug 30. I feel very comfortable to ask for same gender care
when I am concious but what if I am not. If its an emergency and I am unconcious I
dont feel confident that my dignity/modesty will be respected. Will the curtains be
drawn, will the paramedics ensure my modesty is protected from bystanders and
media. Will my husband be permitted to be with me for the entire time? If a film
crew can be present while the patient is unconcious and the medical staff are
working why cant a spouse be present. My husband and I had a conversation while
watching a medical show coming from a large hospital. The patient had just had
surgery and the doctor was talking to her husband. The husband asked when he
could see her and the surgeon replied she has to be in recovery for another half hour
then to icu where she will be cleaned up then you can see her. This is rediculous.
When you wake up the first person you want to see is your partner and who cares if
you havent been cleaned up its your husband/partner. I understand you wouldnt
want 10 people in there as there are other patients but one person, your partner
should be allowed.
Thursday, August 30, 2007 3:52:00 PM

Anonymous said...
A couple of months back, I was
scheduled for a venogram involving
the pelvic area. My doctor's
explanation made it seem as if the
planned x-rays of my groin and
peri-anal area were going to be
quite immodest. I knew about
same-gender care requests, so
after contacting my doctor's
office to see if the hospital O.R. was under his staffing(it was hospital's choice), I
called the hospital's patient advocate and requested that the radiologist
and the tech who administers the
iodine-dye and the twilight calming drugs(I was to be lightly sedated) could be
males. I was
immediately told, "no problem". One of the two normal staff was a
female but they would be glad to
do a swap-out for my session. I set-up the procedure date and did my necessary pre-
op testing. A few days later I received a call from the patient advocate telling me
that due to a staff vacation day, they couldn't comply with my request. I said I
would reschedule if they would
tell me when they could comply.
They moved the event by two days
forcing me to redo my pre-op
blood tests, chest X-ray, EKG, etc., in order to have them within the seven day
window
required by my surgeon. I went in as re-scheduled and soon found
myself being wheeled into the
radiology room with the usual
female NP/tech in attendance.
My doctor was there so I didn't
want to make a scene or ask
what had happened to my request. My blood pressure, normally 115 to 120/80, was
now at 196! I was so anxious I started to hyper- ventilate and they quickly hit me
with the drugs. The next day, I called the patient advocate for an explanation. She
told me she only found out about the gender-staffing problem that morning. She let
me know she had in effect been lied to by the staff nurse in charge. There never
was another NP/Tech to cover for the woman's position in that procedure and the
nurses were scared that my request might lead the hospital to believe that they
needed to have split-gender staffing which would put the 80% female NP/Tech staff
at a disadvantage. Under BFOQ, they are suppose to be able to meet
request such as mine. To recap:
I gave them plenty of time, I changed the date and redid my
pre-op tests, and they lied right up to the moment of the procedure. They allowed
an obviously modest person to go into high-anxiety on a operating table. Finally, if I
hadn't
contacted them to demand an
explanation, they never would have
mentioned it, again. Next time,
I'll get my request documented in
writing from the patient advocate.
Men have to realize that they are
going to have to fight for these
rights. Female medical staff care
about their jobs first, patient
feelings second. They claim they
don't want professional discrimination but BFOQ has been
the law of the land since 1964.
This is not their choice to make.
Besides it is firmly enforced
against male nurses in OB/GYN
and no one ever questions the
rights of women patients to this
added comfort.
Thursday, August 30, 2007 7:02:00 PM

Maurice Bernstein, M.D. said...
Just to educate those visitors who don't know what BFOQ represents:
Bona Fide Occupational Qualification (BFOQ) is a legal exception to an otherwise
discriminatory hiring practice that is "reasonably necessary to the normal operation
of a particular business." The BFOQ may be requested if "the essence of the business
operation would be undermined if the business eliminated its discriminatory policy."
..Maurice.
Thursday, August 30, 2007 7:19:00 PM

Anonymous said...
I have posted my experience with a female tech and a skrotal ultra sound. I recently
called the patient advocate (female) and got little to no comfort, she basically
started the line "they are professionals, etc...the next time if it is really that
important to you, you should ask before, when I told her often the Dr's office
shedule these things not the patients, and told her the same nurses ASKED my wife
if she had a preference...she said well that is standard procedure.....(90% nurses
are female, 50% Dr's) .it is a female dominated industry and it is easier to identify
with your own gender....so sorry to hear of your experience, been there done that,
but I applaud you for standing up for yourself, if more of us do so...perhaps we can
spark the flame of change
Thursday, August 30, 2007 7:28:00 PM

js md said...
There are several issues to be kept in mind. A patient's modesty should always be
respected and one shouldn't have to request anything. By that I mean a patient
should always be kept draped as much as possible, unnecessary people shouldn't be
wandering in and out, etc. Specifying the gender of care providers though is a more
complicated matter. One has no legal right to specify gender, though most hospitals
will go out of their way to provide it if asked, especially if there is a religious
reason. Patients choose their own physicians, but can't generally choose ancillary
personnel. As you found out, specifying the gender of ancillary personnel is a
complicated matter for hospitals and they certainly don't encourage it. I agree that
offering gender choices should be recommended in situations where it is practical,
but it is frequently just not practical. BFOQ doesn't really apply in the case above.
The term refers to exceptions to the general rule under federal equal employment
laws that an employer can't discriminate due to race, religion and gender. The term
would apply only if this hospital refused to hire a male nurse or tech for the same
position claiming that it had to be a woman. Clearly this could not be claimed here.
BFOQ's have been held to apply for example to the use of same sex attendents in
locker rooms. That is they can refuse to hire a women to staff a men's locker room
and vice versa. BFOQs have rarely been upheld in medical cases. It was used to
prevent a male nurse's employment in one California's hospital obstetrics ward, but
this is not general law and jurisdictions in other states have ruled oppositely, ie
that the hospital could not refuse to hire a male OB nurse.
So BFOQ is not involved here and the hospital could have refused your request.
Having agreed to it though, they are bound to it and you could potentially sue them
for breach of contract. It would be appropriate to write a formal letter of complaint
to the hospital so the issue doesn't get forgotten or buried. If you write what you
wrote here I'm sure they will take notice. Most hospitals have a administrator who
handles complaints. If not send it to the CEO.
Thursday, August 30, 2007 7:57:00 PM

js md said...
Anonymous of August 30, 2007 7:28:00 PM, I fully agree with you. The hospital
doesn't have to offer gender preferences, but if they do, they can't do it just for
women. They probably do it because they can always accommodate women, but
frequently can't accommodate men, and women complain more than men. But their
practice is clearly discriminatory. I'd give you the same advice, your complaint to
the patient advocate was appropriate, but if she wasn't responsive, follow up with a
letter to the CEO using terms such as discrimination. Eventually they will have to
rethink their policy.
Thursday, August 30, 2007 8:29:00 PM

Anonymous said...
It makes my blood boil when I hear "we are prfessionals" or "its a nurse/doctor" I
dont care who it is. I would prefer no one see any part of my body but if it is
necessary I would prefer the same gender. I think generally medical people assume
men dont have any modesty issues and if they do its more hassell with more female
nurses than male. My husband is very modest and we have found a huge difference
in the way he is treated in a medical situation compared to me. We both deserve to
be treated with respect and dignity. We are modest people even in a medical
situation. We cant help feeling this way, if I could I would change it, i get so
anxious but I cant help it. I think much of this anxiety has come about because
doctors and nurses can tend to treat patients as "work" and not people. I know then
are busy etc but please take an extra few minutes and think about the fact that
some of us can be traumitised if not treated with respect in regards to modesty.
Thursday, August 30, 2007 8:50:00 PM

Maurice Bernstein, M.D. said...
I just wanted my visitors to this thread to know that I am trying to do my part in
attempting to impress the issue of the need to consider patient modesty into my
group of second year medical students. Today, the students of both genders in my
group were practicing performing pulmonary and cardio-vascular exams. I made up
scenarios that each student acted out as a patient. That student would be examined
by another student of the same or the opposite gender. But before we went through
with the exams, I pointed out all the considerations which were necessary for
protecting modesty in both genders of students but also patients. For example, for
the male students, the student playing "doctor" was to tell the "patient" that his
shirt needed to be removed for the exam but he was offered a cape to wear if he
desired. For the female "patient", after the "doctor" explained the need to expose
her chest (the student still gets to keep on a sports bra)she was given a gown to use
on removing her blouse.
Both were given the option to "undress" behind a screen we had in the room. No
student did. Both men in my group didn't want to wear a gown but one later in
exam felt chilly and a gown was put on. The reason I am detailing this exercise is to
demonstrate that as teachers, we are not just relying on words to express the need
for patient modesty but we are following up with observation that the students are
practicing our words. The same goes for patients on the hospital wards where we
monitor the student's behavior in this regard. I know the other physician facilitators
in our school similarly teach modesty. In fact, attention to patient modesty along
with comfort is one of the initial requirements on the school's physical exam
checklist. ..Maurice.
Thursday, August 30, 2007 9:17:00 PM

Anonymous said...
I can’t agree with js md’s statement that “one has no legal right to specify the
gender” of their healthcare providers. The medical profession is not the authority
that decides what rights their patients have, and the courts have consistently upheld
the right of people to exercise controls over their own bodies, even in medical
situations. People may give up their rights when they sign admission papers, but if
they either don’t sign the papers, or modify them before signing (by making it clear
that gender of providers is part of the essence of the agreement), their rights are
likely still intact.

There are valid moral, ethical or religious reasons for people to have gender
preferences, and the courts are very likely to uphold these rights. In any case, the
patient certainly has the right to choose whether to proceed with the procedure,
and some people would make the choice not to proceed.
Friday, August 31, 2007 8:10:00 AM

Anonymous said...
I think the issue of legal becomes sort of a mute point to some degree in a lot of
cases. I think the court would uphold the medical community most of the time in
that as you said we have the option to sign or not sigh the consent, 1st if we don't
sign the consent I would think they would likely choose not to go ahead, the same
with the modification, they would likely not proceed. On the other hand if you did
note and they proceeded and went against your directive you would have a case to
move on. I think the action becomes more if they won't accomidate you have the
option to go elsewhere, and if they say they will accomodate as above and then
don't, I would think you might have a case for breech of contract. I feel the best
action it so request upfront and if you are not happy with what they offer, take your
business somewhere they will and let the other people know, why you did. Medicine
is becoming much more of a business than it used to be, hospitals are going after
business, advertising rather than waiting for it to come to them. We can't make
them accomidate us, but we can go elsewhere.

That said, it would be so easy in most cases for the providers to address this. A
simple querry on intake on the intake sheet something like "do you have any special
concerns regarding your modesty or privacy" or on a specific procedure they could
simply ask "do you have a gender preference for provider". For those who say no
they could do random, for those that do they could schedule around them, they
could preface it with "we will do our best to accomidate your wish but due to
staffing and scheduling restrictions may not be able to, would you be willing to
accept substitute etc....All they have to do is ask, they don't have to committ 100%,
but at least they could ask and then they would know who cares and who doesn't....I
don't think that is asking to much.

Me personally, and this is just me, I don't like being exposed to the opposite gender
period, but I can accept it if I feel it is nesecary and a reasonable effort was made.
As I said I have had several surgeries and I never asked or expected to have an all
male team, I thought that would be requesting to much, fortunately I was put out
before any exposure and it didn't bother me that much. In the other hand the
imaging issue where a male was obviously available and they assigned a female
anyway...that really upset me. To me it said, it isn't worth the effort to schedule or
even ask.

That said, I wonder what efforts are being made in the other area's of the medical
field. Most of the issue I have had have been support people, imaging tech's, nurses,
etc. We tend to throw all the medical people in one hopper. Does anyone know are
they doing anything different in the other area's of nursing and tech training?

Last thing Dr. B I used to go to the Naked Blog, but there wasn't anything going on
it for awhile, now I can't find it.....is it still active, I am going to send the
addresses to a couple of my providers and suggest they read them.
Friday, August 31, 2007 2:03:00 PM

Anonymous said...
If doctors can be properly trained on "patients" wearing sports bras, why can't actual
patients be examined wearing sports bras?
Friday, August 31, 2007 2:28:00 PM

Anonymous said...
I agree with the last post. I think its time patients change thier way of thinking.
We are the client we are paying for a service and it is our body and we are in
control. We say who, what, when etc. Patients need to not feel intimidated or
pressured into something they dont want or by someone they dont want. If you ask
for same gender this should be accomodated where practicable and not just for
religious reasons. If you are a male patient and need to be exposed for
catheterisation for example and there is only one male nurse or onemale doctor
everyone should clear the room while the procedure is done, cover the patient and
everyone return if it is important to the patient. Yes I know it would slow things
down and the medical staff are busy but it is the patients right to have whom they
wish present and not 15 people watching.
Friday, August 31, 2007 3:40:00 PM

js md said...
Anonymous, August 31, 2007 8:10:00 AM, we have touched on this subject before.
Expressing a gender preference is not a legal right in this country or any other
western one that I know of. It is not a medical question, it is a legal question. I
know of no state where this is a law and federal laws make it difficult. If you can
find anywhere a law that permits patients to specify the gender of their healthcare
providers please let me know. Federal equal employment laws say an employer can't
discriminate based on gender. They don't say a patient can't, but they also don't
grant you the right. So hospitals have to pick a middle ground between patient
preferences and employee rights. They cannot layoff a man because some women
are uncomfortable and vice versa. You're right, that people have control over their
own body, but that right doesn't ordinarily extend to specifying the gender of
personnel that will take care of them. You of course can always refuse treatment.
And in practice all hospitals allow patients to give preferences, they just can't
always accommodate them.
I'm not opposed to your point of view (really!) but I also recognize that for hospitals
to function they need to be practical. They very simply cannot afford to have
personnel of both genders always available for every task.
As 90% of health care workers are female there are far fewer men available to
accommodate men who don't want to be taken care of by women. If that's your
need, you have to state it loudly and frequently and be willing to compromise. The
large majority of patients, both men and women, whether or not they might have a
preference, don't make an issue out of it.
Friday, August 31, 2007 3:45:00 PM

Maurice Bernstein, M.D. said...
The thread "Naked" is still available. Here is the link:
http://bioethicsdiscussion.blogspot.com/2005/08/naked.html#comments.

With regard to:
"If doctors can be properly trained on 'patients' wearing sports bras, why can't actual
patients be examined wearing sports bras?"

Gee, I kind of anticipated that this question was going to come but isn't the answer
obvious? Maybe to many it isn't!
Doctors are NOT fully trained by this exercise of examining their medical student
colleagues who are wearing sports bras. The reason we don't have the female
students examined with a bare chest is simply because medical students just as
many of those writing to this thread have degrees of modesty. They are being
examined, not by some unknown professional physician, but by their own fellow
students who have known them and interacted with them as classmate colleagues
and not necessarily in any more intimate way. It is a sufficient emotional and
intellectual challenge for students who are just beginning to learn to examine the
body of a human in the correct and effective professional manner, an activity they
have never experienced previously, to be able to examine closely the chest of a
female student without the concerns and emotional reaction of examining a fellow
student's bare breasts. For the school to insist arbitrarily to have the students be
examined without bras is unnecessary since the students will have ample
opportunity to examine female breasts of "teacher patients" and regular patients
under supervision.
Every student doing the exams on each other are fully aware that their exams on
the female students wearing bras is a limited exam. But what we don't limit during
this teaching exercise is the repeated instructions about how the exam should be
done on a real patient and still be comfortable and preserve as much modesty for
the patient as practical.

The practical aspects of physical examination of a woman's anterior chest is that of
unimpaired inspection of the skin and contour of skin and the unimpaired ability to
palpate and percuss and to auscultate the chest. Sports bras, bras and other
coverings of the female chest clearly impair and limit full examination and
examination through them is discouraged. We have found, and we teach, that
modesty can be maintained but mitigated by incorporating the patient, herself, as
a partner or helper in the examination. That is, for examples, uncovering the chest
should be done by the patient and that inspection and examination in areas under a
breast is best done if the patient helps and manually elevates the breast. We feel
that if the patient becomes an active participant in the process of all phases of a
physical examination, there will be less concern and negative feelings about the
motivations of the examining physician.

I hope this perhaps lengthy dissertation answers the question. ..Maurice.
Friday, August 31, 2007 4:29:00 PM

Anonymous said...
js,md's statement that "one has no legal right to specify the
gender"(in pelvic care) is wrong
and his understanding of BFOQ is flawed. Being he is a doctor, I
would have hoped for a more credible response. He does agree
that offering same-gender care to
females without extending the same
consideration to males is discrimination but like the medical profession in general
he
then choses to look the other way.
I doubt he can easily find a non-emergency setting where females in OB/GYN (or
having breast, pelvic,or rectal exams)are not
offered the option of same-gender
care. Most times their preference
has already been anticipated.
Medical facilities don't want to
worry about needing chaperones to watch male nurses and techs. But the main
reason woman get what they prefer is because they DEMAND it. Men who asked for
this patient courtesy are seen as troublemakers in a world dominated by female
support staffs. They are pressured and discriminated against because it is the
easiest solution to the
gender-staffing problem. Which brings us to the BFOQ and why it most certainly
pertains here.
Dr. js says the BFOQ only allows for discrimination in hiring to meet staffing needs.
This is off the point. A bona fide occupational qualification allows for the hiring of
say a male actor over a female performer with discrimination. Here the reason is
the simple gender representation involved. The employee's sex is the primary
concern. This is not the primary concern in intimate care situations. What allows
for a BFOQ here is the issue of PRIVACY.
Privacy BFOQs are different. They allow institutions to discriminate in gender hiring
in order to fulfill the modesty needs of PATIENTS, not the staffing needs of the
medical facility. These are always patient-generated requests. The tail of
accomodation is not wagging the dog here. This is why the Privacy BFOQ had to be
written into the Anti-Discrimination Act of 1964 to allow it to pass through
Congress.
People have a RIGHT to discriminate against gender in matters of modesty and
privacy.
Pelvic care has long been the general area deemed covered by
such requests. This right has
priority over all employment rights. That's the law. To date,
I believe twenty-four states have had challenges to the Privacy BFOQ, many of these
were generated
by male nurses refused employment in female intimate care areas.
All rulings supported patient
modesty rights under the BFOQ.
The U.S. Supreme Court has refused
to review any appeals. Furthermore, several key judgements went as far as to state
that hospitals, nursing homes, and medical testing facilities must retain necessary
gender staff in overtime to comply with patient requests. I've known a few hospitals
that advertised gender-sensitive care. Most avoid the issue as it always brings the
nursing/tech staffs into conflict with the administration. So why are medical
institutions able to continue discriminating against male patient privacy needs. It's
very simple. Men have not generated enough legal actions to have the law of the
land enforced. Nursing association editorials are constantly attacking gender-
sensitive care as and insult to their professionalism. The real issue is that half the
world is male and 75+ percent of the nursing/tech population is female.
This is what really needs to change. If men continue to speak up things will change
slowly until
a day comes when privacy requests are no longer met with raised eyebrows by the
female medical establishment seeking to protect
their power and their jobs.
Friday, August 31, 2007 7:04:00 PM

Anonymous said...
js md, thanks for your response. I know that you posed a legal question rather than
a medical one, and my point was simply that patients have a right to make the
gender of their providers an issue if it is important to them. Like other rights, it is
not spelled out specifically and explicitly in a single law, but it is clear to me that
there are many legal precedents involving medical situations that do support a
patient’s right to express a gender preference in their agreement with the hospital.
The fact that few patients ever modify the standard admission agreement does not
mean that no patients have that right. Hospitals have a right to decline the request
if it is really too difficult for them, then the patient can seek another hospital if it
is important enough to them.
I suspect that we actually may not disagree, but are simply looking at question from
slightly different angles.
Friday, August 31, 2007 7:19:00 PM

Anonymous said...
"If you can find anywhere a law that permits patients to specify the gender of their
healthcare providers please let me know."

If you touch a person and do not have that person's consent to do so, it is assault. If
you cause another person to be exposed in such a way that the person did not
consent to, that is likewise a form of assault.
Friday, August 31, 2007 7:33:00 PM

Maurice Bernstein, M.D. said...
Here is a moderator's comment from the moderator. There appears to be a very
interesting discussion currently with a number of participants but they are all
identified as "Anonymous", though their views are slightly to somewhat different
from each other.
Would it be possible for each writer, if they don't want to sign in with a name,at
least end the commentary with the same pseudonym (a false name or even some
letters),so all of us will know which Anonymous is which? Please! ..Maurice.
Friday, August 31, 2007 7:50:00 PM

Anonymous said...
Dr. Maurice: I once had a medical plan that allowed me a choice of seven urologists.
Six of them employed female sonographers for scrotal ultrasound procedures. The
sole doctor with the male tech was always three times harder to book an
appointment with. Perhaps his fellow urologists saw more female patients or they
didn't want to deal with the need for an extra
staff person to act as a chaperone. It would be cheaper to inform male patients they
had no choice and ask them to suffer through any embarassment. Afterall, their
female ultrasound tech was a "professional" (who had a right to be insulted by such
same sex requests). This is the kind of thinking I've found throughout the medical
services world.
The first time I had a scrotal
ultrasound, I never thought about the gender of the sonographer and was actually
shocked when I was introduced to a woman. I had elected to go to a male doctor.
I assumed this obvious choice would follow through technical care. Live and learn.
Her ultrasound room was a small suite off the inner-office corridor. A half-dozen
female administrative staff wandered along it, continuously. I asked the lady tech to
please close the door or screen the examining table as we
were in clear view of the door.
She said she couldn't without another female staff member present. In other words,
if I
wanted any privacy, I would have to tolerate a double assault on my modesty! Even
a woman who finds herself with a male sonographer always gets a female
(same gender) chaperone. Who came up with these rules and why do they think
they're even remotely fair? It's time men started raising their voices.
Very loud, guys!
Friday, August 31, 2007 9:12:00 PM

Maurice Bernstein, M.D. said...
I have a suggestion: this blog is not the place to raise your voices to the
gender/modesty issue. Nothing is going to change by speaking up here. What all
those who want a change in the system need to do is to speak together and loudly
(if in the United States) to the American Urologic Society and all the other
speciality societies and the American Medical Association-- those institutions that
set the practice guidelines and standards for the practice of medicine in the United
States. It is very likely that those institutions have things on their mind other than
the modesty issues discussed here. So you have to wake them up! But I think to
shout about this here or on Voy will not get the changes that you want. Do it! I
await reading in the medical journals more about patient modesty and about the
ground swell of pressure by the people which has begun to affect a change. Good
luck! ..Maurice.
Friday, August 31, 2007 9:50:00 PM

Anonymous said...
Dr. Bernstein --
Are you missing the point of your own PATIENT MODESTY Blog??? You ARE the grass
roots ground swell.
When hundreds of people on the net begin to see how they are all feeling the same
then the organized response has the muscle to begin its move against the standards
of medical institutions.
This IS the place to raise voices.
Encourage your readers to stand-up, rant here, and then go out among their peers
and yell,
"I'm mad as hell and I'm not going
to take it anymore!" Peace.
Friday, August 31, 2007 10:03:00 PM

Anonymous said...
Dr. M Would you have the address or contact information for these institutions. I
have started sending correspondence locally to Dr's, Hospitals, etc and included
these web sites. But nothing above the local level. JD
Saturday, September 01, 2007 6:25:00 AM

Maurice Bernstein, M.D. said...
If you go to this link you will find listed links to websites of hundreds of medical
professional associations and healthcare organizations. You should be able to get
contact information from the individual organization's website. I hope this helps.
..Maurice.
Saturday, September 01, 2007 6:49:00 AM

js md said...
Anonymous of Friday, August 31, 2007 9:12:00 PM, your story is outrageous by any
standards. Nowhere is it considered proper to have a patient exposed to passersby
in the hall. No laws or regulations require there to be a chaperone present either.
That had to be a rule of this particular practice. You were right to protest. I would
have gone further. I would have gotten up and left and complained loudly to the
doctor. You could even protest to the appropriate state board that takes complaints
against physicians. That would really get their attention. That's how I'd suggest
dealing with the matter. I know of no national agencies that deal with such
matters.
I know of many circumstances where male ultrasound techs do studies on women
without chaperones present by the way. But if you're talking about vaginal
ultrasound, not even a physician would do it without a chaperone present. But of
course the chaperone would always be a woman. Most women physicians and techs
don't use chaperones when examining men as they are at low risk of being accused
of misconduct. When they do though, you are right that it's almost always a woman
and the exposure is doubled. I would not permit it if I was the patient, not because
I have major modesty concerns, but I find it a violation of my privacy that is totally
unnecessary.

In reference to the prior discussion about male ob nurses, I'd be interested in any
review articles on the subject that anyone has. But I will tell you that although male
ob nurses are not common, they are not rare either. There is lots of discussion in
the nursing literature about it, most of it quite supportive. I have seen decisions in
West Virginia and Florida that uphold their employment and voided a hospital's
refusal to hire them. Remember that contrary decisions apply only to individual
hospitals and don't set state law. I'll bet that there are hospitals in California for
example that do use male Ob nurses. Most hospitals won't fight it, and plenty of
studies support their use and acceptance by ob patients, though there are
conflicting studies. Times are changing, though slowly in some areas.
Saturday, September 01, 2007 7:22:00 AM

Anonymous said...
If it is not considered proper why do doors get left open that expose patients? This
has happened to me also. The birthing room door was left open during the birth of
my child. Tp add insult to injury the business end of the birthing table was aimed at
the door. Even more alarming is that I know several people that have had similar
incidents.

Modesty is an issue. It is an issue that has been lost in the craziness of today's
world. Some may consider my preference for modesty to be an infringement on
THEIR rights, but when it is my body, MY rights take precedence.

Jade
Saturday, September 01, 2007 7:51:00 PM

Maurice Bernstein, M.D. said...
Jade, you are perfectly correct when you say "Some may consider my preference for
modesty to be an infringement on THEIR rights, but when it is my body, MY rights
take precedence." Others have NO rights to or with your body except those for
which you give specific permission as informed consent. Your informed consent to
their request has nothing to do with their rights. The job of the caregivers is to
serve the patient. If the caregivers find diminution of their rights, they can opt out
but first, to avoid abandonment, find another caregiver resource for the patient.
..Maurice.
Saturday, September 01, 2007 10:02:00 PM

js md said...
Jade, the situation you described is likely not too uncommon. Possibly the hospital
feels it needs to keep doors open so that they can more easily monitor the patient's
progress in delivery as they don't have the personnel to stay in every room. So it is
likely a safety issue with them (unlike the urology ultrasound example above where
no safety issue could possibly be involved). That doesn't make it right, but it may be
a response to a real problem. Did you ask them to close the door when you were in
labor? They might well have done it.
Once again you need to make your feelings known to the hospital. My hospital asks
patients to fill out a discharge questionnaire which does include questions as to
whether your modesty was respected. It’s important that they get feedback on what
actually concerns patients.
Sunday, September 02, 2007 7:39:00 AM

Maurice Bernstein, M.D. said...
OK.. here is an example of what I have to do to serve my responsibility as
moderator of this Bioethics DISCUSSION Blog:
Today I received a posting comment from Anonymous with no further identification
which was composed only of 5 words: "Rationalize and blame the patient!"

To me, regardless of the moral validity of the statement it is totally unsatisfactory
to be formally posted on a DISCUSSION blog since it appears as something someone
would carry holding a poster in an activist demonstration but itself demonstrates no
response to a previous commentary and does nothing to further the discussion. This
is particularly true since there is no name identification with a previous comment
to which we can attribute the message as a followup to one that the writer has
previously posted.

Obviously, on an unmoderated blog and without identification of the writer's true
name, the writer can express anything the writer wants. On a moderated blog like
this one, the moderator insists on postings that are civil, contain no ad hominem
attributions and provide a basis for further discussion with facts and rationales. I
again request writers to identify themselves with some consistent pseudonym on
each of their postings. Thanks. ..Maurice.
Sunday, September 02, 2007 1:00:00 PM

Maurice Bernstein, M.D. said...
May I switch the direction of the thread a bit here with another question? Do you
think or know that those who express concern about the inadequacies of attention
to their own patient modesty have any feelings or attitudes about those folks whose
modesty concerns may be substantially reduced both in the medical situation but
also with regard to their ease in breast feeding in public and nudity in clothes
optional beaches and so forth? In other words, how do those who write here about
their modesty experiences in medical care feel about those whose modesty appears
to be minimal or apparently nil but still behave within the legal boundaries.
..Maurice.
Sunday, September 02, 2007 3:46:00 PM

Anonymous said...
Everyone, TIME OUT!!!
Dr. Bernsteins, let's not switch
direct of the thread. When you
start getting rude, five word,
entries(which you should not post),
it simply means there is heat in the furnace. The last dozen or so entries have been
intense and
for the most part more constructive than this blog has
been for quite awhile. The reason for this is you've finally got a
good focus point. That's naturally
going to create tension. It will
get a lot of juice flowing and
(unfortunately) it's going to
push some of your more angry readers over the edge. As moderator, you need to
keep them
from posting (if you deem their entries are thoughless and uncivil).
Now, back to the job at hand.
Patient modesty has been more or
less the topic of your 360+
postings to this site. What we
need to push for, besides contacting outside medical gatekeepers to facilitate
change,
is a clearer understanding of
what is more than an isolated
situation that needs to be met
with more aggressive response.
(i.e. -- Shut the door, Goddamit!) Where are the real systematic
flaws in this system regarding
modesty and who is really being
left out in the factoring of what effects this. The last group of
blog postings are pointing to men
who are modesty as being the clear
victim of discrimination that
doesn't seem to be fixable within
the current medical staffing situations. Women readers can
relate and help with postings by making suggestions as to how men
who are modest can be helped, a
point-of-view that most of the
female medical staffing is short
in considering. Therefore, I
propose two types of posting that
would be most welcome at the
moment -- (1) tales of infringement on modesty (2) reaction on how each situation
should have/or could have been
addressed by the patient, and
suggestions as to how medical
staff needs to deal with these
requests beyond saying, "We're
all professionals, here." My
own point of view is that everyone
has a right to the level of modesty they require in regularly
scheduled medical procedures and
limitations on options need to be
presented to them in advance by
staff anticipating these needs.
Women have a right to breast-feed,
beaches can have nudity if a community agrees by vote, women can
have all-female medical attention.
I see no problem with letting each
individual make their own decision
as long as the option exist equally for all to chose their preference. The only clear-
cut
area of medical modesty that does
not appear repairable with a little courtesy is the same-gender
care issue for modest men. This
is simply being pushed aside and denied to uphold the less important
demands of others. STAY WITH THIS
TOPIC. Let's give men some guidelines on what they need to do,
what resistence they can expect,
and how they follow-up with personal action that will result in change, not only at
their next appointment, but with the whole
medical staff community as well.
Peace.
Sunday, September 02, 2007 7:27:00 PM

Anonymous said...
I was angered to read the post of
31 August, 9:12 PM, regarding an
ultrasound exam. This is a clear
example of how staff at a medical office have decided to run things
to their liking over any consideration for the patient's feelings. There's far too much
of
this going on, especially as regards male patients.

Earlier this year I had a situation occur that I never would have believed possible.
This was right here in your great city of Los Angeles, Dr. Bernstein.

I went to see a surgeon about a
medical situation that regarded
my butt and was shocked when he
opens the room with his female assistant and announces my condition, "You have
_____ in
your _____ !!! Behind him, I could
see heads turning among the office
staff and patients at the counter just beyond. The two of them then stepped into
the room and closed the door. A second later he is turning me around and pulls
down the undershorts I have under my gown to view the condition.
"Look!" he exclaims to her, "He has
___in his ___!" As she comes over to have a good look for herself, doctor turns to
me marveling and asks if I know how rare this condition is. I feel like the elephant
man as he has me lie on the table to continue the exam
in front of his assistant.
This is all happening so fast that
I haven't even been introduced to
this young woman.
I know I'm feeling very embarrassed
by his actions in front of her but
I've never been this deep into the medical world and I have no idea
what to expect. So I assume this
must be the way the exam works.
Asking to be examined in private is water way under the bridge by now.

Well, a few days later I called in
to this doctor's office to check
details of an anticipated next
procedure. The doctor wasn't in
so I asked to speak to his nurse.
"His nurse? There's no nurse, here?", was the response.
"Well who was with me during the
exam," I asked. "Oh, that was Marcy(name changed), the surgical coordinator."
Well, this was a surprised. I wasn't schedule for any surgery and none was
anticipated. Again, I figured this must be the way exams worked.
I would have hoped Doctor's assistant was at least an RN or NP needed for some
reason in the exam but what did I know.

A week later I was back in for
another post test exam. Once
again doctor comes in with his
surgical coordinator. She stands
at the foot of the exam table
holding a clip board, serving no
purpose I can see while he starts
to exam me. Again, I'm not introduced to her or given any reason for her presence.
At one
point he asks me to turn over, "I need to check for hemmoroids." This was just too
much so I got
offthe table, faced away from her,
and leaned forward, indicating he
would have to get down and behind me for that view. He looked at me puzzled for a
moment and then complied. I don't think he understood how embarassed I was
feeling as she stood their with a clipboard across her chest like a
voyeur.

On my next call into the office,
I once again found myself needing to talk to this young women as
doctor was not in. "Marcy the
surgical coordinator," the receptionist asked, puzzled.
"You must mean Cathy(name changed). She's the surgical coordinator." "Then who's
Marcy?", I inquired. "Oh, she's the office manager. She was just covering for Cathy
when Cathy went on leave. Cathy's back, now."
Well, I was shocked. Initimate exams twice in front of the
office manager for the administrative convenience of this doctor. I wrote my
medical plan.
I didn't go back after that but I
know he now makes rounds with an
NP,when needed,or no one at all.

Yes, you will be humiliated and
compromised... but you can fight
back for change. Do it! Then
change doctors. F.A.
Sunday, September 02, 2007 8:31:00 PM

Maurice Bernstein, M.D. said...
I was not implying that issues of patient modesty not be continued here..of course
they should, including the role of gender, but what I thought would be appropriate
would be to also include views of those with modesty issues about how they accept
or react to those folks who don't seem to have the same modesty concerns.
TIME IN!

F.A.'s experience is disgraceful. F.A. I support your action to leave that doctor. The
physician by accepting you as a patiet and vice-versa has established already a
doctor-patient relationship. You should expect no one else to invade that
relationship unless they are fully and truthfully identified, their role is fully
explained and YOU approve. PERIOD! ..Maurice.
Sunday, September 02, 2007 9:20:00 PM

js md said...
There are multiple issues we could talk about:
What percentage of patients have great concern about their modesty vs. having
little concern? Is this a major problem in medicine or a minor one? I really don’t
know the answer. Based on the interest this and similar blogs arouse, it seems like
a major concern, though I don’t think you would get that impression if you worked
in a hospital. Patient safety, health outcomes, and costs are much larger concerns,
as they need to be.

What are the guidelines for respecting modesty? Offhand they would include keeping
patients covered at all times whenever possible and avoiding unnecessary exposure.
This would include not permitting unnecessary people in the room. People involved
should be professional, that is medically trained. It is not appropriate to use
secretaries as chaperones for instance, though it is probably common in some
practices. I do believe that men are afforded less modesty and choices than women.
There is an historical basis for it, but is it still justified in our present society? I
don’t think so. Modest men should be accommodated to the same extent that
women are.

What can patients do about it? That’s the easiest to answer. Make your concerns
known. The sooner the better, preferably while the exposure is occurring. Complain
to the physician, the hospital administration, or regulatory agencies if you deem it
warranted. It does not take many complaints to effect changes in practices. That
does not mean that every concern is justifiable or avoidable. If you’re having
surgery and general anesthesia, the staff is very likely to see you naked. I do not
recommend asking for all male or female OR staff. You will increase the risk if you
force the OR to change their ordinary routine.

Lastly, medicine is different from the other situations Dr. B referred to. Breast
feeding in public (which doesn’t bother me) or clothing optional beaches are all
voluntary and people retain their full free will. Medical exposure is involuntary and
causes a much higher degree of anxiety. Public nudity is strictly regulated in this
country and is easy to avoid if one is offended.
Monday, September 03, 2007 6:44:00 AM

Anonymous said...
I consider myself a modest person, I have a lot of anxiety over these situations. But
I really don't care about what others practice as long as they are comfortable. If a
female feels comfortable breast feeding in public, if someone feels comfortable on a
nude beach, more power to them, its a matter or choice, and that is what is not
being afforded in the medical arena. While I think the above it absoutley true and
valuable, something Dr, Berstien has brought up something that may be of value,
not only what do we thing of those who appear to deal with it easily, can they help
us in dealing with it when we have to face it jd
Monday, September 03, 2007 4:35:00 PM

Anonymous said...
In response to js md comment re patient safety, health outcomes and cost are more
important than modesty issues, I disagree. It may seem like a trivial issue to some
but for many the anxiety felt by their modesty issues could well effect thier health
outcome anyway. And as for cost I pay my taxes and for my healthcare and so feel
intitled to have some say in my healthcare. The other comment which I dont agree
with is that the patient should speak up while the exposure is occuring. How about
recomending the patient protest before. If the doctor says they are going to invite
someone else in to the examination, say no there and then before it goes any
further. Dont feel like you are going to be unliked or feel embarassed that you have
said no this is your right. Demand the medical proffession respect your views to
modesty, you are paying for a service on your body. You are in control as the owner
of your body. Im not suggesting you treat the medical proffession rudely but if they
are willing to not treat you as a person with feelings then you have the right to say
so. Most doctors Im sure do the best job possible and help save and prolong lives
everyday but each patient is different and thier views on different subjects such as
modesty are different too. As i've said before males and females deserve to be
treated the same in respect to modesty. Talk to your patient and work out what
they need to feel safe/secure and the best health outcome will occur.
Communication is key. I use to think I was going crazy having modesty issues in a
medical setting. Always being told doctor knows best and that the medical
proffession see naked bodies every day. Ive come to realise they may see naked
bodies every day, but they havent seen mine and this attitude doesnt make me feel
any less anxious. I've also come to realise I'm not the only one with modesty issues!
Renee
Monday, September 03, 2007 6:40:00 PM

Anonymous said...
I am from Australia. In this country we dont have physical examinations yearly
unless there is something wrong. What worries me is that in America from what I
understand children are expected to undergo physicals in order to participate in
school sports or to go to camp. What purpose does this serve besides scaring a child
for life. Surely parents are aware if thier child is not well enough to participate in
sports or go on camp. Surely this practice impacts on a childs modesty and they are
looking to the adults to protect them. I would never subject any of my three
children to this unless I had a concern. One more thing why do the boys have to
show thier genitals but the females dont. Is it a case that is you have a pimple on
your penis you cant participate. Im sure any child would seek help if there were a
problem as would an adult. Surely Everyone is able to check thier own naked bodies
for anything not quite right and conduct thier own breast or testical examination. If
you find anything then seek help.
Monday, September 03, 2007 8:12:00 PM

js md said...
I'm sure that Dr B is more qualified to respond to Australia than I am. I think the
utility of annual routine physicals in adults has been questioned and could be
discussed. If a child sees their pediatrician regularly and is up to date on
vaccinations I doubt that a separate sports or camp physical is needed. Indeed my
guess is that the pediatrician often just fills out the forms without doing much new.
But I certainly don't agree that a parent would necessarily be aware if their child is
not well. Conditions that would put one at risk for sports are often not
symptomatic. And boys would often not be aware that they had an undescended
testicle, a testicular mass or hernia and they might well be too embarrassed to
mention it to their parents. If all is well though on a genital exam I don't think it
necessarily needs to be done yearly especially if the child is old enough to self
examine and is instructed in how to do it. A routine male genital exam takes only
30 to 120 seconds to do in any event. Girls just don't need regular genital exams
until they are sexually active plus the exams are much more intrusive and
prolonged. An external inspection would be common though. No properly done
physical should scar anyone for life.
Tuesday, September 04, 2007 4:01:00 PM

Anonymous said...
I disagree that a physical exam wont affect anyone. My husband was examined a
few months ago as he had a lump on his testicle. No sheet was offered so his whole
groin was exposed not just the area in question. We both still feel terrible about
this and feel as if he was violated. I know this sounds pathetic but we cant help it.

As for needing to check for a hernia or undecended testicle of a child in order to
participate in school activities how does an undecended testicle prevent a child
from doig this. In Aust. Boys are checked for this at birth and at their 6 week
check. Its up to parents to decide about their childs healthcare not be dictated to by
schools. Children deserve to have modesty protected just like adults. As for reading
about group physicals and those done where other students and teachers can see is
borderline child abuse.
Tuesday, September 04, 2007 8:41:00 PM

Anonymous said...
I don't think annual physicals are bad in themselves, many times we don't recognize
or admit we have problems. Catching issues early has a lot of benefits. We had a 11
year old discover early stage cancer from a sports physical from conversation with
the doctor. In itself conducted correctly it can not only find issues, but establish
comfort for a young person in having an exam. doing it where modesty is not
respected and the child embaressed and teh modesty ignored or not respecte, it can
cause the exact opposite. It can casue a young person to dread and avoid medical
attention. Mass physicals or exposure to the opposite gender at during these years is
at best insensitive, or as the above post puts it abuse, if we intentionally expose
these kids to strangers it could be considered abuse, put them in a gym and its OK?
Having proper physicals with respect for the kids feelings could be a very positive
thing, its all about putting how they are feeling 1st jd
Wednesday, September 05, 2007 5:39:00 PM

js md said...
I'm not sure how we got on the subject of group physicals in the last two posts. They
are a different topic, an ordeal that only men and boys have routinely been
subjected to, though girls have occasionally had group physicals, usually with much
greater respect for their privacy. Group physicals have always been used for military
inductions, all involving a large degree of exposure to other inductees and
examiners. In some centers exposure occurred in front of women as well, some of
whom may have been there for purely administrative purposes. I doubt that these
kinds of physicals are still practiced widely in today’s all volunteer army, but I have
no current info. Otherwise group physicals are generally restricted to sports, usually
on a college or high school level. Few schools do them otherwise preferring kids to
go to their own doctors which costs the school nothing. These physicals can be
conducted with substantial privacy with guys in shorts except for brief genital
exams which can be done behind privacy screens. Though I'm sure practices vary
widely, I fear they are often done with little or no privacy. Big time college sports
may be the worst offenders in term of lack of privacy. It's hard to gather info on this
topic.
I'm sure no humiliating exams would occur on a high school level if parents and
athletes complained, but they're frequently afraid to if their kid is trying out for a
team. On a college level, big money and scholarships are at stake which athletes
don't want to jeopardize.
But I think the average student can easily avoid any group physicals. I agree that
they can be humiliating by today’s standards. It wasn't as bad 50 years ago when
this treatment was more or less expected.
Wednesday, September 05, 2007 9:01:00 PM

Anonymous said...
I agree with your post js md, I used that example as an extreme that has been
reported. My point, and probably more to the point would be annual physicals, I
have one every two years for my CDL, while I now have a desk job the 2 yr
requirement forces me to have one. My personal Dr is very good about respecting
patient modesty, he even "slides" through a door in one of the exam rooms that
faces his receptionist station. Did my vasectomy by himself etc....if we would talk
to the kids, find out what is comfortable for them, would the prefer the same
gender Dr., do they care if a nurse is present, do they mind if a parent is present,
does it matter which parent....etc. if we would take a little, and come on it is a
little effort to ask, we could make it as unstressful as possible and make not only
that proceedure, but set the stage for them to be comfortable. What we do now is
we haul them in to the doctor we choose or use without asking, opposite gender
parents stay in the room, we don't think twice about having a nurse present, after
all they are just kids....if we respected them, focused on what they are feeling it
should not be that bad and could be positive. It really should be something they can
use to monitor their health for life...not sure if they need it every year at a young
age, but it should not hurt them
Thursday, September 06, 2007 5:07:00 AM

gve said...
Some hospitals greatly resent patients asking questions about how their modesty
was protected while in the OR. I have had to make a formal complaint in order to
be taken seriously. All I really wanted was honest (but specific) answers to how I
was treated while in the OR. I want to know was i totally naked and who was in
attendance at my procedure. Each time I ask, I am told "usually" such and such
happens or "probably", nobody will ever be sepcific. It is almost as though they are
protecting national security! I have been told I am suffering a form of PTSD as a
result of my procedure, this is being exacerbated by being ignored in my quest for
information.
Friday, September 07, 2007 4:18:00 AM

Anonymous said...
If a patient wants info they are intitled to that info if it is about them. Surely there
are records stating who was in the room at the time and what their job was. Keep
fighting for the information and goodluck. Sometimes information about what has
happened to us when we were not concious is needed so we can work through our
feelings. When I had my first child I felt quite vague from the drugs given and for
the next few days would ask my husband "what happened next" or "when did such
and such enter the room". My advice for the previous person who contributed to the
blog re who was present in the OR assuming it wasnt an emergency, ask questions
as many as you need before the procedure and if you get the feeling they think your
nothing but a pain or that they dont want to help, they probably are not very
compassionate and you probably dont want to trust them that they will cover your
naked body, go to another hospital.
Friday, September 07, 2007 9:31:00 PM

js md said...
I don't really know what kind of OR records most hospitals keep, but I'd be surprised
if they are as detailed if you seem to think. The surgeon, head nurse,
anesthesiologist/anesthetist would certainly be listed. Assisting surgeons and other
nurses will probably be listed. I'd be surprised if other techs, especially personnel
that come in and out as needed would be listed.
Specific requests for that info must be exceedingly rare.
Saturday, September 08, 2007 8:13:00 AM

gve said...
So if I were to be threatening to sue the hospital for some reason about what went
on in the OR, how are they able to bring all manner of people "out of the woodwork"
in their defence?

In any case, all I wanted was some information about roughly how many people were
there (were there any students of any description) and any non essential staff.

I also wanted (and 12 weeks later still do want) to know if I was completely naked
at any time and if so who was present then.

Most medical people probably think my concerns to be irrational. They are VERY
real to me. Why would me knowing that be something they feel they have to keep
secret?
Saturday, September 08, 2007 9:03:00 AM

gve said...
perhaps I should also say that I asked for a spinal (and was given one) so that I could
be awake and see what was happening in the OR, only to be sent to sleep (sedated)
almost as soon as I entered the OR. If my wishes had been observed I would not be
asking questions now as I would have known the answers.
Saturday, September 08, 2007 3:29:00 PM

Maurice Bernstein, M.D. said...
Gve, what the anesthesiologist should have told you was that it would be clinically
important to have you sedated and to explain to you why that is necessary to
stabilize your blood pressure, heart rate and respiration. Even if you are free of all
pains, if you are wide awake, you may become agitated simply from trying to look
around at your environment and may move your body interfering with your surgeon's
work or you might be listening to the necessary comments from the surgeon to
others in the room or misunderstanding what is being said, done or found at the
time or also from side effects of the spinal anesthesia chemical. Your pulse may go
up from this or get too slow from a vasovagal reaction or blood pressure goes high
from your anxiety or your blood pressure drops from a vasovagal reaction or you
begin to hyperventilate from anxiety and deplete necessary carbon dioxide from
your blood and cause electrolyte imbalance. All this can potentially happen and be
an unnecessary risk for you which adds an unnecessary burden on your
anesthesiologist whose job is to keep your body as stable as possible and try to avoid
some anesthetic/surgical catastrophe such as cardiac arrest. You should have been
told that a spinal provides only analgesia (relief of pain itself) and in no way
provides for sedation. There are injected medications which can be administered to
provide the necessary sedation. If you had informed your anesthesiologist that you
desired no sedation, all of what I wrote would be appropriate to explain to you. If
you insisted on no sedation, the anesthesiologist might have refused to be involved
in the procedure. I hope I have explained to you satisfactorily what are the facts.
..Maurice.
Saturday, September 08, 2007 6:52:00 PM

amr said...
To gve:

Please read my enteries earlier in this blog. I too know EXACTLY how you are
feeling. However, I went through these feeling about my wife, not myself. After
going through now 4 operations with my wife (in the last year) and 4 operations of
my own, although I am a lay person, I can answer some of your questions. First I
would like to refer you to an allnurses blog entry entitled: Cone of Silence.
http://allnurses.com/forums/f39/cone-silence-226695.html It might help to have
you understand a little about what is going on. However, as Dr. B has mentioned in
this blog, basic modesty is almost universally denied in the surgical setting.
Depending upon the site of your surgery and the extent of your surgical prep, you
can be assured that all or most of the personnel in the OR saw you naked for some
period of time at the beginning (after you went to sleep) and at the end of your
surgery when the drapes were taken down, you were washed down, and before the
gown (generally a fresh one) was put back onto your body. The recovery team
(PACU) will also lift the drape to asses your condition, and most probably, they will
have seen you as well.

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.

No one in the OR keeps track of how long the patient is exposed, its just a part of
the job. The order of things change with each and every operation, and with an OR
doing up to 4 operations or more per day, what exactly took place with you is going
to be really hard for anyone to remember. It is frankly, just a part of the “job”.
Also, with the need for OR turnover, often times the entire team descends upon the
patient to get things moving at the beginning and at the end of the operation. So,
as my wife just said reading this so far: “What did you have for breakfast, 12 weeks
ago on a Tuesday?”

Those are the mechanics (shortened). It ends up being the crew (and doc), if they
are sensitive to the issue to try and minimize the exposure. However, exposed you
are. This issue of patient concern is common enough that at institutions like UCLA,
there is a charting code for patients expressing issues of modesty and/or loss of
dignity issues.

Also, it is clear from my research and talking to OR nurses, that the medical
profession have learned to just say as little about this issue as possible, because
they have learned that it is a touchy issue. Dr. B, here has in fact exhibited this
same resisents about the subject in these blogs. It’s pretty universal. And I believe
that it is wrong. If someone has questions, they should be answered forthrightly. I
do believe also that many patients just don’t want to know, and that is OK too. Doc
have a hell of a time striking the balance of how much info to give.

Now, have you spoken or written to your doctor? Also, you can request ALL of your
hospital records from your surgery. They must give it to you. In that record will be
an OR report that has been pretty much adopted throughout the US. It is part of
your medical/legal chart. In that document, the anesthesiologist is responsible for
logging in (to the minute) everyone who came into and left the OR during your
session. This includes people that were there before you even arrived. It is a
requirement of law as I understand it. That document will also tell how you were
positioned on the table, what positioning devices were used, how you were prepped
(part of body and chemical), if any hair was removed, who and how it was removed.
It will also indicate when the surgery actually started, when anesthesia was stopped.
You can compare these times and know exactly who was in the OR and who
therefore had the opportunity to see you exposed. I say opportunity, because there
is lots of activity in the room and their backs could have been turned when you were
exposed.

It’s as close as you are going to get to finding out what happened that day. And
since it is a requirement that it is to be “accurate”, it will give you a very good
idea of what happened. BTW, it will also tell you all of the drugs that you were
given. In today’s more modern hospitals, this chart is entered into a computer
terminal and is printed out at the end of surgery. I was reading my wife’s log as she
was waking up in recovery on the last surgery she had this last Tuesday. Also, the
in/out personnel log is automatically kept by the computer in some hospitals by the
personnel needing to swipe their ID card. If someone comes in that doesn’t have an
ID card, a notation of who that person is, is made as a notation by name and title.
For example a 3rd year med student scrubbed in at my wife’s surgery, and it was
noted.

Who is generally in surgery: Circular nurse – responsible for the room management
and is considered the primary patient advocate; Surgical Tech – scrubs in and helps
doc with surgery; Anesthesia of course and your doc. That is the very minimum.
Often times there is an assistant surgeon. Now if you were in a teaching hospital,
there could have been observers and other personnel “learning”. If you did not opt
out of industry reps being allowed into the surgery, it is possible that those sorts
could have been let into the OR. The log that I just spoke about will tell you
“legally” what the record showed happened.

At the end of the operation, those that were in the OR will probably have seen you
undraped and prepared for recovery.

I want to stop here and say that I hoped that you had a positive outcome to your
surgery. I know how these modesty issues can really effect the emotional healing
after surgery.

Now, if you feel comfortable telling me (the blog) or emailing me personally more
details, I can look the surgery up in some of the text books I now have, and give you
more details on what most probably happened in the OR that day. Was it day
surgery or in patient; how long was the surgery; are you a man or woman; what
type of surgery was it; did you have a foley placed; was it an open surgery or
laproscopic; and were you in a teaching hospital or private hospital.

Bottom line, there record exists and you have a right to your complete medical
record from you stay. Also, your doc is required to generate a detailed report of
your surgery. You can request your complete medical records from your doc. But the
detail surgery report should also be available from your hospital records.

I really hope this helps. Unfortunately, you trade modesty for wellness at a hospital.
As my mother-in-law told me: At least they are strangers.

Please take care. I believe that the issue of patient modesty does not end at the
surgery suite door. Gve is a perfect example of the harm that the profession does
when simple questions are not answered. Especially since they are a part of the
legal record of the surgery. Being treated as adults – as more than full members of
our health team – is vital for our well being.

-- Amr
Saturday, September 08, 2007 9:16:00 PM

gve said...
My Aneasthetist was rude (apprently he had been looking for me before my arrival
on the ward and my absence had upset him) this made discussion difficult. I did ask
for some sedation to be given to me but only once the procedure was well underway
and I had seen who was in the room. Despite being very anxious (obviously so
according to the nurses on the ward) I was not even offered any pre med by the
Anaesthetist.

My procedure was a total hip replacement. I was not given a foley as I specifically
refused one for modesty reasons. Post operatively I aslo declined to use the
analgesia pump as I had read that would increase my likelihood of urine retention
and necessitate catheterisation. I was in agony for the first 24 hours. I would have
though that the fact that I put up with the pain in the interests of modesty would
tell people something about how strongly I felt. Instead, the hospital has been
evasive and unhelpful in my requests for information. I live in the UK and we are
not (yet!) as well protected by such rules as you are in the USA. The staff I have
dealt with have treated me as though I am seeking state secrets and that I should
be ashamed of myself for seeking the information at all. The word compassion is
the complete opposite to the way I have been treated since my discharge. Clearly
the medical profession would rather I went away and just got on with my life. That
would be 1000 times easier if they would just tell me what I want to know. Can
anyone suggest to me why they should be so reluctant to tell me?
Sunday, September 09, 2007 1:11:00 AM

Anonymous said...
There is an outside chance, and you would have had to sign a waiver...that the
surgery was videoed. Amr has a good point, I really struggle with the issue of
modesty, it does effect my seeking care as often as I should, and while I have always
questioned what went on, who was there, how was I exposed during the surgeries I
had, I really don't want to know, it makes it easier for me to accept, for me that
part ignorance is bliss. It makes it easier when I don't even see the people, if the
anesthist is opposite gender and comes into talk to me, it makes me feel
uncomfortable...getting to "know" her, having a face to put on who is there...same
with the nurse that comes in and gives the this is what will be happening speach,
While I think it is a good and needed thing to inform the patient....it does make it
a little more uncomfortable..other than providing me a same gender to tell me, or
someone who isn't going to be there, not much you could do about it and it is good
to know what is going to happen.

That said, I had to go in for dreaded hemmroid surgery at age 48...if you go to the
net you read all sorts of accounts, I was so stressed by the time I got in the prep
room my blood pressure was so elevated the nurse called in the Dr to see what to do
about it..ah drugs...anyway, I had tried to get information from the Dr. who was
preforming the surgery, his office sent a very generic paper on hemmroids but
nothing on what was going to happen...I wasn't worried about the procedure at all,
it was hemmorid not heart surgery and I have a high tolerance for pain, so what
was I worried about? Was I going to have to have an enema, were they going to
shave my butt while I was awake, how many people were going to see me naked
while I was awake....as it turned out it was nothing like I imagined, not exposure
while I was awake, not emema, they had my wife help me get dressed, now
obviously I was exposed for the surgery, but other than the anesthesiologist (male
who whas a roit) and the charge nurse who came in and said she would be in the OR
and gave me a quick rundown...I never saw anyone other than my Dr. who saw me
naked..and that was a relief. I had another surgery, the Dr.s office gave me a very
detailed and facility specific agenda right from park here and enter here, to this is
who will be in the room, this is how you will be preped, when you wake up, this is
who will be in the room, you have these options, etc...it was great, I was so much
more relaxed, they asked if I had any questions, the had obliously thought about the
exposure issue as they used terms like "you will be given a gown and asked to
remove all clothing and jewelry after the nurse had left, after you have put your
clothing in the bag provided by the nurse you may lay down on the bed and cover
yourself with the blanket at the end of the bed, the nurse will knock before entering
to make sure you are ready...etc..it was great they were so considerate and
concerned believe me, that is where I go now.

The other point made "at least they were strangers" We have read where medical
students are not required to be subjects for physicals etc becasue they know the
other students, I still think that is a bunch of crap, but the other side of that, I live
in a small town (3000 people) we know the providers and nurses in our hospital...so
after reading the all nurse and this thread, I decided my anxiety about hospital staff
I know seeing me during medical situations were justified and not just me, so I go
out of town for procedures....I would be curious to hear medical providers thoughts
on this?? Not knowing them helps, but does not eliminate the anxiety...medical
personell can help a great deal to reduce that if they choose to.
Sunday, September 09, 2007 8:47:00 AM

js md said...
AMR, thanks for your well researched and thoughtful response to GVE.
A few comments only. I doubt very much that there are any applicable laws that
apply to all hospitals in this country in terms of OR record keeping. Each state may
have some but they would not be uniform. If there are formats that most hospitals
follow, they would probably be based on recommendations from JCAHO (the joint
commission covering hospitals) which semi-officially licenses hospitals. The majority
of hospitals are not fully computerized and do not have electronic medical records
so those comments are limited to a minority of hospitals.
But you’re accurate on most of your statements and the allnurses blog reference is
useful. Modesty is a concern at most hospitals, but a minor one overall. For surgery
with general anesthesia expect to be totally exposed at some point. To 99% of the
staff it is business as usual with no sexual overlay at all. They will not remember
who was there and when in all likelihood. It’s rare that anyone would comment on
the patient’s body except as it pertains to the surgery. It can be frustrating to get
medical records from a hospital no matter how routine the request. If you're asking
for unusual requests, they are likely to review the chart carefully first to see if
litigation is in the offing.
Sunday, September 09, 2007 9:42:00 AM

Maurice Bernstein, M.D. said...
There will be some visitors here that won't like what I am about to write. But that's
OK, if it stimulates thought and discussion. I am not personally attacking anyone.

When a patient is unconscious in an operating room, I am sure as js md has already
stated, virtually everyone there is concentrating on the job and not on nudity or
sex, though if you were to observe activity in the OR, you would see that there is
covering of the genitals if that area is not involved in the surgery preparation.

My point, which I have noted in my previous comments, is that patient's modesty
issues when the patient was awake should have no weight or power to trump
standard procedures for the safety of the unconscious patient during the operation.
When the patient awakens then modesty should be seriously taken into
consideration.

Here is what I might consider an analogous situation. Just visit the Coroner's Office
as I have repeatedly with my medical students and you will see fully naked deceased
human bodies laying on tables in various stages of examination. There is no
covering up of the bodies for either personal emotional or modesty concerns of the
pathologists present. Although there is always expressed awareness that these were
once alive humans and should be respected with dignity, however a respect for
whatever the deceased's views were on modesty had been when alive is ignored for
thoroughly and accurately completing the autopsy.

I think the same holds for the anesthetized surgical patient within the limits of
what the patient had approved by informed consent: patient modesty is and should
be ignored for thoroughly, safely and properly completing the surgery. ..Maurice.
Sunday, September 09, 2007 11:03:00 AM

gve said...
Dr B,

I understand what you are saying.

If I had been told what was to happen, that would have been informed consent. I
was NOT. If I had been told I would not be having these issues now.

It is the secrecy that causes the problems. Doctors need to be more open with their
patients, they do not work in a vacuum, patients are not pieces of meat, we are
human beings. We have rights. The tenuos argument that in an emergency access to
the groin area might be needed is spurious, how long would it take with a pair of
scissors to gain such access by cutting off underwear? I understand you trying to
defend your profession.

It took me a GREAT deal of courage to raise this issue, which I did pre operatively.
The usual way this appears to be handled by your profession is to bluster and take
the subject elsewhere. I was in great pain prior to my procedure, I was a soft touch
for the blustering.
Why are guides not produced as to what (in great detail) will happen in the OR?
Patients who do not want to know would not need to read them. Patients like
myself might choose not to proceed without certain assurances. That would be
informed consent.
Sunday, September 09, 2007 2:30:00 PM

Anonymous said...
gve: I agree with everything that you said and agree that you have shown integrity
and courage. Medical professionals must learn to be both honest and forthcoming if
they really respect their patients. Patients have a right to make fully informed
decisions when they are contemplating whether or not to have procedures
performed.
Sunday, September 09, 2007 3:26:00 PM

Anonymous said...
I have to agree with Dr. B....and,
gve while patient modesty should be trumped by safety, I think if you looked at the
way hospitals do business you would find opportunities to provide additional
modesty while not compromising patient safety. If you watch any of the plastic
surgery proceedures on TV you will often see them in what look like g-strings. These
would cover the genitals and provide access to the other areas if needed, and if
sterile is an issue, for other than a few instances, staff gowns and clothing is closer
to the surgery site than the "g-string" here really isn't any reason some of these
things can not be done. That said, it really doesn't bother me that much when I
don't know anyone and it happens when I am out. I think, and I do not mean this
negatively, an unconscious naked person is pretty much a piece of meat, it would
take alot of the person out of it, and unlike when we are awake, there is no
personality, emotion, or reactions, I would think it would be very
depersonalized....almost dehumanized.....
still think they could and should do things like provide a sterile covering as I feel
while it is not sexual to providers, it still ignores something that is important to
patients. One snip of a string and everything is exposed...pretty non threatening,
but I personally have much less concern about it, but that is me and if we have
learned anything from this thread...we are all different
Sunday, September 09, 2007 4:15:00 PM

Anonymous said...
Dr B,
I have read that the patient needs to be completely naked for general anasthesia.
Can you please tell me why.
Sunday, September 09, 2007 5:18:00 PM

Maurice Bernstein, M.D. said...
First, let me remind my visitors again to identify your anonymity with some
consistent pseudonym either as a name or even with a few letters at the end of the
posting. With so many anonymous writers it certainly would be more helpful for the
continuity of responses to identify which series of commentaries represent which
individual visitor. PLEASE, PLEASE PROVIDE SOME CONSISTENT IDENTIFICATION IF
YOU INSIST TO REMAIN PERSONALLY ANONYMOUS.

With regard to being naked for general anesthesia, I am not a surgeon and rarely
attend actual operations and believe it or not I have never asked anyone about this
question. I would assume that what is required is rapid, emergent access to the
chest and to all arterial and venous ports of entry and if that requires the patient to
be without clothing, so be it. I have no absolute facts about this and I certainly
welcome a surgeon or OR nurse visitor to speak to this question out of their
knowledge and experience. ..Maurice.
Sunday, September 09, 2007 6:37:00 PM

gve said...
Dr B,

"if that requires the patient to be without clothing, so be it."

Says who? surely this is what it all boils down to, if as a patient I am given the
information and still want to take any associated risks, that (as owner of my own
body) is my right.

I would readily live (or die) with the risks associated with me wearing my own
underwear to the OR.

I would happily sign any disclaimer or indemnity the hospital would require, It HAS
to be my decision, not some arbitrary policy decision which I may not agree with.

I will probably never again undergo any more surgery (even life saving) without such
assurances. I really do feel that strongly about my own rights. I don't care how
professional the staff are, how silent they are about my body etc., none of that is of
any consequence whatsoever to me, I simply want to control who sees me naked and
when.

I am delighted for those who post who have no such concerns, I accept they have a
right to feel that way, unfortunately, the medical profession seems to feel that
their wished override my own, they do not.
Monday, September 10, 2007 4:06:00 AM

Anonymous said...
If a provider responding could clarify, does naked mean wearing only a gown, or
does it mean they remove the gown and have only a drape? While I hate the open
back mini skirts (at 6'1" they are kinda short), and I still feel exposed to a degree,
it is atleast some minimal covering. I had a procedure (endoscopic exam) and was
forced to wear only the gown, but I was also covered with a blanket. Is this the case
in OR except they cover with a drape? or do they remove the gown for even say
shoulder surgery?

After reading my post the term "meat" sounded pretty mean, I didn't mean they had
no concern, rather it becomes just the mechanics of physical treatment rather than
a person with emotions and identity. JD
Monday, September 10, 2007 4:43:00 AM

Maurice Bernstein, M.D. said...
Gve, you write "I would readily live (or die) with the risks associated with me
wearing my own underwear to the OR.

I would happily sign any disclaimer or indemnity the hospital would require, It HAS
to be my decision, not some arbitrary policy decision which I may not agree with."

It's not that simple. If you insist on a practice, whatever practice, that the hospital
or physician perform which is not within the standards already set and which leads
to an injury or death that could later be found related to your request, your injury
or death would be an indication of unprofessional or worse action by the hospital or
physician by investigative boards irrespective of your permissions. They just can't
respond to the investigations with the excuse "the patient made us do it!"
It just is inexcusable.

To JD: Based only on my limited observations but understanding of the issues, the
patient is covered with drapes and does not wear a gown for most procedures
except for certain ones such as colonoscopy under sedation as an example. But
where are the surgeons here to answer these OR questions?? ..Maurice.
Monday, September 10, 2007 7:19:00 AM

gve said...
Most OR conventions are just that, conventions, based on outdated ideas which no
longer hold true.

http://www.his.org.uk/_db/_documents/Rituals-02.doc

This site (a UK report) has a review of such rituals and condemns many as needless.

Just because a surgeon "likes" his patients preppped in a given manner does not
mean it is safer for the patient necessarily, probably just more convenient for the
surgeon. I repeat that in an emergency, scissors can provide access through any
cloth material.
Monday, September 10, 2007 10:15:00 AM

Anonymous said...
To the person who has responded by saying live or die its up to you as you want to
wear underwear and be covered, I totally agree with you. It is the patients body,
they are in control. Still no one has answered my qn as to why you must be totally
naked, it seems rediculous. Dr b you said maybe it is because they can have access
to your whole body, really how likely is that in most cases, rare I would imagine.
And if it were necessary it would take next to no time to remove underwear. People
like myself who are horrified by being exposed when not concious or anytime really
are even more so reading from a doctor that it is of no matter when the patient is
unconcious, "so be it" that sounds just like the comment I would expect from a
doctor, no regard to the patient! And as for being dead and examined I think
dignity should be respected just as if the person was alive or should I say concious. I
would be horrified to know my husband dead or alive was layed out naked with
anyone walking through and so would he.
Dissapointed in your attitude Dr B, I thought this blog was to give med students a
look from the patients side and have some compassion....RM
Monday, September 10, 2007 3:13:00 PM

js md said...
Interesting reference gve. I looked through some of it including the section on
patient's personal clothing. Hard to know how widely applicable it is. Certainly in
reference to the cataract surgery that they mention I don't think anyone would think
that a patient's underwear would make any difference. That's very brief local surgery
that uses only local anesthesia. Maybe there was more said, you'd have to check out
the footnote referenced with the topic.
Like Dr B, I'm not a surgeon and have only distant medical experience with it
except as a patient. But I would think the situation would be quite different for
major surgery under general anesthesia where emergency access may be needed and
urinary catheterization may be required. Further patients are occasionally
incontinent during prolonged anesthesia and underwear would certainly complicate
that.
But there is no doubt that many medical procedures and practices are based more
on custom and experience then evidence. That doesn't make them wrong, but
certainly they can be challenged. Most medical therapies have never been proven by
rigorous research including penicillin which was so obviously effective that no one
would have withheld it when it came out.
Monday, September 10, 2007 3:26:00 PM

Anonymous said...
gve has a very valid point, I don't think you are going to find to many patients that
will agree with you on this one. Just becasue it has always been done this way,
becasue that is the way providers want or think it should be done, I doubt you are
going to convience to many patients wearing a G-string covering or something like
that would signicantly increase the threat to their lives to say you can not choose.
We may not be able to force it, but it does not make it right. I would bet money
that if we scrutinized provider behavior and actions they would provide more risk
than a patient wearing underwear or even provider furnished underwear. We often
hear of providers working unreasonable hours 60-80 per week, double shifts, I know
I personally have been at parties late in the evening with a couple of nurses who had
to get up early for thier shifts, providers going to work sick becasue they didn't
want to miss a shift, then there is student nurses & interns "practicing" or getting
experience on patients, from what I hear soemtimes others are allowed in the
room, and what about the practice of NP's and allowing NP's to be anesthisit (sp)
without all the training the Dr.s that used to do this, these are all caculated risks
that providers are willing to take with a patients well being...yet, its to risky to
allow a patient to choose whether they want to risk wearing underwear for shoulder
surgery? Sorry Dr. B. I think you are to be comended for this blog and your efforts to
bring this issue to the front, but I think sometimes we all get so caught up in what
we have always done, we maintain or defend the status quo without realizing it, I
mean this will all due respect as I really do value what you are doing, can you
honestly say that giving a patient a g-string type covering would significantly pose a
risk, you could get to the arteries without removing it, but if you needed to it
would take but 3-5 seconds to cut the strings to remove it....do you think I am
wrong on this? JD
Monday, September 10, 2007 5:02:00 PM

Anonymous said...
to jsmd if you need a catheter for surgery why cant that be inserted by one person
before surgery begins then be covered as apposed to have several people in the OR
in full view of the naked patient. Why too cant you have underwear over the top.
Plenty of people have a catheter long term do you think they should be naked for
the duration...rm
Monday, September 10, 2007 8:15:00 PM

Maurice Bernstein, M.D. said...
RM, you write: "Dissapointed in your attitude Dr B, I thought this blog was to give
med students a look from the patients side and have some compassion."

In our "Introduction to Clinical Medicine" over the first two years of medical school
we do give the medical students a view of many of the concerns the patient may
hold, including patient modesty issues. We have always stressed modesty in terms of
the physical examination. I, personally, have not talked to them about modesty in
the operating room (they are not involved in this phase of medicine now until their
third and fourth years) however in response to what has been written on my
threads, I will disclose what I have learned here from my visitors to prepare them.
The purpose of "Introduction to Clinical Medicine", beyond teaching the students
how to take a history and perform a physical exam is to understand the importance
of professional behavior, humanistic approach to patients and their problems and to
understand in order to make a intellectual, emotional and spiritual connection with
the patient much more is involved beyond learning about symptoms and making a
diagnosis but the doctor needs to be empathetic and compassionate. ..Maurice.
Monday, September 10, 2007 8:22:00 PM

Anonymous said...
Dr B, I hardly think you teach students empathy and compassion toward patients by
treating the patient differently when they are awake compared to when they are
concious. Why would you not give the patient respect and dignity whether they are
awake or not. I cant believe we need to have this discusion. If you dont need to fix
it, dont touch...or look! If you do need to expose the body, expose only what is
needed for the time needed. My husbands doctor thought de may need a
discectomy. When we researched the topic there was no way he wanted to have the
surgery, no matter what the consequence. The photos/video we saw of patients
lying totally naked with staff walking around. Would no one have thought to cover
the genitals or why couldnt they have had at least underwear on. Then seeing the
patient placed in the kneeling position, again no attemp to cover the naked body
with several onlookers. We were and are horrified and the whole experience has
changed our lives and the way we look at the medical profession. I spent several
nights having nightmares about what may have happened. If it actually did happen I
dont think I would have survived...well I wouldnt have ket my sanity anyway...RM
Monday, September 10, 2007 9:19:00 PM

Anonymous said...
I went to the allnurse cone of silence blog. I think there is a very telling statement
in that blog. The statement was directed to why providers do not tell patients or
families details of surgery, in paticular the exposure of patients "we tend to avoid
talking about it (to patients) as to us it us no big deal, its just another day in the
OR, but it is something that we know would greatly upset the patient or thier loved
ones and cause them a great deal of concern". This I think it the crux of the whole
problem in and out of the OR. The seriousness of the situation to patients is down
played or dismissed by caregivers who feel since they don't think it is a problem of
any consequence, compared to the physical/medical aspects of what they are doing,
it has no place in procedures. They realize it is a big deal to patients but they do
not feel it is warrented so it is given no priority. While a patient may protest when
awake, they will not have to deal with it when the patient is out, so they don't.
Again this issue for me personally while a concern, and it bothers me, is small
compared to other area's, none the less it bothers others alot, (obviously). I honestly
feel the safety argument, while very important, is used to justify a don't want to
change procedure rather than can't. The fact that medical providers down play the
issue to the degree they do, allows them to justify or at a minimum, view the issue
from a self serving point of view. While they can justify need to access the femeral
(is that the right?) they ignore the options that have never been provided in the
past that would allow this and provide the patient a degree of modesty. What they
also fail to factor, exactly what RM has stated, how many people put off, or avoid
medical attention due to concen for modesty. I think medical providers under value
or ignore this aspect. While they acknowledge the concern, they do not fully
attempt to address it, there has been efforts, but, there could be more and I think
providers are so caught up in defending their actions, they fail to see the
options...Sorry Dr.'s M & Jms, I really think there are some pretty obvious, easy,
and non threatening options...sterile, paper, exam/OR shorts, paper g-string type
coverings, there really is no rational reason these could not be provided...they
would cost next to nothing, they could be removed in a heatbeat in an emergency,
and they would give the patient a lot of comfort, and if the effort was made all
along, how many people might seek medical care, that don't now....the trade-off, a
balance? Just becasue we have always done something, doesn't mean we should
continue..times change. Please don't take this as condemning you, we all learn from
hearing the other side. The small-small risk for providing these coverings could be
many times outwieghed by not only the emotional feelings and positive opinion of
the procedure by the patients, but may actually benefit as people who avoid help,
may actually seek help.

AMR you referred by medical charting of patient concers for modesty at hospital
(UCLA?) or somewhere, could you send me additional information or a link to where
I can get more information about this?

Thanks everyone, great exchange JD
Tuesday, September 11, 2007 6:05:00 AM

gve said...
The point made by JD is indeed valid. I have a prostate problem with a very high
IPSS score. I am doing nothing about it because all my efforts to secure an all male
team are being met with derision and disdain. I will suffer in silence.
Tuesday, September 11, 2007 9:39:00 AM

js md said...
Just some general comments.
I asked the patient advocate at my primary medium size hospital just how common
modesty complaints were. She said they were rare and that she had never received
any complaints on this subject concerning surgery.
So my tentative conclusion is that all the complainers on this board are well under
the medical radar. I tend to agree that much more could safely be done to
safeguard modesty concerns, but hospitals and the medical establishment just see
no reason to do it.
The trend is against you. Medical care is much more gender neutral than it was
when I started medicine. Nurses then did not catheterize males and there were very
few male techs and nurses that took care of women. Today both are common.
I really don't know if the complaints on this board represent a severely
underrepresented minority who can't bring themselves to lodge complaints or
alternatively avoid all medical care so that they won't have to face the issue. Or is
it really that very few people care to begin with and that you're a fringe minority? I
will say that unless you're much more vocal little will change IMHO.
Tuesday, September 11, 2007 10:05:00 AM

Maurice Bernstein, M.D. said...
As I have previously noted here, I am not a surgeon and have only very limited
experience within operating rooms. Therefore, I posted a request on a bioethics
listserv for a surgical consultation regarding "standards in ORs and philosophy and
behavior of the staff which deal with patient modesty." Today I received the
following reply from a surgeon:

Dr. Bernstein,



I will try to get the official standards from the AORN (Association of Operating
Room Nurses) for you, but, basically, the goal in the operating room is to do all we
can to preserve patient modesty while at the same time minimizing the risk of
perioperative infections. The latter concern often requires skin preparation of a
significantly larger area than a patient might think necessary. For example, for a
laparoscopic cholecystectomy (removal of the gallbladder), because the telescope is
placed at the level of the umbilicus, and because, in case of a difficult operation or
complications that might require a generous incision, the prep generally extends
from the level of the nipples to the pubis. One can’t prep for the minimal
operation, but for the worst case scenario. After the prep, however, the patient is
draped with sterile towels and sheets, and the area exposed may only be a few
inches square for some operations.



The question of undergarments is a tricky one, unless they were provided by the
hospital. Some patients, remembering their mother told them to always wear clean
underwear in case they were in an accident, will always have clean underwear.
Others, not so much. It is probably more respectful of patients to not allow
underwear than to point out to some patients that theirs isn’t clean enough.
Additionally, the potential need to place catheters, etc, makes underwear
problematic.



There is always a question of evidence-based procedure vs tradition related to OR
requirements. There is, for instance, a good, randomized study from Scandinavia
suggesting that one can operate without a mask without any increase in infections,
as long as the OR team isn’t sick (coughing, sneezing, etc). Much of what we do is
ritual, and (given the time of year) can be analogized to the requirements given to
Aaron before entering the Holy of Holies after his sons were killed for not knowing
the rules. That is, we change our garments, bathe (scrub), and follow other rituals
known only to other members of the priesthood (i.e., surgeons).



Finally, although the issue of modesty is important for patients and should be
respected to the extent possible, I think OR staff are much less titillated by naked
bodies in the OR setting than one might imagine, and certainly much less so than if
they saw the same bodies in another social setting. In over 35 years in operating
rooms, I haven’t seen much in the way of ogling or inappropriate behavior towards
patients, nor is it tolerated.

When the surgeon gets the official standards from AORN, I will publish them here. I
hope that my attempt to get the facts and not simply speculation about this
important topic will be appreciated by my visitors. ..Maurice.
Tuesday, September 11, 2007 1:41:00 PM

gve said...
I have an IPSS score of 25, I am avoiding treatment because I cannot find an all male
team, below is an extract from an email reply to such a request, it is typical of
dozens of such replies

"Not necessarily. We do employ male nurses but as I said, the profession is
very heavily female dominated. Certainly at least one or two of the biopsy
team would be female, if not all. Depends on the rota."

I am not in the least bit concerned by the effects of my nakedness on the OR team
or hospital staff generally, that is their problem, I am concerned about how I feel.
Because some patients wear unclean underwear, we are all condemned to the same
level of abuse? Yes, I do feel the disrespect can amount to abuse.

JS asked if the posters in here were a minority, it took me weeks of trying to find
an appropriate blog on this topic, if the medical profession is so confident that what
they are doing meets with patient approval, why not set up a well published blog
and see what the reuslt is?
Tuesday, September 11, 2007 2:36:00 PM

Anonymous said...
Dr. jms a question I would like to put to the advocate, have they ever asked? When
they do an experience questionaire, do they include anything about modesty? One
thing that could probably give a little insight to the unspoken, when you read the all
nurse blog and others, providers frequently acknowldege they recognize this is a
concern for patient...it doesn't appear that the concern is unknown to providers,
nor is it seen as a isolated incident....I think it is more of a case of not speaking up
than no concern or problem with this. I have spoken to very few who say it is no
issue, however most probably do not verbalize it for a number of reasons, it is often
after the fact so they just try to get past it, don't think it will matter so why
bother, don't want to draw attention to it, don't think they have the right to
complain about it, and perhaps even though they care..or ...it is at a level that it
doesn't matter enough to say anything. I would venture a guess to say that the
"complainers" on this site would would be on the it is a big deal of center on the
modesty continuim...that is a guess, but I think that the people that are troubled
by it would be a vast majority.

The question I would pose to providers, if you know it is an issue, regardless of
severity, but don't do anything about it becasue people don't complain, what does
that say about the profession. I'm not dealing with it until people scream isn't the
best customer service model...

Iwould be very interested in what the AORN has to say, and I really appreciate the
post by the surgeon, I think most people would accept rationale if we felt it was
truely a this is really important to the outcome vs this is the way we always do it.
Also, if we felt they were truely doing everything they could to maintain modesty,
but one of the down side of internet...broadcast surgeries, it informs...sometimes
in ways we had not intended. There was a video of a surgery from a east coast
hospital referenced on this blog. I turned it on, it involved correcting incontinence
for a woman. At one point her pelvic area was left uncovered in the background as
people walked around the OR and the cameras rolled, it remained so for quite
awhile, finally one of the nurses looked like she realized there was a camera in the
room and just matter of factly pulled the drape down until they were ready. One
would thought the presence of a camera crew would have increased the attention to
the patients modesty...but it didn't...that is the stuff that bothers most people.

None the less, thanks Dr. B and jms for taking the time to discuss this with us and
bring in other professionals....it isn't easy to put yourself out there for criticism JD
Tuesday, September 11, 2007 2:59:00 PM

CLW said...
Could be, JSMD, that many people are simply unaware of the many ways in which
their modesty is likely to be violated in a hospital setting. Your sample size, namely
one interview in one medium size hospital, does not justify the "tentative
conclusion" that you draw.

A side point, could you clarify or identify where in the "myths" report that you read
anything about underwear in reference to cataract surgery. I read the report, and it
recommends that the patient keep all his or her clothing on, including shoes, during
the surgery.

CLW
Tuesday, September 11, 2007 3:57:00 PM

Anonymous said...
just a side thought (sorry I have been posting so frequently, this is a subject that
really wires me), I run a chain of retail outlets, we survive by trying to our "service
our competition" If we can provide better service, something the competition we
get thier customers. I went to a customer service seminar, one of the people in the
audience made the comment, well our industry is no worse that the others, the
moderator jumped all over it, said OK lets make that our motto, lets hang that over
our door, we are no worse than the rest, or we will give you exactly what everyone
else is doing...becasue that is what everyone is doing.

I heard of a hospital in Alanta advertising "gender sensitive care". Maybe the answer
is convinicing a few hospitals to promote this, and if they take business from the
rest.....after all medical care is getting more and more competitive, you can't
throw a rock without hitting a new facility JD
Tuesday, September 11, 2007 4:40:00 PM

js md said...
CLW,
Here's the relevant section:
"A recent editorial from Canada noted no increase in infection rates in patients
undergoing day-case cataract removal when the patients remained fully dressed to
enter the theatre, including their ordinary shoes.
Brown describes the ritual of making patients coming to the operating theatre
remove their underwear as the “most illogical of rituals”. It is still practiced in
many surgical units and should be stopped for the good reason that it causes
embarrassment to the patient and serves no useful purpose."

The second paragraph specifically about underwear does not give a reason. That's
why I said that one would have to lookup the actual reference which I'm not sure I
can get. The statement does not appear to be based on any scientific study or it
would likely give more info. It may be just another opinion with no clearer validity
than current practices.

The reason I said my conclusion was tentative was that the hospital does use a
questionnaire which I know includes a question about modesty. The advocate did
not offhand know the specific results of it as the questionnaire is processed
elsewhere. If the results had stood out, it's likely she'd be aware of them. If she gets
back to me with more info I will post it.
Tuesday, September 11, 2007 4:54:00 PM

Anonymous said...
I feel compelled to add a few thoughts to this discussion. First, the statement
quoted by Brown seems to indicate an obvious conclusion: if there is no compelling
reason to do something (remove patients underwear) and there is an important
reason not to do it (it causes anxiety or embarrassment) then it should not be done.
The dirty underwear argument a few posts ago to justify removing all patients’
underwear is not a scientific argument (it is a matter of opinion). To me it seems a
little silly to worry about telling someone their underwear is dirty, and use this as a
justification to ignore everyone who wishes to keep their underwear on.

I agree with js md that “…much more could safely be done to safeguard modesty
concerns, but hospitals and the medical establishment just see no reason to do it.” I
am not sure of all of the reasons for this, but I think that it is useful to acknowledge
this situation.

Unfortunately, I cannot agree with the implication that unprofessional and sexual
references regarding patients’ bodies are not tolerated in the medical setting. I
suspect (and hope) that these references are rare, but I have heard too many myself
to believe that they are not tolerated as a general rule. Rather than take my word
for it, I would recommend the book “Women and Doctors” by John Smith (a doctor
and surgeon himself). I think that chapters 3 and 4 of this book are relevant to this
discussion. A brief passage from page 32-33 of the book about the OR: “I have seen
more than one gynecologist walk into an operating room where another doctor’s
patient was already asleep for surgery, lift up the sheet, admire the patient’s
breasts, and continue his conversation without pause.”

kcm
Tuesday, September 11, 2007 6:45:00 PM

Anonymous said...
On Sept. 11th, 10:05 AM, js md said that a patient advocate at a medium-sized
hospital basically said she never sees this issue of modesty in the OR come up... and
that as a result he believes all persons on this blog are a fringe minority. Well, I
know a patient advocate at a large metropolitan hospital who has told me that her
boss told her that doctors and staff want her to "deflect the crazies" on rare issues
of overmodest patients in the OR, as well as the more common requests
that accompany scheduled procedures and tests where the patient is very conscious.
I don't feel as strongly as GVE does about the modesty issue in the OR when one is
unconscious but I do believe he should speak up for what he wants and let others
know there is someone out there who has the courage to make "unreasonable"
demands. This
action eventually influences the balance of power. This month the hospital must
deal with one "crazy", next month it will be two, then three, etc. It's obvious the
problem is under JS, MD's radar because patients aren't making big enough blips.
Once the word gets out that its sane to complain then a shot can start an
avalanche. Many of the posters on this site are talking about problems they are
running into for the first time with a new
will not to accept what has long been suffered through. I have to believe that this is
starting to register. Just looking over some of the outrages listed on this blog site
in the past two weeks, I can see several situation outside the OR that have nothing
to do with patient safety and everything to do with control by the medical staff. I
hope the next time Anonymous of 8/31 7:04 PM is lied to by the patient advocate
(or the staff they represent), he or she will sue for breach of contract. I think
Anonymous of 8/31 9:12 PM will never go to a Urologist who doesn't employee a
male tech and if he can't have one he'll at least have a shut door and a male
chaperone or he'll walk. I'm sure FA of 9/02 8:31 PM is not going to endure any
more pelvic exams in front of the wide-eyed office manager. He'll know why ever
female is in the room and then he'll tell his doctor to exam him in private or he'll
look for another doctor. These are just three situations that went badly. These
inexperienced patients learned valuable lessons from each experience then went
searching for a blog like this to share their anger and frustration. When these three
hit their next appointment they'll be above the radar and so will many others who
have read their painful accounts and have been enlightened and fortified by them.
JS,MD keep your ears open. Your standing on Concord bridge and you're about to
hear the first volley of a patient revolt. It's been a long time brewing. PO
Tuesday, September 11, 2007 10:27:00 PM

gve said...
Might I make a suggestion? Why does Dr B not set up a patient modesty blog aimed
primarily at patients who attend his hospital and publicise it widely within the
hospital (not difficult to do) and sit back and wait to see how few (or I would guess
how many) posts he receives. Whilst one hospital is not definitive, it may give a
taster for what people are (silently for the most part) feeling on this issue.

Can I thank Dr B for taking the time and effort to moderate this blog, he has dipped
his toes into water most doctors prefer to pretend does not exist.
Wednesday, September 12, 2007 12:58:00 AM

Maurice Bernstein, M.D. said...
I am in the process of trying to get permission from ethicists writing to a bioethics
listserv to publish here their comments about patient modesty in the OR that are
supportive of the views expressed by seemingly the majority of visitors to this
thread. ..Maurice.
Wednesday, September 12, 2007 10:59:00 AM

Anonymous said...
I am a little perplexed by what seems to be a recognition by providers that this is a
concern of patient, but not an issue for providers. I don't think I have heard more
than a very very very few (if any) providers say that they did not think patients
cared about this or it wasn't an issue for patients. Almost universally in the allnurse,
this, other blogs, and many articles providers openly admit they recognize this is
important or an issue to most patients. They even admit when they are the patient
it is an issue. But when challenged as to why something isn't being done it becomse
a non issue, one that only applys to a fringe minority, or one that is of such low
importance that it does not justify changing the status quo. I think PO hit it on the
head, how do we as patients start the ground swell that we feel is there, that the
silent majority is there, it just needs to be awaken. I know I have a whole different
attitude and approach to this as a direct result of this blog...how do we
communicate to everyone else...you don't have to silently take it, you have every
right to speak up.
Wednesday, September 12, 2007 11:31:00 AM

js md said...
PO,
I did not say that I believed that all participants here are part of a fringe minority. I
did say that it is one possible explanation for the contradiction I see, that the
hospitals I have been at don't seem to recognize it as a major problem as opposed to
all the interest it evokes on this and other blogs. I really don't know if patients with
major modesty concerns are in the majority, 10% or under 1%. The people on any
given blog represent such as small sample that you can't tell. Hospital questionnaires
may have the answer, but if so I haven't seen them reported.
As I said before, I believe hospitals could do more for modesty issues if they
targeted it. However they will have great difficulties satisfying patients who only
want one gender to take care of them, and I can understand why some have
reported here that the hospitals said 'no' to these requests and turned patients
away. It is up to patients to publicize these concerns if you want it to change.
Wednesday, September 12, 2007 1:37:00 PM

gve said...
"It is up to patients to publicize these concerns if you want it to change."

that is what the great majority of providers are relying on, the onus NOT being on
them.

Patients are by their very nature, vulnerable. Providers that seek to take advantage
of that vulnerability by pushing the onus back on to them show NO regard for
patient health and well being.

I have decided to make this a crusade. I will push for patients to be given choices at
every turn, There are so few areas where it really matters (urology, surgery
Obs/Gyn), that providers can't (or more correctly don't want to) help MUST be
challenged.
Wednesday, September 12, 2007 2:59:00 PM

Anonymous said...
GVE, let's give Dr. Bernstein a break here. He's already distanced himself from most
doctors by moderating an online blog like this. Asking him to further alieniate
himself from his colleagues by holding a similar patient forum within his teaching
hospital(UCLA?) is just too much to ask. Do you realize what a sacred cow you're
trying to slaughter here? Doctors, nurses, and administration are always working to
deny there is a problem here. Behind closed doors the level of this activity often
reaches that of conspiracy.
The only reason Dr. Bernstein can
survive this blog is because he's in an academic role. So let's stop for a moment and
applaud him for the risks he has already taken. This "Patient Modesty" blog opened
May 11, 2006. By September 11, 2007, 487 days later there were 419 postings.
That's one posting every 1.16 days. But yesterday, that average grew to 11 per
day!!!
It's very clear the tide is rising. More angry patients are joining together here
everyday.
Perhaps Sept. 11th, 2007, will mark a new 9-11 wake-up call in the war to defend
patient modesty. Thank you, Doctor, for
making this all possible. WJB
Wednesday, September 12, 2007 4:26:00 PM

Maurice Bernstein, M.D. said...
WJB, thanks for your supportive comments about my behavior on and intent for this
blog and thread.
I want you to know that I reported the consensus of the postings on this thread to a
bioethics listserv and I am totally impressed by the great interest the topic has
taken for the physicians,nurses,lawyers and philosophers who populate the listserv.
And virtually all are describing patient modesty in the OR and in other medical
situations as a true and underregarded, therefore an unmet problem. Those who
have written agree that even if the incidence of misbehavior of the OR staff is
miniscule, it should be stopped! So those who have concerns about patient modesty
actually have professional support from those ethicists writing to the listserv. As
soon as I get the permission I requested I will put their comments here so you can
see for yourself their views.

By the way, I am sure I have previously identified on some threads the institution
where I teach first and second year med students as the Keck School of Medicine of
the University of Southern California, not UCLA. We basicly use the giant Los
Angeles County/USC Medical Center hospital as a teaching resource. Remember,
teaching these students good behavior is not the same as monitoring their behavior
and the behavior of their physician and surgeon "role models" when they are in their
3rd and 4th years or during internship or residency. It is in these years where the
"hidden adjenda" appears and it is the years where medical school teachers are most
concerned about and trying to find ways to prevent the instilling of bad behavior
into the students or graduates by these "role models".
..Maurice.
Wednesday, September 12, 2007 5:36:00 PM

Anonymous said...
I could not agree more, if there were more Dr.'s like Dr. B we would not need this
blog. I hope I have expressed my appreciation enough that you know, while I
challenge some of the comments, I have a great deal of respect and appreciation for
what Dr. B is doing here, and for jms MD for his partcipation, I wish more
professionals would join in. Kudos to both, and I would not expect him to stir the
pot in his own back yard. I think he is probably already raising a few eye brows
among his colleges.
As per my above post, one can look at the way medical procedures are so
inconsistant and realize the industry is either in denial or just flat out
misrepresenting the issue. Why would we recognize the issue in OB, GYN,
mamograghy, etc and then try to say patients don't complain so they don't see
modesty as an issue...obviously they recognize it becasue they provide for
it....sometimes,..... when they choose to. The inconsitancy in application can tell
alot about the issue.
Dr. B can't solve this, but he may have very well struck the spark that can
help....don't know what I can do to have widespread impact, but I am going to try.
Maybe we can use this blog to share what we are doing to further this
cause...thanks again Dr.s Look forward to debating these things with you and hope
other professionals will join in. JD
Wednesday, September 12, 2007 5:39:00 PM

CLW said...
gve: you might be interested in our discusson group:

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

If you are interested, use your initials and mention Dr. Berstein's blog. CLW
Wednesday, September 12, 2007 6:00:00 PM

Anonymous said...
I am actually a little confused as to where Dr B sits with the modesty issue. On
earlier posts he has written if a patient needs to be naked "so be it" and that its
perfectly satisfactory that when you are unconcious or dead modesty is a non issue.
Maybe I misunderstood or maybe most other people have a different opinion to me
and dont think modesty is an issue for the unconcious. I dont care if i'm awake,
asleep, unconcious or dead I want my modesty protected if it doesnt need to be
exposed dont expose it...rm
Wednesday, September 12, 2007 8:58:00 PM

gve said...
It was never my intention to undermine what Dr B has so far done. I do NOT include
him in the group of providers who are clearly indulging in a conspiracy of silence.
He is obviously not as he is moderating this blog!

My suggestion that he set up a locally relevant site was so that he could readily
publicise its existence. This blog is not widely know about. Unless you get the right
search crireria, you will never find it by chance.

No nationally recognised body wants to raise this issue as they already know what
the responses will be, if they are honest.

Does anyone know of any other sites which discuss this same topic?

Thanks to CLW for the site he/she has cited.
Thursday, September 13, 2007 12:27:00 AM

Anonymous said...
There is voy.com, go to health then procedures and examination. Be fore warned
there are some there who are into it for the shock or what I would call the "pervert
value" and they are mixed in with the rest. Allnurse.com is interesting as it is
nurses talking about these things, there are some related topics in the archives
"cone of silence" was one directly related to this topic, however don't think that is
interactive as I don't think the public can partcipate. You have really hit on a valid
point, how do we get more people to this and other sites, I know it made a
difference in how I approach it, if anyone has an idea I would sure like to hear it.

Dr. B I am not trying to speak for you, just my take away. I think Dr. B has always
indicated he felt it was an issue and one that needed to be addressed. He as also
consistantly said safety trumps modesty. I think where we are split is on some
specifics as to that balance, I feel the OR protocol is over kill, no reason a parient
can't have their privates covered unless they are involved in the procedure. He and
other Dr.s seem to feel it isn't unreasonable and the fact that the patient is out has
a mitigating effect on the level of what is "reasonable" accomodation, and I think
we differ from him there, but we also have different views among ourselves as to
what level of concern this is.....JD
Thursday, September 13, 2007 11:57:00 AM

Maurice Bernstein, M.D. said...
"..so be it!" is simply my expression which represents my life long responsibilities as
a physician in that the safety of a patient trumps any other parameter of patient
management including modesty issues. Modesty vs life/death responsibilities of
physicians is a no brainer.

But don't jump on me yet. Listen me out. Now, I am just as concerned about the
validity of safety procedures as you all are. The question clearly arises especially as
suggested by the UK review previously noted-- how much of the argument regarding
safety practices are evidence based and proven and how much are simply
unnecessary rituals. I am all in favor of getting rid of rituals and instead to look up
to patient modesty as an important consideration when dealing with patients in and
out of the operating room. I am with you.. and as I hope to put some of the
ethicists comments here, they are with you too. ..Maurice.
Thursday, September 13, 2007 1:32:00 PM

Maurice Bernstein, M.D. said...
Here is the text of the discussion between two ethicists A and B writing to a
bioethics listserv after I posed to the list the issues of patient modesty in the OR
that have been of concern on this blog. Thanks to the ethicists for permitting me to
publish their comments here. ..Maurice.

Ethicist A:

I teach bioethics to undergraduate nursing students. For one of their
assignments they write about professional ethics cases they have
personally observed. Over ten years, there have been a steady stream
of cases from the OR setting of exactly what your blog visitors fear --
all occurring to the patient after they are anesthetized. For my students,
the issue is always that no one spoke up, no one defended the unconscious
patient's dignity. They struggle with the complicity inherent in their own
silence. Examples: female patient undergoing abdominal procedure --
breasts are exposed and attending physician fondles them and then
comments to resident, "Now these haven't been enhanced; they're
the real deal -- just feel them." Young woman undergoing surgery for
broken leg -- naked body is exposed and physicians comment on
attractiveness of this patient compared to the "usual" obese patient.
Male patient having surgery for unrelated issue is exposed and comments
made about body hair, penis size and tattoos. In addition, many cases
about what might be characterized as simply unkind remarks made
about physical attributes for the purposes of humor.

In addition to these examples of course, there is the discourse in the
surgical literature regarding the acceptability of doing multiple
vaginal exams on anesthetized female patients for teaching purposes
without the patient's consent or even knowledge.

I think the ideal is that anesthetized patients are treated with dignity
and respect -- and deviations from standard are not tolerated. Unfortunately
the reality does not always match this ideal. The culture of the OR is one
where the surgeon truly is the 'captain of the ship' making speaking up
against the power gradient very difficult for nurses, scrub techs,
residents, and even anesthesiologists.

Your blog visitors fear something real. The solution is more elusive but
probably lays in finding a surgeon that one trusts around these issues
in addition to surgical skill -- and potentially raising the issue directly
with the surgeon and possibly the surgical team. From an ethics
perspective, this is an area where building a culture of respect is key vs.
the attitude of finding and eliminating "bad apples". Using the test of
"what if this were my ______ (sister, daughter, wife, son, brother)" can
help clinicians to consider their practice under a bright light.

Ethicist B:

Would not a culture of virtue ethics solve such a problem or at least come close to
solving it? What is needed, IMHO, are role models. Physicians who embody virtues
and act with respect towards the patients (whether the patients are awake or not,
whether someone is looking at the physicians or not).
The issue of consent is a different issue altogether, I think, and can be dealt with
differently. If the patient has expressed (prior to anesthesia) that she would not
want the test to be done then (please correct me if I am wrong) doing it would
constitute battery.
I think it all comes down to issues that were already raised in previous posts: the
character of the physicians, admission policies, etc. What are needed are ROLE
MODELS. Physicians should not do what is right or abstain from doing what is wrong
because someone is looking, because there will be whistleblowers or because they
worry they might be followed or sued; rather, they should do what is right simply
because it is right (the old ring of Gyges story). This has practical implications and
can be solved.
Call me an idealist, but when did idealism become the opposite of realism?

Ethicist A:

I think you pose a good point regarding the role of virtue ethics
in this issue. The problem with situating the solution in role models is that
the nature of OR practice is one where a particular surgeon is unlikely (once
he/she is out of training) to observe another person's practice. Because of
the culture of the OR where the surgeon literally "reigns", you have to approach
changing the culture a bit differently. You can do this through video clips
where an unacceptable behavior is demonstrated and standardized training
occurs. But the challenge is getting often technically good clinicians to see
that a behavior is socially unacceptable. One case I consulted on was a
pediatric surgeon who following surgery on a child's genitals, drew a happy
face on the end of the boy's penis. He had a history of similar interactions
with children post op that involved odd "joking" behavior and genitals.
The nurses who raised concerns were eventually forced out of their jobs.
This surgeon brought a great deal of money and prestige to the institution.
Parents generally put up with the "happy face" behavior because he was THE
specialist in the area for a particular set of conditions. He had no "peer" to

observe or role model. His colleagues refused to pass judgment. I don't
know what eventually happened in this case b/c it occurred in another city
and I consulted with the nurses who were losing their jobs.



Ethicist B:

I sure hope other members on the list will join in, particularly surgeons.
What I am reading here is distressing. And this is so for more than one
reason.
1. I agree with you about changing the culture. Yet, I do not see why it
should not be changed if it must. Whether physicians "reign" or not is not
an excuse. Those who reign can be overthrown when they fail to honor a trust
given to them. The physician-patient relationship is fiduciary and should be
honored. This is inherent in the meaning of the term "profession". I am
assuming that respecting the patient is a "moral absolute".
2. This surgeon's behavior and history cannot be condoned. It seems that it
has become a "history" because it was not stopped the first time it
happened. WHY? More so is the parents' reaction. If parents or patients
continue to accept this kind of abuse (which can lead to a slippery slope),
where do we stop? Where is community education?
3. Why did his colleague refuse to be involved? Is this MEDICINE?
4. Why did the nurses lose their job for doing the right thing and why did
it end there? - I am assuming this physician is still joking and drawing
smiling faces and probably has students who will be doing the same. He has
become a model to emulate, at least for some. Where is the hospital
administration?
I have always believed in Burke's saying: all that is necessary for evil to
flourish is for good men to do nothing. Patients are week, vulnerable, they
entrust physicians with their lives and intimacies. This has to be honored.
Eventually, everyone becomes a patient.
Friday, September 14, 2007 11:10:00 AM

Anonymous said...
Dr. B. Thanks for the great postings from the bioethicists.
You went to a bit of trouble to get these views and they are very worthwhile. The
incidents are a bit frightening but somewhat expected. People don't stop being
sexual beings when they go to work on the human body. We can't hope to control
what's inside a person's mind but I do expect a very professional facade.
Keep it friendly and clinical.
I also don't think this attitude is restricted to surgeons in the OR. It invades all
levels of staffing. Perhaps it has something to do with the black humor which
provides relief when you're around so much sickness and death. Have you ever spent
an evening with a half dozen female nurses getting drunk at a bar? I still can't
believe some of the irreverent observations I've heard. And I once rented an
apartment to three medical students and was at their frequent weekend parties.
The
stories chuckled over there were enough to make you enter the OR in a trenchcoat,
if not a suit of armour. WJB
Friday, September 14, 2007 2:58:00 PM

gve said...
Until it becomes the norm to respect the body of whoever is in front of you such
abuses will continue. Patients feel VERY worried about raising issues before their
treatment for fear of being labelled "odd" or "a crazy".

The onus has to shift to the professionals, they should be asking if anything of this
nature is a concern to their patients, NOT waiting for them to raise the issue.

Hospitals rely on patients being complicit and accepting their lot, I honestly believe
the tide is turning and EVERY individual will be given the same respect in the OR
that the chief of surgery would expect for him/herself.
Friday, September 14, 2007 4:02:00 PM

Anonymous said...
Very interesting, shocking to read but not unexpected. Again I am still wanting to
know why underwear needs to be removed. If it was kept on the patient would feel
safer and there would be nothing to comment on on that area eg. penis size
etc.(not that this should be comented on anyway.) Again if I needed a catheter I
would ask for this to be placed before being anethetised. I know this is more
painfull but I would prefer that. Then put underwear on and begin surgery. PLease
someone tell me why do you need to be totally naked for surgery???
Friday, September 14, 2007 4:57:00 PM

Maurice Bernstein, M.D. said...
To maintain continuity in the discussions here, please remember to indentify your
anonymity with some consistent identification, such as a pseudonym or letters.
..Maurice.
Friday, September 14, 2007 5:33:00 PM

Anonymous said...
Maurice, thank you for posting the comments from the ethicists. I am glad that they
strongly condemn the unprofessional actions that they described. This is an
important first step in putting these actions to an end. I think that many in the
medical profession do everyone a disservice by denying that these things take place.
The profession should acknowledge that these things happen, condemn them as a
serious breach of the trust that patients put in their doctors, and make it clear that
anyone who acts in that way will be punished. Hospitals must revoke the admitting
privileges of surgeons who act that way no matter how much money these surgeons
bring in. Defending and protecting the honor of the profession is more important
than the money, but that fact seems to be lost in the shuffle. It is very sad that the
ethically conflicted nurses who tried to do something to protect the patients were
the one who were punished in the example described by Ethicist A. This gives the
appearance that the actions are not only tolerated, but somehow enabled by the
hospital administration.

I found myself understanding and agreeing with both of the ethicists. Ethicist A gave
patients good practical advice on how to try to protect their own dignity since,
indeed, the surgeon wields tremendous power in the OR. Ethicist B is also correct
that the situation cannot be allowed to continue. In my opinion, this has been
happening in medicine for far too long and will not be stopped until the profession
makes it a priority to do so.

KCM
Friday, September 14, 2007 7:40:00 PM

Maurice Bernstein, M.D. said...
A suggestion: the next step in accomplishing a change in the medical professions
and institutions regarding patient modesty would be to develop an action group of
modesty activists who will contribute personally to the effort. I would suggest
someone start up a distinct blog for this issue as a beginning and develop a
documented membership. You can all go from there based on the consensus of the
membership.

My bioethics discussion blog has a premise to enable all views of ethical issues to be
discussed. This premise is not appropriate for developing one view. Leaders of the
modesty activist group must create their own blog advancing their own views and
demands.

Just a suggestion as to where to proceed from here. ..Maurice.
Monday, September 17, 2007 11:26:00 AM

gve said...
The deafening silence in response to Dr Bs suggestion that an alternative blog/site
be established is not suprising. The one thing I have encountered almost universally
when seeking same sex practitioners has been the attempt to make one feel "silly"
for raising the issue.
I guess nobody wants to be "the one" associated with pushing this forward, it is what
the medical profession appears to rely on.

Would it not be possible to create and moderate a blog anonymously but base it on
a single hospital to get started? That way the publicising of the site could be
acheived fairly easily.
Thursday, September 20, 2007 8:53:00 AM

Anonymous said...
Thanks for the thought, we were starting to stray weren't we. Out of curiousity I
googled patient modesty shorts, surgery shorts, colonoscopy shorts, and found there
are numerous products out there that could help eliviate some of patients concerns
with this, even in surgery. The availablity of these products, for instance there were
surgery shorts that from discription were paper, disposable, that had a slit down the
side, with a closure (not sure if it was snap, velcro, or just a paper tie/link) at the
waist line and the leg cuff. It would appear these products would address the
providers concern for acces in an emergency, and provide the patient with some
consideration for modesty. The failure of providers to use these would indicate it is
more of a this is how we do it rather than need to with these products on the
market. DJ
Thursday, September 20, 2007 10:18:00 AM

Maurice Bernstein, M.D. said...
Don't pick on a specific single hospital if you feel that this is a generic problem
regarding the attitudes of hospitals and the medical profession in not meeting
patient modesty issues.

Also I think there should be no anonymity by the moderator of the blog or the
membership. If the need for overhaul of how modesty is handled, a hidden group of
participants is not going to make any impact on those to whom the overhaul is
directed. How would anyone disprove a possibility that only a single person created
the entire membership of anonoymous. individuals?

Think.. modesty of the body is one thing but to extend modesty to refuse to be
personally identified as a proponent of an important viewpoint and action is totally
wrong and may defeat the whole attempt for change. Here is your chance to change
a system--don't let inappropriate modesty hinder your attempt! Best wishes.. I look
forward to look at the blog. ..Maurice.
Thursday, September 20, 2007 9:27:00 PM

Plain Jane said...
I have created a new blog that is specifically for Patient Modesty.

http://patientmodesty.blogspot.com/ I encourage everyone to please stop by the
blog and leave your comments.

As I have stated on my blog, one of the purposes of the blog is to increase public
and medical awareness of the need for patient modesty.

Thank you!

Plain Janet
Friday, September 21, 2007 8:01:00 PM

Maurice Bernstein, M.D. said...
Plain Jane, maybe your blog could be the very activist blog that I was suggesting in
the above postings. Gather a membership of folks with their names and e-mail
addresses who are all willing to contribute their voices and action to change the
system, promoting the recognition and attention to patient modesty issues. Good
luck. ..Maurice.
Friday, September 21, 2007 8:18:00 PM

Anonymous said...
Janet

I applaud you for your efforts and will do what I can to help. I went to your blog but
could not figure out how to post. could you give me a hand here. JD
Saturday, September 22, 2007 5:22:00 AM

Maurice Bernstein, M.D. said...
Mr. G. who is not part of the medical profession wrote me e-mail about the topic of
patient modesty in the operating room and gave me permission to post it here. He
wrote the following:
"For what it’s worth:

I am also good with hospital modesty, especially when I’m under. I don’t want them
worrying about my feelings when concentrating on my spleen or whatever. Plus,
there always seems to be many people around. From what I’ve heard, I would be
nervous getting the gas in a dentist’s chair. Well, even more so."
Saturday, September 22, 2007 2:06:00 PM

Plain Jane said...
JD
Please go to the bottom of the page on Patient Modesty and click on the "Comment"
section. It will take you to the leave a comment box. I have not figured out yet how
to get the Post a Comment link at the bottom. I will have to do some playing one of
these days.

Thank you for caring enough to ask for help.

Plain Jane
Saturday, September 22, 2007 8:45:00 PM

CLW said...
One aspect of the physical exam that is sometimes bothersome to modest women
and their husbands or significant others is listening to the chest with the
stethoscope, since sometimes breasts and nipples are "accidentally" or "unavoidably"
touched by the examining doctor's hand or fingers, not just with the bell of the
stethoscope. There is increasing interest in the use of MP3 recorders to replace the
antiquated stethoscope. A same-gender nurse or tech could easily be trained where
to place the microphone of the recorder on the patient's chest. Besides help
preserving patient modesty, the use of MP3 recording also promises to provide
sigificant diagnostic benefits.

Here is a link to an article about the potential of MP3 recording:

http://www.medicalnewstoday.com/articles/82278.php
Sunday, September 23, 2007 1:53:00 PM

Maurice Bernstein, M.D. said...
I can't disagree more with CLW's approach to examination of the chest (including
heart, lungs and breasts). Touching the skin of the chest is called palpation and
students are trained in the nuances of the feelings of the fingers and palms with
regard to the clinical significance. I am afraid there is no substitute technology
availabe for palpation. If palpation is not tolerated, why not eliminate inspection..
looking at the surface of the chest. There are many signs of pathology that can be
detected by inspection and there is no technology substitute for that either. We
don't need same gender technicians to perform ausculatation. If the patient doesn't
want an opposite gender physician either looking at, touching or listening to the
chest then the patient should by all means have a physician of the same gender
selected. With regard to the role of the stethoscope as a means for effective
auscultation, I would agree with CLW that digital reception and recording may be
developed into a much more sensitive and diagnostic tool than the analog sound
waves which go directly into the physician's ears from the stethoscope.

I think one of the major problems that arise from the modesty issues discussed on
this thread is that each of the two parties, patients and physicians, are ignorant of
the other's interests and concerns.
Doctors are ignorant about the significant concerns about modesty by many patients
and need to attend to their concerns. Patients are ignorant of the process of the
physical exam and medical procedures and the responsibilities of physicians to be
thorough and maintain safety for the patient. Any value to this blog thread will be
to provide information to each party which will allow them to work together toward
the common goal of the best patient care. ..Maurice.
Sunday, September 23, 2007 4:15:00 PM

js md said...
Dr B, thanks again for posting the comments of the ethicists. I am frankly surprised
that the surgeons are allowed to get away with that kind of talk in this day and
age. Crude macho surgeons are kind of a characterture that certainly existed. But it
is generally poorly tolerated nowadays. Not that it can't happen among non surgeons
as well. Do your ethicist contributors have any feel for how common this was or is?
Was this one bad surgeon or many? Or were some of these incidents indeed old?
I'm not a surgeon as I've stated, but I've only had one run in with a crude surgeon in
the past few decades. I was once viewing a chest x-ray where a chest tube was in
place. This surgeon walked by and commented that she had nice big boobs. He
nearly crawled away when I angrily responded that it was my wife who was then
quite ill. I learned my lesson on this topic as a med student in the OR when I once
commented as a lady was having a breathing tube placed that she had very stiff
hair. The lady was not fully under anesthesia yet and complained afterwards. I never
did anything similar again.
In response to WJB's comments above, of course doctors and nurses, especially young
ones, may relate interesting anecdotes or funny stories about patients when they
are together. They are human after all. It is acceptable as long as the patient is
never identified and cannot be reasonably identified. That doesn't mean it's always
appropriate or in good taste, but people will talk about their jobs.
Sunday, September 23, 2007 5:06:00 PM

Anonymous said...
"they are human after all. It is acceptable as long as the patient is never identified"
While I can accept they are human, it is not acceptable. Providers can not have it
both ways, to tell us we should be OK with the nudity as you are professionals, you
stand above these things, then justify talking about patients bodies even without
identifying them, that is not professional. You can't ask for a level of trust that
exceeds what we are comfortable with then justify betraying that trust with they
are only human. Either we can trust providers or we can't, evidently if its
acceptable to talk about paitents as long as we aren't identified, we can't. Goes
back to the OR, as long as we are out, it doesn't matter. Sorry, but I could not
disagree more, it may happen, they may be human...but it is never acceptable to
the patient, we are not amusing ancedotes or funny stories, we are people who
place an unparrelled level of control and trust in your hands. JD
Sunday, September 23, 2007 7:05:00 PM

Maurice Bernstein, M.D. said...
I would like to pose a question to all those visitors who sincerely and earnestly are
concerned about personal modesty issues in medical care. The question arises from
the visitors stating that they would feel more comfortable and would want to be
examined and have procedures performed by someone of the opposite gender. My
question involves the basis of a patient's personal modesty. Is the modesty out of
sexuality concerns: that the healthcare provider of the opposite gender will find the
patient's body heterosexually provacative and that sexual behavior might enter into
the relationship or procedure? If so, then wouldn't concern for homosexual behavior
also be considered if the patient has a provider of the same gender? Or maybe it
doesn't have anything to do with homosexual or heterosexual concerns but simply a
concern that others might find one's body odd, unusual, ugly, unattractive, in poor
condition, unwholesome,not in keeping with the patient's intellect and an object for
ridicule and comment. I think that for everyone to understand each other, the
basis, the origin, the reason why patients are concerned about their personal
modesty in medical care should be openly discussed. It is my reading of this thread
that that much has been written about the consequences and the suggestions for
mitigation of the issue but not about the psychological basis for the modesty. Any
suggestions? ..Maurice.
Monday, September 24, 2007 8:11:00 AM

Anonymous said...
Whow! JD, I think you just knocked JS,MD right out of the ring. I give you this
round!

All modesty related to intimate exposure is deeply rooted in fears and insecurities
that are as varied as life itself. The only thing that can be addressed is the
discomfort of the patient. Some want male providers, some want female, the only
real issue is with the fact that the patient often doesn't have access to the provider
gender which provides comfort. This is especially true with support staff. In the
patient modesty arena, it's very clear this is basically a problem for males who want
same gender care. The big issue is that nothing is being done on the institutional
level to address it. This is the most basic core problem in patient modesty, today.
Addressing it will cause the other dominos to start falling, too. WJB
Monday, September 24, 2007 11:16:00 AM

Anonymous said...
Yeah Sorry js md If I went off a little, from a patient point of view it just seems
providers justify a lot of issues and status quo. I meant no disrespect to you and
appreciate your contribution here. It's a little like my cousin the state cop, runs 75-
80 to a ball game but would hand out a ticket for others doing the same...no
disprespect or personal attack intended, you appear to be more comcerned than
most.

Dr. B. I have questioned long and hard why I care. I think it is a combination of
several/many things. We were raised in my house it was not proper to see or be
seen naked by the opposite sex. I also think in my and other males I know I feel
controled or ...perhaps helpless in these situations being "forced" to do something I
feel uncomfortable with so perhaps that is part of it, though it doesn't explain why I
am uncomfortable to start with. I do know for me part of it is with male providers,
I don't care what they think of my body or the size of my anatomy, there is no
sexual tension for, me, I have grown up being exposed to other males in the locker
room etc so it is a little more normal, I never saw, or was seen naked by a female
in these same venues. That is where at least part of the modesty issues start with
me, and the anger comes form the fact that I still believe much more could be
done, if providers wanted to...theychoose not to. By the way, google patient
modesty surgery shorts...they make special shorts for patients to wear into surgery
slit down both sides, velcor closures at the waist band and leg...paper, disposable,
cheap,....anyone ever heard of them being used? Same google, they have
colonoscopy shorts...I don't know anyone that was offered them...that is where the
anger comes from..JD
Monday, September 24, 2007 7:50:00 PM

Plain Jane said...
Modesty is about respect for self and for others.
Modesty is a state of mind and involves attitude as well as dress and behavior.
Modesty is also about honoring the bonds between a husband and a wife.

Respect is about honoring what is of value to an individual. My body is of value to
me and to my husband and I do not want to share it with every person that happens
to walk by an open doorway when I am in a hospital or medical setting. It is
considered respectful to not go through a person’s purse or wallet but totally
acceptable to look at a naked person. What is wrong with that picture? I do dress
modestly and am considerate of my husband’s wishes in my dress also. Modesty is an
issue that affects both men and women.

Modesty is more than visual it is also about the attitude. Wearing suggestive
clothing or moving in a suggestive manner do not reflect modesty. This mindset can
be identified often when a woman has been raped. One of the first questions asked
by the defendant’s attorney is “What were you wearing when the event occurred?”
This is hardly a question that would be asked if society did not assume that clothing
reflected the inner person.

The bond between a husband and wife is very special because each has pledged
themselves to the other. This bond is strengthened and encouraged by the modesty
of the couple. Saving some things to be admired solely by one’s spouse gives a sense
of privilege, honor and intimacy. Anytime a person exposes their body to a member
of the opposite sex they take away a part of the marriage intimacy and chance
weakening the bonds between a husband and wife. This intimacy is further
weakened by the encouragement of the medical establishment for women to expect
to be examined intimately and for a woman to reveal intimate thoughts to her
doctor, regardless of the reason for the visit to the doctor.

Sexuality is a driving force in the very nature of human beings and this issue can not
be ignored when considering the merits of same gender exams. For some people the
very thought of potential sexual abuse is going to be a strong factor in their
insistence for same gender exams. Given the prevalence of misbehavior of
physicians not only within the United States but within other countries it is not
surprising that knowledgeable patients are not only leery about seeing a member of
the opposite sex but are insisting on same gender caregivers. Homosexuality is a
fact of the current times and can be a concern with same gender care givers also.
However prevalent homosexuality is in the news and media, it seems to be well
concealed in professional fields such as medicine. If someone is not making an issue
of their sexuality and forcing their attentions on patients it will not be a problem
for most people.

In summary, Modesty is a choice and lifestyle that some people have chosen. The
very basis of the current medical system makes a mockery of this lifestyle that
people have chosen by insisting on maintaining the same status quo. The ridicule
people receive for this choice has created a hostile environment for those of us who
request same gender care givers. At times this hostile environment has delayed the
medical care needed while the person requesting same gender caregivers is
questioned intensely and pressured to reconsider his/her request.

Modesty is a choice and I choose to be selective about who gets to see more of me.


Plain Jane
Monday, September 24, 2007 8:10:00 PM

Anonymous said...
I think we should mention medical
procedures that went well in the modesty department to help establish what can be
done if
doctors and staff care.

Today, I saw a male colo-rectal surgeon at a large metropolitan hospital. My history
was taken in private by his male nurse.
I remained fully clothed in the examining room waiting for the doctor. That wait
was less than
three minutes. The doctor knocked, twice, waiting for my permission to enter
before he did so. He then had me get on the table fully clothed(even wearing shoes)
and had me lower my pants and underwear to upper thigh. I was as little uncovered
as was necessary for him to actually work. Then he totally surprised me by covering
me with a paper sheet and raising it only enough to work. When he was finished, I
asked about why he had used the sheet as it appeared quite unnecessary. His
response was quick. "Most patients feel more comfortable if they're covered and
there is a one-in-a-million chance someone's going to open that room door by
accident." Now, that's a doctor who is aware of patient modesty. He also happened
to achieve what I found to be just the right balance of humor and professionalism
that colo-rectal exams require. In all, a model appointment, one that I'm going to
use as a yardstick to measure others against. Todd
Wednesday, September 26, 2007 7:48:00 PM

Maurice Bernstein, M.D. said...
It is good to read about some professional behavior of a physician for a change. Yes,
maybe there are more physicians like him and his behavior can be used as a role
model for those who are not like him. ..Maurice.
Wednesday, September 26, 2007 8:48:00 PM

Anonymous said...
I think this is one of the things that creates so much dissention, some providers do
provide it, so we know it CAN be done. I had a vasectomy, my Dr. did it by himself,
used a drape, rolled up a towel and laid it over my penis I assume to hold it out of
the way, it was very unstressful. A friend, different Dr. had the guy strip from the
waist down and lay on the table, no drape, puts his gloves on, goes over and kicks
on the door to signal he wanted help, the nurse, female, an acquaintance of the
patient enters, so there he lays naked from the waist down door opens, female he
knows walks in, the only thing she did was hold his penis out of the way....on the
other hand, I had a colonoscopy, female anestesiologist, two female nurses, they
started the procedure before I went under...a friend, different hospital,
anestesiologist, who helped the Dr. they gave him a gown and disposable
colonoscopy shorts, intentionally chatted with him till he was out........goes back
to can, just don't and that is what angers patients.
Thursday, September 27, 2007 5:01:00 AM

Anonymous said...
problem is most patients are like the one from the last post and dont expect to be
treated with dignity this way and dont demand they do. Things will not change until
you settle for nothing less. You are paying for a service, you are in control. Doctors
wont change until you demand it. It is quicker and easier for them to treat you as a
number and not a person.I think for bsome theyre on a power trip!
Wednesday, October 03, 2007 7:01:00 PM

Anonymous said...
The big problem with modest male patients is that they let the moment pass in
quiet humiliation and then complain to male friends.
Men have go in prepared for their
medical experiences. They must address modesty issues ahead of time and not be
afraid to do so. Blogs like this help you to know that you're not alone and you do
have the right to protect your feelings. Finally, when the moment arrives, open
your mouth. You must be willing to make trouble for providers who will tell you
you're out-of-bounds on your requests. Remember, yesterday's taboos are often
today's customs. This is how change happens. I think it was Gandhi who said, "If you
want change, you must start by changing yourself." KLN
Wednesday, October 03, 2007 9:30:00 PM

Anonymous said...
The trick is to get on the front end of the problem rather than to address it after
and of course to be reasonable, the occurance can not be completely eliminated,
the problem however can be drastically reduced it we express it before we are in a
gown. The previous post was mine, after the 2nd event I found this blog and now I
attempt to get some things clear before I agree to the procedure, and if I don't get
what I feel we agreed to I will complain. JD
Thursday, October 04, 2007 4:42:00 AM

Anonymous said...
In addition to the new "Plain Jane" patient modesty blog, there is also another that
opened Sept. 9, 2007. It's at: http://modestpatients.blogspot.com Doesn't have a
single posting as of yet. Drop by and give this guy some support. Direction of the
blog is against the "mocking" of male modesty concerns and the non-optional use of
females in Urology testing. I think the point is well taken. Except for the
homophobes and the CFNM fetish crowd, men only appreciate being naked with
females when their having sex with them. Try
pulling the reverse of this crap on women. Jack S.
Thursday, October 04, 2007 2:48:00 PM

Anonymous said...
I posted on the site but it did not show up....that might be part of the problem...I
am not very skilled with technology so it could have been me. Is it possible to e-
mail this or other blogs or just the address, I have a couple of facilities I would like
to send it to
Friday, October 05, 2007 10:08:00 AM

Maurice Bernstein, M.D. said...
For those who don't find their postings published there can be two explanations: 1)
The posting did come to me and I rejected it because it represented purely a spam
advertisement or because it wasn't in any sense a discussion or that what was
written was grossly uncivil and/or making ad hominem remarks or accusations. 2)
That there was a technical problem and I never received the posting.

Rather than reposting a question as to why a previous post did not appear, simply
write directly to me: doktormo@aol.com

Thanks. ..Maurice.
Friday, October 05, 2007 10:29:00 AM

Anonymous said...
I have a group that occarionallu get together for wine tasting (actually wine
drinking), I brought this blog up, one of the members is a Family Practitioner. The
observation was made that he never talks about patients or experiences of this
nature, he said he doesn't even talk to his family about patients as he feels if it ever
got out that he was talking about patients whether he identified them or not, many
would never trust him the same again so he made it a habit to just not talk about
it, he said most of the Dr's he knew were the same way...we a;; had to agree none
of us had heard any of the local Dr's discussing intimate details of patients....on the
other hand several people said the had been present when nurses-tech's etc had
gotten a little loose and the stories flew freely. I was curious if this a common
feeling of other posters, and how many issues are Dr and how many are support
people...JD
Saturday, October 06, 2007 2:41:00 PM

Anonymous said...
Two things:
First, Maurice asked a ways back about what responsibility patients have toward
modesty. The discussion about nudity during surgery touched on a point which
partially answers this. Patients can help with modesty by doing things which don't
set them far apart from others. My clients (mental health) most frequently stand
out when there is something unusual, the woman who insisted on showing me her
surgical scar (and proceeding to lift her top) for example. Patients with unusual or
extensive "body art" are probably more likely to be remembered, for example, and
their modesty will be compromised in the process since others will notice what
would otherwise be fairly routine. I will probably be cajoled for this point since in
theory we should all be treated equally despite our idiosyncrasies. Nonetheless, I
will remember what I had for breakfast 12 weeks ago if was really unusual, despite
my right to eat it.

Second, in response to JD, I agree with his observation, and with the family
practitioner's approach. I do think we may share "vignettes" with other
professionals, but to speak openly to casual friends about specific patients (even
maintaining anonymity) will serve to decrease trust in our professions. -je
Sunday, October 07, 2007 8:08:00 AM

Anonymous said...
I have sent emails to you doktormo@aol.com and have not received a reply. In
addition, I have sent a few messages through the blog referencing patient modesty
and have yet to hear a response. I am guessing that the subject matter is delicate
and you are feeling uncomfortable discussing it publicly. Rest assured, I am an
extremely private person and respect the privacy of others; therefore, the surgeon's
name will remain anonymous as will any input you may decide to provide. If you are
unwilling to discuss this with me, please at least send an email letting me know
that you received it and wish not to discuss. sweetie_6301@yahoo.com

Approximately 6 months ago I had a reduction mammaplasty. I have been in to see
this surgeon for post operative exams since the day following my surgery. Lately,
we have been in the examining room alone and I have undressed while he sits and
watches. When I say undress I am referring to my blouse and bra - nothing else! I
want you to know that I am not one of those "seductive patients" I read about on
your blog. I simply undressed in front of him because he was not going anywhere
and I figured that since he had already seen me naked that it would not make a
difference. Regardless, he has watched me get dressed and waited until I was ready
to leave the room and then escort me out of the room. He has never touched me
inappropriately or made suggestive comments (other than to say how nice my
breasts looked after the surgery). The last visit was a few weeks ago and his
assistant was in the room with us, but she was on the other side of the curtain and
unable to watch him perform the exam. That struck me as being odd and defeating
the purpose of her being in there. As he was examining me, he managed to gently
brush my hair away from my face and shoulders as he has always done.

My question is this: Is this normal practice? Or maybe I should ask if this is standard
practice for some of your colleagues? I am sensing there is more to this situation
that I am aware, especially since there appears to be seductive overtones in his
behavior. He is a very nice surgeon and has done an outstanding job on my breast
reduction. I guess I am somewhat confused as to what is considered normal with
today's medical practice. My concern is this: If this is unethical behavior, he is
obviously putting his livelihood in jeopardy. I respect him enough to let him know
how his behavior may be perceived by some of his other patients. Although, I get
the distinct impression from his assistant that I am a "special patient" that he feels
comfortable examining without a nurse being present. What is your perception of
this? What do you suggest I do, if anything? Should I mention this to him or let it
slide. I would hate to see him be reported to the medical board for his practices and
I am trying to figure if there is more to this other than just a doctor-patient
relationship.

Any suggestions you have would be appreciated. Thank you for your time and
consideration to responding to this email. Hopefully I will hear from you soon. tlk
Wednesday, October 10, 2007 1:07:00 PM

Maurice Bernstein, M.D. said...
tlk, with regard to your e-mail, it may well have gone into aol's spam folder and I
may have ignored it since the address or title was unfamiliar.

However, with regard to the issue with your surgeon that you raise, I think you have
every reason to bring your concerns about his behavior directly to him and soon.
Unless he has some compulsion to treat himself to the pleasure of observing his
obviously good handiwork, there is no reason to continue to do this or for any other
reason to watch you undress and dress. All physicians must attend to minimal
modesty in all patients by allowing them to undress and dress in private and
unobserved. The fact that your doctor doesn't do that requires an explanation by
him. I am also concern about "brushing" your hair away from your face and shoulders
especially if it was without your specific request. If this is the beginning of some
demonstration of a more intimate behavior toward you, you should put a stop to it
now. I doubt any other physician who understands the sexual boundaries in the
profession would give you any other advice. ..Maurice.
Wednesday, October 10, 2007 2:40:00 PM

js md said...
A slightly different perspective tlk. I really cannot tell from your description if your
doctor is being deliberately inappropriate or not. But he is certainly not picking up
on your discomfort. You should ask him about it, and I'll bet he'll stop.
I never stay around while patients are getting dressed. But on infrequent occasions
while I'm still talking to a female patient about the visit, she will take off the gown
and start getting dressed. These are usually older women who really don't care;
they're not being seductive. In such circumstances I feel I'd be insulting the lady if I
told her to stop or ran out of the room. I finish talking without mentioning her
dressing. I've never had a complaint or problem. If I felt the patient was being
seductive which is very rare, I would excuse myself though.
Wednesday, October 10, 2007 4:16:00 PM

Anonymous said...
js and Maurice,

Thank you both for the input. I get the sense there is an attraction on my surgeon's
behalf, especially after reading your input. I would not be honest with you if I said I
was not attracted to this man; however, I have never been seductive nor lead this
doctor in any way. I have simply been a patient - nothing else. I do not wear
seductive clothing, nor make gestures that would lead him to believe I am
interested. I am married and so is he, at least I presume so since he wears a
wedding band. That is why this is so puzzling to me. Also, the evening after my
surgery I awoke and found him standing there watching me sleep. I did not get a
creepy sensation, nor did I feel uncomfortable. I simply went back to sleep for
approximately two minutes. After realizing that I had awakened and gone back to
sleep he cut on the light, called my name, came over and talked with me for a few
minutes.

He also called my house three days after the surgery to see how I was doing (I have
never had a surgeon call me after a procedure). This was after my husband had
called and spoke with him about a few questions we had. So, there really was no
need for him to call but I thought he was being polite and just following-up.
However, two weeks after the surgery his assistant called and said he was asking
about me and wanted me to come in. I made the appointment for a follow-up.

As for my last appointment, he had his assistant in the room with us but she was on
the other side of the curtain. She was unable to see how he was examining me, not
that he was doing anything wrong (to my knowledge). Of course he brushed my hair
away from my face and shoulders again which was not outside the norm for him.
Nurses are supposed to be on the inside of the curtain, are they not? I am confused
about that one as well. Not to mention, I was orignally told that I would need to be
seen maybe twice after the procedure and one year after the surgery. Last time I
saw him he said that he would see me in six months which is odd because that is
two months shy of one year. Why not make the appointment for eight months? I
have seen him approximately six times after the surgery.

I want to speak with him about this but I have read that it would have to be notated
in my chart. I do not want that, especially if it will cause problems for him. Please
understand that I like this doctor and I am a "loyal" patient who refers other
potential cases to him. I dislike confrontation and avoid it if possible. tlk
Wednesday, October 10, 2007 11:50:00 PM

CLW said...
JSMD,

Wouldn't it be simple enough to tell patients "I'll let you get dressed and then we can
discuss your case" or "Let me tell you what I found and then you can get dressed"?

CLW
Thursday, October 11, 2007 4:22:00 AM

Anonymous said...
From a patients point of view I have had a couple incidents that are a little similar
to this, one I know was just a Dr. being a insensitive I assumed due to dealing with
it all the time, the other I felt it was likely the same deal but was less sure. One
was a male Dr. (I am male) I had to have an rectal exam for hemmroids, he had me
lower my pants, lay on my side, and covered me with paper drape. He called in the
nurse, did the exam with a scope and says "yep your going to have to have surgery
for internal and external, non surgery options won't work, stop by the front and
schedule the surgery" the nurse walked out and he started to follow her...I was
thinking wait a minute I have questions, so I sat up with the drape around my wasit
and started asking him questions how long off work, etc. He stood in the hall with
the door open answering my questions as I sat there pants around ankles, drape
wrapped around my wasit...very uncomfortable, very unprofessional. The other was
a female tech, did a scrotal ultrasound, that was tough enough, but when it was
done she just handed me a kleenex and said you can clean yourself up, and just sat
there watching me...she was pretty professional to that point, she made no effort
to step out or look away. There as a male tech available to do it when I came in but
she took the chart and called me back. While I would have taken not being given
the option to have the male tech do it as being insensitive, it made it all more
stressful and suspect when she did not excuse herself to allow me to clean up and
redress. I still think both were just insensitive (esp the Dr.), but it sure makes one
wonder if it is insensitive or getting cheap thrills at our expense when you add them
up and read what other providers feel is proper or not....JD
Thursday, October 11, 2007 1:51:00 PM

Anonymous said...
Why did you not insist that the male perform the ultrasound or ask her to leave so
you could get dressed in private. If people are assertive and not aggressive in
dealing with the medical profession it would make life easier for everyone. I do not
understand why people just do as theyre told even if theyre uncomfortable and have
terrible feelings afterwards. Yes they are a doctor/nurse but theyre a person just
like you and its your body and your in control.
RM
Thursday, October 11, 2007 2:40:00 PM

Anonymous said...
I think this must have been JD's first time with scrotal ultrasound. Like many
others, he won't be making the mistake, twice. Patients who experience these
moments in private pain actually go through a long period of PTSS. Next time JD
will assert more and suffer less. Posters to this blog should also check out "Dr.
Keagirl's Urostream" blog at http://urostream.blogspot.com/2006/02/sexism-at-its-
best.html Dr. Keagirl is a female urologist who started this thread to complain
about a male patient who had treated her rudely... but lately she's being getting hit
with angry male feedback. She moderates what's posted but rarely comments, so
don't expect much in the way of feedback. I suggest JD and others like him log-in
and sound-off. Her blog bias is slightly anti-male. She thinks men better get use to
female urologists... even though she only sees female doctors for her own care. In
your face double standard here. KYLE
Thursday, October 11, 2007 10:59:00 PM

Anonymous said...
RM, that was the very event that changed the way I viewed providers and my role in
my health care. It was after that event that I went to the web to see if anyone else
was out there and found this site. Once I discovered it wasn't just me, I started
doing several things different. I went for a follow up ultra sound, when the nurse at
my urologist wanted to schedule it, I made them let me schedule my own and
requested and recieved a male, I also wrote the facility, when I did not recieve a
response I e-mailed, I currently have a call into the vice-president of patient
services...I am not going away until I talk to someone incharge about the 1st visit.
I think the problem is compromising a patients modesty first came about from
nesesity and has evolved into an event of convience. It started when there was little
or no choice but when patients accepted the event out of nesescity, providers do it
for speed and becasue it is easier. If you have a bunch of proceedures in image
center, its quicker and easier just to hand out charts as they come up rather than
ask the paitent and schedule them. As such providers have become more amd more
numb to patient feelings as they do it so often they see it as just the way the do
things. And you are 100% right, if we just take it and go home and feel bad about
it, they won't change and we will be more likely to put of seeking care when we
need it. JD
Friday, October 12, 2007 4:48:00 AM

Anonymous said...
Dr. Bernstein, things have been quiet here the last couple of days because the MOD
SQUAD is over at Urostream.com jumping all over Dr. Keagirl's bad attitude.I can
only imagine it's your regular readers who have left 6 or 7 postings, several well
written(including one from a doctor and another from a nurse). Whenever I need
support on a patient modesty issue, I now know where to come. Hope you'll get over
to Dr. Keagirl's and perhaps comment here as the good female urologist appears to
be hunkered down in her foxhole for the moment and not seeing any patients! KYLE
Monday, October 15, 2007 1:41:00 PM

Maurice Bernstein, M.D. said...
KYLE, is urosream.com the correct URL for the site? ..Maurice.
Monday, October 15, 2007 2:30:00 PM

Anonymous said...
The correct URL is in my posting
to your blog --October 11th, 10:59 PM. KYLE
Monday, October 15, 2007 2:42:00 PM

Anonymous said...
just a quick thought, the diversity of opinion is reflective of what we see here.
Some men want a female, others don't. A lot of the conversation runs with what we
are saying here, patient want providers to ask, but if they don't we need to ask. It
was also interesting that there was several different takes on the Dr.'s post. Many
felt the main focus was her contention the issue was the sexism of the male(s)
patient. Other thought it was him being rude. The url indicates sexism was her
gripe, but her post seemed to reflect his shortness was the issue. Dr. Bernstein,
how did you take her post? There were some very good points, how this man got
clear back to the introduction before he knew his urologist was female makes one
wonder.
Wednesday, October 17, 2007 8:02:00 AM

Maurice Bernstein, M.D. said...
My experience is that most patients really are not gender oriented with regard to
who is their primary physician. With regard to specialties such as urology and ob-
gyn, obviously as an internist I have no direct experience. I think the way gender
issues should be handled by the patient, if the gender of the physician is an
important factor in choosing a physician for whatever the reason, is for the patient
to verify as part of making the appointment through the doctor's office what is the
doctor's name and if ambiguous name what is the doctor's gender. The patient
should also verify that the selected doctor will attend to the patient during the
initiation of the doctor-patient relationship and there will be no last moment
substitute. If, by some chance of staff ignorance, the patient is questioned by the
office staff what is the patient's concerns about gender, I would suggest that the
patient clearly inform the staff about the patient's personal importance of gender
concerns in establishing a doctor-patient relationship. If the patient is assured that
the selected physician will attend the patient and on arrival a physician of the other
gender only is available, I would think there is a system problem in the office and,
unless it was an emergency, the patient should say "good bye" and leave and go
elsewhere. To me, if I had gender concerns, which I really don't, (having no
concerns when I was examined by a female doctor in the past who actually worked
in the same clinic I did), I would follow the above advice. ..Maurice.
Wednesday, October 17, 2007 9:10:00 AM

Anonymous said...
While I feel it is a shared responsiblity for the provider and the patient to address
the issue, as a patient I feel the current system requires patients to take
responsibility for this if it is important. You have more experience in medicine than
we as patients so I will take your word that a majority of people are gender nuetral,
personally I think most are just silent. But, what I was really after was if you read
the thread, what was your opinion of the dialouge? Did you take the encounter as
sexist, and several people made the point that the real issue was not the man being
rude it was the provider's view that it was sexist and she was insensitive to his
feelings/rights. Your take from the providers side of the table? JD
Wednesday, October 17, 2007 6:09:00 PM

Maurice Bernstein, M.D. said...
JD, when I last looked at the site a few days ago, I didn't find that the urologist was
responding to the comments. So all we know is her initial statements but there may
be some nuances, if she would only write further,that we need to hear about her
attitude towards that patient to make a judgment. ..Maurice.
Wednesday, October 17, 2007 7:51:00 PM

js md said...
JD, Dr Kea hasn't posted on that blog in over a year and it's doubtful if she ever will
again.
I think she back tracked early on saying that patients have a right to preferences.
But if that's the case, why did she label it sexism instead of just rudeness? I'm sure
we'll never know.
I try to pick my own physicians for reasons that have little to do with gender. I
prefer the most competent caring physician I can find, but it is certainly not sexist
to have a gender preference, especially for 'intimate' care.
Wednesday, October 17, 2007 8:17:00 PM

Anonymous said...
Dr. Keagirl was worth a day trip for the readers of this blog but she shouldn't remain
the sole
focus. That said, Keagirl does
have about fifty different blogs.
One that shows her in quite an
unprofessional light is -- http://blogspot.com/2006/10/so-you-want-to-make-
appointment-with.html This female urologists obviously has a real problem. If you
thought the "sexism" thread was out of bounds, wait until you read some of this.
That a female urologist is having these thoughts in an online forum is very
disturbing.
JS
Wednesday, October 17, 2007 9:56:00 PM

Maurice Bernstein, M.D. said...
JS,I am not sure that the URL is correct. I keep getting the blogger.com page.
There is something missing that should come before .blogger.com ..Maurice.
Wednesday, October 17, 2007 10:15:00 PM

Anonymous said...
Right you are. Sorry about that.
Correct address is: http://urostream.blogspot.com/2006/10/so-you-want-to-make-
appointment-with.html JS
Wednesday, October 17, 2007 11:22:00 PM

js md said...
JS, thanks for the new url. I'm not exactly sure what you find inappropriate about it
though. Dr Kea has a better understanding of the types of male patients who prefer
to see her than I would have guessed from her 'sexism' blog. Perhaps she is too
cynical, but female urologists certainly don't tend to attract the 'average' male
patient and there's no reason why they shouldn't be aware of it. She clearly
recognizes in this blog that most male patients prefer male urologists just as she
prefers female gynecologists.
The discussion of general gender preferences breaks no new ground. It seems to be
commonly said that women physicians are more caring and males more arrogant.
There is likely some truth in it on the average though many male physicians were
trained in an era when their word was taken as gospel and they may be less attuned
to give and take discussions than younger docs. Nonetheless it behooves any patient
to evaluate their physicians on an individual basis and not accept stereotypes. A
doctor's gender is the least important attribute in evaluating how good a physician
they really are.
Thursday, October 18, 2007 12:09:00 PM

Anonymous said...
JS I think you may be right in saying that some people probably do prefer a
particular gender but remain silent. Dr B do you think that you believe many
patients dont care about gender or do you think many dont want to say so. I urge
patients to speak up before hand because I know that the feelings of not speaking
up can torment you for a long time. RM
Thursday, October 18, 2007 1:46:00 PM

Maurice Bernstein, M.D. said...
I really think that a large number of patients who look to the physician for other
signs of competence and trust than gender BUT I wouldn't be surprised by the
responses to my blog (even though I can't count the number of separate individuals
who commented since because of many Anonymous signatures) that there must be a
host of patients who clearly are intimidated or for other reasons fail to express
their gender concerns to physicians or the office staff. ..Maurice.
Thursday, October 18, 2007 9:43:00 PM

Anonymous said...
JSMD's comment, "What do you find inappropriate?" (regarding Dr. Keagirl's second
Blog in question) is most puzzling. Did he read what I just read? She's DAMN cynical!
I don't think it's professional for a doctor to take such views of her patients. And
when you combine the fact that she knows exactly which males want to see her(a
woman urologist)with the fact that she -- "understands it completely when female
patients request to see me as opposed to one of my male colleagues... I would much
rather see a female gynecologist (and I do)... (because) the field of urology usually
involves sensitive(read modest) areas of your body -- you're left with a position that
shouldn't allow her to go near any male who doesn't want her care. Yet, later in the
posting replys, she says, "And yes, I have PLENTY of male patients who don't want to
see me because I am a woman"(instead of because they are modest). This indicates
that these men are seeing her under duress. The fact of this doesn't bother her
because she views it as their sexism, not their modesty. Therefore, she has a right
to assault their patient comfort in the name of females in medicine. Sounds like
very inappropriate B___ S____ to me! CHUCK McP
Thursday, October 18, 2007 10:18:00 PM

Anonymous said...
I think one of js md's comments bleeds into several area's. Just as many of the older
physicians may be lableled arrogant or uncaring as they were brought up in a time
when they were not questioned, it is logical patients would not question including
the gender concerns. I personally was in that group and still find it hard to address,
it just wasn't done. I would guess just as younger Dr's have a different demeanor and
approach, younger paitents may be less intimidated both by nudity and from
expressing their preference. I am 52, when I was a kid, a girl's bra strap
showing...yike, a guys underwear sticking out how embaressing...now its
intentional. We have taught the younger generation to question authority, we are
encouraged to get a second opinion. But that isn't the way I was rasied so I struggle
with it. It would be interesting to see a age breakdown on this JD
Friday, October 19, 2007 6:25:00 AM

Maurice Bernstein, M.D. said...
First, I would like to suggest to my visitors that it isn't fair and ethical to extend
the discussion to sexism specifically directed to criticism of the views of Dr.
Keagirl. She is not participating on this discussion blog and therefore there is no
response by her to the criticism here. She has her own blog where the criticism is
best written.

Notwithstanding what I just wrote. I think that specifically sexism as related to
modern medicine is a very important issue and should be discussed. To get what I
felt was a balanced series of comments by academics on the issue of sexism in
modern medicine you should go with the link to the WMST-L listserv. The listserv is
a international forum for women's studies in general, but as I said I think the
responses you will read are generally well balanced, constructive and informative.

Because I think that any sexism in medicine is an important ethical issue involving
justice and other ethical principles, I should set up a new thread on my blog
specifically dealing with the issue of sexism in modern medicine and have a general
discussion there. Again, on that thread I would expect civil, fair (not sexist!) and
constructive comments without ad hominem criticisms. What do my visitors think
about a new thread specifically on that topic of sexism in modern medicine?
..Maurice.
Friday, October 19, 2007 11:15:00 AM

Anonymous said...
Dr. Bernstein, don't think you need a new thread on your blog for sexism because
the sexism issues your posters have been covering here lately really relate to patient
modesty and the confusion of one female doctor in this regard. If you do start a new
blog thread make sure it sticks to research and spending issues and gender quotas,
otherwise it will have the same effect as this Patient Modesty blog had on your
Naked thread.
All the readers and posters just switched over. In the case of the Naked thread, it
was a case of Patient Modesty being a better name and the real issue at hand.
Let's not confuse sexism in general with sexism that assaults modesty. If you can
keep them very separate, then your new thread would have its place.
ARA
Friday, October 19, 2007 2:01:00 PM

Maurice Bernstein, M.D. said...
ARA, you are very observant and absolutely correct. Certainly, there is many more
issues in which sexism could be involved that would have a far more important
impact on healthcare in general than simply (and I do say "simply")the issue of
personal modesty.

Of course, if visitors to this blog want to continue discussion of personal modesty in
medicine, this thread and the Naked thread are the places to make the comments.

If I put up a thread on sexism in modern medicine I will moderate it so it will be
about the general issues that you noted and others but NOT about modesty.

Thanks for your reminder. ..Maurice.
Friday, October 19, 2007 6:00:00 PM

Anonymous said...
Interesting thoughts, the two issues can be very intertwined, some of the modesty
issues are related to sexism, some of the sexism issues are related to modesty,
While I think either way will work...seperating thing threads may get more focus on
the issues where they do not relate...ie medical resarch dollars...vs allowing
unauthorized people in a room..and it may make the size of the thread a little
more managable for Dr. B., it may as the previous poster indicated split the posters
and reduce the energy, either way Dr. Berstein, we look forward to discussing the
issue(s)
Saturday, October 20, 2007 7:18:00 PM

Maurice Bernstein, M.D. said...
My new thread "Sexism in Modern Medicine: Advantages, Disadvantages, Cost
and Justice"is up and running. I thank Anonymous from today for expressing
support and explaining the need to separate the threads. That was the rationale
given by ARA and is also mine.

I hope those who come to this thread will expand their problems with sexism
(beyond that of personal modesty) and go and write about them on the new thread.

By the way, you might even find that my putting the graphic on that thread, though
as a public signage it seems to symbolize the very issue of sexism,in fact, my act
itself suggests sexism. But forgive me, I just couldn't find an equivalent classic
public domain graphic bearing the image of the opposite gender. If anyone finds an
equivalent one which is in the public domain, I'll be most pleased to add it to the
other graphic. ..Maurice.
Saturday, October 20, 2007 8:36:00 PM

Anonymous said...
I fortuitously happened on this blog site while googling, of all things, "dentist
sexually assaults patient" and I've not been able to read all the postings yet. But I do
think I can add add a bit to the discussion.

First, the employment discrimination cases cited can be used to help address the
question, "Can health care organizations legally engage in gender discrimination to
protect patients' (as an aggregate) privacy and dignity?" These cases do not help
address the question, "Do patients, as individuals, have the right to demand that
intimate care be given by same-sex providers (when available) in order to ensure
patients' privacy and dignity?" The first question deals with gender discrimination by
health care employers in order to protect some people within a class of people while
the second question deals with gender discrimination by health care consumers in
order to protect themselves as individuals.

There are no cases with which I am familiar that directly address the second
question, but there are two cases which directly address the first question and
indirectly address the second. The two cases are Backus v Baptist Health Care
(1981) and EEOC v Mercy Health Care (1983). These two hospitals, the first in
Arkansas and the second in Oklahoma, limited intimate health care to same-sex
providers unless it was infeasible and unless patients requested otherwise.
Consequently, they hired only female nurses for labor and delivery and were sued by
male nurses for doing so. Both decisions were in favor of the hospitals. The courts
drew on the 1991 Civil Rights Act which allows employment discrimination if the
defendant can persuade the court that discrimination is based on a bona fide
occupational requirement or a bona fide business necessity. In Backus and EEOC, the
courts were convinced by the evidence that being female was a bona fide
occupational requirement for employing labor/delivery nurses. The defendants had
to provide evidence that 1) many labor/delivery patients felt humilated,
dehumanized, and even mortified when they received intimate care from males and
2) to replace a male nurse with a female nurse would tend to interfere with
patients' continuity of care. Furthermore, Mercy Health specialized in caring for
high risk labor and delivery patients. Thus, it argued that care by male nurses could
unnecessarily add stress to the already existing stress of a difficult delivery process
thereby increasing patients' risk. Backus was appealed but became moot because
the hospital changed its policy.

Regarding patients' rights to same-sex care, the courts in Backus and EEOC
concluded that the desire of Americans to cover their naked bodies from the view of
others, especially those of the opposite sex, is a matter of "elementary self
respect," "personal dignity," and "fundamental right to privacy." In another case that
was not "on point," (Ruth Shulman v Group W. Productions) the court articulated
what it thinks of those who intrude on the privacy of others when it proclaimed, "He
who may intrude upon another at will is the master of the other and, in fact,
intrusion is a primary weapon of the tyrant. . ."

Given these cases, then, it is, at the very least, premature to conclude that
patients undergoing intimate care don't have a legal right to protect their dignity
by demanding same-sex nurses/nurse assistants/med techs/etc.

Also, let me add that there were many studies published in the 1980s and '90s that I
reviewed regarding patients' preferences for same-sex intimate care. All those
studies which were methodologically sound found that both male and female
patients were most likely to prefer physicians who were the same gender as they if
their medical conditions involved genital or anal examinations. My own research
clearly revealed that when nursing care involved genitals or rectum, both male and
female subjects tended to prefer that the care be given by same-gender nurses,
whether the care was technical or nontechnical. Both male and female subjects
were significantly more likely to prefer same-gender intimate care than they were
to have no preference or to prefer opposite-gender intimate care. Very few
confessed that their preference was due to characteristics of the same-gender nurse
(e.g., level of competence). Instead, they overwhelmingly pointed to personal
reasons -- such as embarrassment, modesty, discomfort, humiliation -- for their
preference.
Saturday, October 20, 2007 10:27:00 PM

Maurice Bernstein, M.D. said...
Anonymous from 10:27 pm today, thank you very much for your insightful and
documented commentary. It is much appreciated. Please, if you plan to return and
post, end your post with a pseudonym as a name or some initials so you can be
recognized from the other Anonymous posters. Thanks. ..Maurice.
Saturday, October 20, 2007 10:46:00 PM

js md said...
Anonymous of October 20, 2007 10:27:00 PM, thanks for the references. Yes,
distinguishing between patients' rights and employers rights is vital. There is no
doubt that patients have the right to request whomever they want, but it is not
clear that hospitals can only hire who they want. I'm sure the cases you cite are
correct, but these are individual cases against hospitals and do not set national or
even state policy. Decisions have also gone the other way. I believe I have previously
cited one in West Virginia. Equal employment opportunity laws put the onus on the
employer to prove the case for 'discrimination' against employees, who are nearly
always men. Do you think that it would be declared legal for an institution to refuse
to hire women in a urology suite? It will never happen.
But it's much easier for a hospital to hire anyone than to try and defend
discriminatory hiring patterns. Though male ob nurses are not common, they are
not rare either. Nursing associations generally support them. It's not a lot different
than having a male OB. Theoretically women can choose their physician's gender,
but in practice it doesn't always work out that way.
Sunday, October 21, 2007 6:49:00 AM

Anonymous said...
Patients have a right to make the gender of their care providers part of the legal
contract they make with a hospital. This right is not denied by any law, and is
supported by many court rulings, including the ones sited by the recent poster.
Hospitals have standard agreements that give them tremendous latitude, but
patients do not have to sign them. If a hospital refuses to accomodate peoples
religious, moral and ethical standards in this matter, many patients will find
another hospital, or decide not to have the procedure. To imply that this right is
only "theoretical" but is impractical is a stop toward denying that the right exists.

KCM
Sunday, October 21, 2007 11:19:00 AM

Anonymous said...
Dr. Bernstein, I am not versed in Blog communication. In fact, what you read are
the first words I have offered on a Blog. I'll end this piece with an identifier that I
hope will be sufficient.

Thanks for your response js md. I'll have to track down your reference to the W.V.
case; I'm curious about what reasoning was used.

You ask, "Do you think that it would be declared legal for an institution to refuse to
hire women in a urology suite?" Were one to infer from the reasoning used in
Backus and EEOC, the answer would be an unequivocal "no." As far as I know,
urologists provide services to both males and females. Consequently, provider sex
could not be considered a bona fide occupational requirement. However, if a
urology provider served only males (and I know of none who do) and convincingly
argued 1) that many of their patients would be humiliated by care given by female
nurses and 2) to accommodate patients' request for a male nurse would interfere
with the continuity of care, then it seems to me that in order to be consistent
Federal District Court Judge Elsijane T. Roy, who decided the Backus case, would
have to conclude that sex (in this case, male) is a bona fide occupational
requirement for employment in that particular urology suite. If she did not, then
she'd be revealing her sex-bias. So, I can conceive of the Backus and EEOC judges
deciding in favor of the provider, but I doubt if a case such as this would ever come
before them in the first place.

As an aside, I know nurses who think Backus and Mercy should have been sued for
gender discrimination for their policy granting same-sex intimate care to all
patients when feasible and unless patients requested otherwise. My efforts to
explain to them that plaintiffs would have a difficult "row to hoe" in convincing the
court that the policy, in and of itself, was discriminatory fell of deaf ears.

You write, "It's much easier for a hospital to hire anyone than to try and defend
discriminatory hiring patterns." That's what Baptist Medical Center figured and
truckled to the demands of the ANA and male nurse plaintiffs.

You also write, "Nursing associations generally support them [males in OB]."
Actually, I know of no nursing association which does not support the employment of
male nurses in OB. My analysis of nursing publications regarding this issue found
that there were some individual feminist nurses who opposed the employment of
male nurses in OB; they argued, unconvincingly, that maleness precluded
competence in the provision of OB services. Otherwise, nurses tended to express a
belief that they were entitled, by virtue of being nurses and professionals, to
provide services to patients of the opposite sex, no matter how intimate the
procedure. The most common response by nurses to Baptist, Mercy, the judges'
decisions, and to patients who wished services from same-sex providers was moral
indignation. There seemed to be general consensus that nurses were "genderless"
and that patients should be "counseled out of their modesty," as though it were both
feasible and desirable for a nurse to expunge a lifetime of socialization in a few
minutes of counseling.

You suggest that, "Theoretically women can choose their physician's gender, but in
practice it doesn't always work out that way." This statement is, of course, correct.
However, women generally have the opportunity to "shop around" until they find a
physician with whom they feel most comfortable. Unless patients request same-sex
nurses, nurse assistants, and med techs and unless health care facilities are able and
willing to meet their request, people in these positions tend to be "thrust" on
patients. The observation that in practice most women can't choose their physicians'
sex was used as an argument by plaintiffs in Backus. Judge Roy agreed with the
observation but did not consider it a strong argument. Even if all patients in labor
and delivery were uncomfortable with their attending physicians, it does not follow
that hospitals are obliged to add to their discomfort by putting them in the
untenable position of either submitting to the intimate minstrations of male nurses
or risk disturbing the continuity of care by requesting a female nurse.

That said, I am unconvinced that Judge Roy made the correct decision; although she
was undoubtably correct in accepting as fact that many if not most patients in labor
and delivery would be humiliated by intimate care provided by male nurses, she
may have erred by accepting as fact that hospitals could not accommodate patients'
request for same-sex providers without interfering with the continuity of care.
There are reportedly hospitals that accommodate (and, possibly, all could
accommodate) patients' preferences by asking them long before they go into labor
what their preferences are. Were Judge Roy convinced that this observation was
correct, then, it seems to me she would be obliged to reverse her decision. -- c. ray
b.
Sunday, October 21, 2007 11:42:00 AM

js md said...
c ray b, thanks for your response.
If you want to read a lengthy legal treatise basically outlining the case against
permitting BFOQs in medical situations I recommend this:
http://www.yalelawjournal.org/pdf/112-5/kapczynskiFINAL.pdf
Sunday, October 21, 2007 4:10:00 PM

Anonymous said...
c.ray b. you made a reference to studies indicating patients of both genders
preferred same gender providers for intimate care, could you give me some
direction toward those studies. Your posts are appreciated Thanks JD
Sunday, October 21, 2007 5:40:00 PM

Maurice Bernstein, M.D. said...
js med, thanks for your link.

Amy Kapczynski in her Note "Same-Sex Privacy and the Limits of
Antidiscrimination Law" writes at its conclusion:

We ought, I have suggested, be much more critical of the notion of
“same-sex privacy” than courts have been to date, and attend to the kinds of
subjects and harms that we are imagining when we talk about same-sex
privacy. In the washroom cases and the labor and delivery room cases,
where “modesty” or the avoidance of “tension” is all that can recommend
the current regime, such an analysis will almost certainly militate against a
BFOQ. Other cases suggest more caution—for example, where individuals
have very little volition over the circumstances in which they participate in
the changing of gender norms. Here, we ought to consider potential costs to
both bodily and psychical integrity, but also recognize that regulating sex is
not the same thing as regulating harm, anxiety, or the possibility of sexual
abuse. In almost all cases, systemic rather than sex-segregationist
approaches will likely provide better prophylaxis against abuse and anxiety
about abuse because they will better serve to correct power imbalances that
generate risk of abuse and that make abuse so injurious.

You know, maybe the discussion on this thread should really get down to a nitty-
gritty issue and decide whether modesty or avoidance of emotional "tension" should
trump the actual situations which could or indeed has caused severe emotional or
physical harm when it comes to deciding whether there is any BFOQ (bono fide
occupational qualifications) that permits sex descrimination in hiring practices.
Does the risk of significant injury to a patient's mind by becoming embarassed about
their bodily exposure to a member of the oppposite gender have as much or greater
risk of significant injury compared with the evidence supporting the occurance of
sexual abuse or other direct physical or mental harms arising the occupational
duties of members of the opposite gender? ..Maurice.
Sunday, October 21, 2007 6:29:00 PM

Anonymous said...
Dr Berstein wrote:

You know, maybe the discussion on this thread should really get down to a nitty-
gritty issue and decide whether modesty or avoidance of emotional "tension" should
trump the actual situations which could or indeed has caused severe emotional or
physical harm when it comes to deciding whether there is any BFOQ (bono fide
occupational qualifications) that permits sex descrimination in hiring practices.

Etc., etc.

Huh?

I'm sorry, your run-on sentences with their poor grammar and omitted and
misspelled words make it very difficult to follow your train of thought. Would you
mind trying again on this one?


CLW
Sunday, October 21, 2007 7:07:00 PM

Maurice Bernstein, M.D. said...
Sorry CLW for being unclear.

For the purpose of getting around the law regarding discimination and instead allow
the hiring of only one gender for a specific occupation (such as only females for
delivery room work) what argument should be presented to the courts? Should it be
argued that the emotional tension and embarassment by some patients regarding
the exposure of their body to an employee of the opposite gender be as strong and
convincing or greater an argument compared to evidence showing a significant
chance for mental and physical injury by the same employee at the same
occupation. If the courts accept the latter argument to allow the hiring of only one
gender, should the courts also accept the former? If anyone understands what I am
trying to express and can express it more clearly..be my guest. ..Maurice.
Sunday, October 21, 2007 8:32:00 PM

js md said...
I'm not sure fully what you mean either Dr B. But I would like to point out that the
refusal to hire ANY male nurses is an extreme remedy for the probably few patients
who would be in great emotional distress. They could still request same gender
nurses and the chances are great that the request could be granted. If you read
nursing discussions on the matter you will find though some women expressed doubt
initially, most accepted it very well. That's one of the points of the Yale link above,
that preconceived notions can never be altered if you refuse to permit change. If we
did that there would still be no women physicians.
Sunday, October 21, 2007 9:04:00 PM

Maurice Bernstein, M.D. said...
I was trying to suggest the possibility that patient modesty itself is no excuse for an
exception to the anti-discimatory law and that despite modesty issues both male
and female nurses should be allowed to be hired and have the opportunity to care
for all patients. I did not say or imply that patients should not have the opportunity
to ask for a nurse of their own gender and, if possible, their request should be
accomodated. ..Maurice.
Sunday, October 21, 2007 9:49:00 PM

Anonymous said...
we really have two different issues, one for hiring and one for patient preference
that are so intertwined it is nearly impossible to seperate them completely. The
more limited a facility is to staff by gender, the less likely they will be able to
accomodate patient request/needs. That said as Dr. M stated, if we do not test the
waters we will never move forward, males would never become L&D nurses, etc.
However it appears to me some providers are using these laws and advances to
simply forward their agenda of forcing patients to accept their wish for a gender
nuetral acceptance of providers. What began as an occurance due to need, has been
advanced by providers as occurance by convenience. While we have different
opinions on this, I still think most patients feel more uncomfortable with opposite
gender care for intimate procedures. The problem is not nesecarily with forcing
hiring of both genders, it may be more an issue of providers drive to make it easy
on themselves. For instance, how often have patients ever been asked if there was a
concern for provider gender. If it is the case where most don't care, they could
schedule accordingly and still provide accomodation for those who do. Perhaps the
issues are: hiring rights of applicants, do providers right to work trump patient
right to chose which may carry anxiety and emtional issues above what providers
acknowledge, and once hired...what effort do providers go to so as to minimize the
issue to patients. I think the answer still lies mainly on providers, they have proven
they recognize the issue and can provide i.e. every mammographer I have seen has
been female, if they did what they could to ask and accomodate as much as
possible, the other issues become less of a problem. JD
Monday, October 22, 2007 5:16:00 AM

Anonymous said...
In regard to the recent discussion regarding gender preference of care providers, I
think you are missing something. It's not a case of granting a patient's request if
convenient. A competent patient has the absolute right to refuse any procedure for
whatever reason they choose, including gender of the intended provider. Any
attempt to force care by an unwanted provider on them after their refusal is a
criminal act (assault and/or battery depending on the specific state statute).

If the patient refuses a specific care provider based on gender or any other reason,
the facility has two options:
a) provide a qualified caregiver acceptable to the patient
b) discharge the patient (if condition is not immediately threatening to health) or
arrange for transfer to another facility.

The patient is the customer and has the absolute right to choose who provides their
health care.
TT
Monday, October 22, 2007 8:50:00 AM

Maurice Bernstein, M.D. said...
I don't think that anyone can provide an argument in opposition to TT's conclusion.
However, it is up to the patient, after being informed regarding whether an
alternate gender healthcare provider is available to balance modesty vs best
diagnosis or therapy before deciding to change institutions. ..Maurice.
Monday, October 22, 2007 2:09:00 PM

Anonymous said...
Well said TT I totally agree with your comment. The patient is paying for a service
and has the right to chose based on gender or anything else. Have to admit though
it is sometimes hard for male patients to request a male nurse for personal care.
We need to do more to get more males into nursing. Get rid of the stigma that its
womens work, then both genders (patients) can have a choice of same gender care.
Some males are also very modest, its not just females. If my husband goes to
hospital I do his personal care. RM
Monday, October 22, 2007 3:15:00 PM

js md said...
TT is essentially correct though it is a little more complicated than that. Like race,
gender (especially female gender) is a protected class in this country though the
laws are not applied to the same degree. If you requested that the provider or nurse
had to be e.g. Caucasian or Christian the hospital could not comply. My guess is
that 50+ years ago requesting a Caucasian doctor or refusing a doctor of color was
far more common than gender preferences. Today a hospital could easily be sued by
employees for granting racial preferences. Much more leeway is given for gender
preferences which are usually accommodated if possible though when carried too far
lawsuits are also possible.
But you are absolutely correct that the patient has the absolute right to refuse
treatment for any reason generally even in the case of life threatening emergencies.
Critically ill people needing urgent therapy rarely refuse treatment for such reasons
as gender. For elective care the onus does appear to be on the patient to push for
preferences as few institutions make any effort to discover this beforehand.
Monday, October 22, 2007 3:22:00 PM

Anonymous said...
Thanks so much for the reference, js md. I'll be checking it out ASAP. I also came
across a Friday, August 31, 7:01 posting by one of the "Anonymouses" that looks as
though it could make for interesting and enlightening reading. If "Anonymous" is out
there or if anyone knows the sources of his/her assertions, I'd sure like to know
what those sources are.

Dr. Bernstein wrote, "Patient modesty itself is no excuse for an exception to the
anti-discimatory (sic.) law and that despite modesty issues both male and female
nurses should be allowed to be hired and have the opportunity to care for all
patients."

If I recall, the courts in Backus and EEOC framed the issue in the context of citizens'
right to privacy rather than their right to modesty, albeit the two are not
unrelated. And, the attorneys in the audience can tell me if I am incorrect, I do
believe the courts consider privacy intrusions to be harmful in and of themselves.
That is, for one to prevail in a privacy intrusion case, the plaintiff does not have to
provide evidence that s/he has been harmed by the intrusion; s/he need only prove
to the satisfaction of the court that her right to privacy was violated (deliberately
or negligently) in a place where she had a resonable expectation of privacy. For
example, the U.S. Supreme Court unanimously agreed in Wilson v Lane that police
illegally intruded on the privacy of a couple by inviting a film crew into the couples
home as they searched for a suspect. Of course, this case is not on point, but it
does illustrate the Court's position that privacy intrusions are harmful in and of
themselves. Another case, which is closer to being on point but still no cigar, is a
California Supreme Court case Ruth Shulman v Group W. Productions. Shulman sued
because she was filmed, without her consent, in an emergency vehicle as she was
being rushed to a hospital. She won her case. She did not have to demonstrate that
the intrusion caused her psychic pain or violated her sense of modesty. She had only
to prove that she was filmed in an area where she had a reasonable expectation of
privacy.

So, if the courts consider hiring male providers in an all-male facility and female
providers in an all-female facility a privacy issue, then they could legitimately
conclude that sex is a BFOQ for hiring in these facilities. That's what the courts in
Backus and EEOC did in the case of male nurses in labor and delivery and if the
August 31st "Anonymous" is correct, maybe other courts have done the same. In
other words, they decided that patients' privacy, as distinct from patients' modesty,
was a legitimate "excuse for an exception to the anti-discrimination laws." I would
also submit that this decision was consistent with generally accepted ethical
principles.

Regarding your request,Dr. Bernstein, there are a mess of studies including the
following: Harr, Ester, Victor Helitsky and George Stricker. 1975. "Factors Related
to the Preference for Female Gynecologists." Medical Care. 13: 782-90; Levinson,
Richard, Kelly T. McCollum and Nancy O. Katner. 1984. "Tender Homophily in
Preferences for Physicians." Sex Roles. 10(February): 315-24; Cooke, M. and C.
Ronalds. 1985. "Women Doctors in Urban General Practice: The Patients." British
Medical Journal. 290: 753-8; Nichols, Sally. 1987. "Womens' Preferences for Sex of
Doctor: A Postal Survey." Journal of the Royal College of General Practitioners. 37:
540-3; Fennema, Karen, Daniel L. Meyer and Natalie Owen. 1990. "Sex of Physician:
Patients' Preferences and Stereotypes." The Journal of Family Practice. 30: 441-6;
Kelly, Michael. 1990. "Sex Preferences in Patient Selection of a Family Physician."
The Journal of Family Practice. 11: 315-24; Weyrauch, Karl, Patricia E. Boiko, and
Barbara Alvin. 1990. "Patient Sex Role and Preference for a Male or Female
Physician." The Journal of Family Practice. 30: 559-62. These all have to do with
preference for male or female physician.

In the 1980s and 1990s a number of studies were conducted designed to tap female
patients' preferences for female or male nurses. Most of these studies took place in
the United Kingdom. In two studies, patients who received care from female nurses
were asked their preferences for male or female nurses. Depending on the
procedure, anywhere between one-third and three-quarters of the subjects objected
to receiving intimate care from male nurses (Mynaugh, Patricia. 1984. "Male
Maternity Nurses: the Patient's Perspective." American Journal of Maternal Child
Nursing. 9(November/December): 373-8; Cooper, Maryn. 1987. "A Suitable Job For
a Man?" Nursing Times. 83, 34(August): 49-50; Mathieson, Elizabeth. 1991. "A
Question of Gender." Nursing Times. 87(October 17): 40-3). Only Mathieson's study,
which was conducted in a psychiatric hospital, used male subjects. She found that
thirty percent "were uwilling to discuss sexual problems with a female nurse." Brian
Lemin (1982. "Men in a Woman's World." Nursing Mirror. 155(November 24): 32,34)
and David Newbold (1984. "The Value of Male Nurses in Maternity Care." Nursing
Times. 80(October 17) 40-3) found that between one-third and one-half of their
female subjects objected to having been cared for by male nurses.

I and nursing students in a research course I instructed found the following regarding
subjects' gender preferences of nurse for different procedures: genital exam -- 77.3%
same sex; rectal exam -- 66.7% same sex; shave pubic hair -- 71.2% same sex,
27.3% doesn't matter, 1.5% different sex; empty bed pan -- 59.1% same sex; 37.9%
doesn't matter, 3.0% different sex. All the differences were statistically significant
at below the .001 level except bed pan (p = .069). We broke up the reasons subjects
gave for their preferences into four categories ("personal" including discomfort,
humiliation, embarrassment, modesty, shyness, and stress; "patient rights"
including violation of privacy and compromise of dignity; "culture" including not
used to them and goes against my upbringing; and "prejudice" including don't like
opposite sex, don't trust opposite sex, opposite sex not sensitive, and technical
knowledge not sufficient. "Personal" responses were, overwhelmingly, the most
frequent and the differences were highly significant (p < .001).

Back in the early '90s, students and I conducted research which resulted in findings
consistent with comments made by a number of the posters to your Blog. We
hypothesized that the greater the social distance between male physicians and their
patients, the greater the patient dehuminization. We failed to find a significant
relationship using all our indicators of social distance except on the variable sex.
And, the relationship was the opposite of what we expected; women were less likely
than men to be dehumanized. After one of the subjects proclaimed that she would
never go seek health care because she didn't want to be "clinically raped," we
decided to do a little probing. We created an instrument to measure how badly
people felt about having been dehumanized (some items reflected the affective
reactions of rape victims) and found that men who were dehumanized tended to
feel worse (more embarrassed, more humiliated, more angry at themselves, etc)
than women who were dehumanized. We also found that men who were
dehumanized were less likely than women who were dehumanized to complain
about it. In short, men were more likely than women to be dehumanized by health
care providers and were less likely to complain about it in spite of feeling worse
than women about having been dehumanized. We also expected, consistent with the
literature, men's "macho" image of themselves would explain their tendency not to
complain. Instead, we found, consistent with what some folks have written in this
Blog, that it was dehumanized men's perception that others would think of them as
being less of a man that deterred them from complaining.

That tired me out. Sorry about the long-windedness -- c. ray b.
Monday, October 22, 2007 6:48:00 PM

Maurice Bernstein, M.D. said...
c.ray b., I thank you for your "long windedness"..I hope you didn't end up too
dyspneic. I thank you because you provided us with empiric data and legal
references supporting much of the personal commentary already written to this
thread. All this adds to the significance of the views expressed about modesty issues
in medical practice.

On another aspect regarding patient modesty is some recording here of cultural
differences and how medical care is managed. So far it seems that visitors from
Canada, UK, USA and Australia/New Zealand have written here but it would be most
interesting to read the experiences and knowledge of other cultures such as those in
Asia, Middle East, Central and South America and those in the various parts of
Africa. I really encourage visitors from those areas of the world to write to us about
what they know and how they feel and what is expected of the doctor when a
physical exam or intimate procedure or operation is being performed. ..Maurice.
Monday, October 22, 2007 8:23:00 PM

js md said...
Thanks for your comments c. ray b. I hope I can find your references. In terms of
your research, was any published that we could look up? How did you define
dehumanization in operational terms for the study? I believe what you conclude but
I'm not sure how you measured it.

The other aspect of this discussion is should society encourage gender preferences in
a medical setting? As I've said before, IMO modesty serves no useful function setting
only causing pain to those who have extreme degrees of it. We all have some
degree of modesty so it is an issue we all deal with to a greater or lesser extent. I
suspect we'd all have been better off if we were exposed to providers including
nurses of both sexes routinely as children. In this day and age it is unlikely that
anyone can go thru life without seeing providers of both sexes and they should be
comfortable with it. It's arguable but I believe modesty is far more a product of
upbringing than of anything inherent in the human condition. Many civilized
societies get along fine with much less modesty than in this country.
Monday, October 22, 2007 8:57:00 PM

amr said...
Is the OR considered a place where there would be an expectation of privacy on the
part of the patient? Put another way, what is the definition of privacy as it relates
to the OR?

--amr
Monday, October 22, 2007 9:21:00 PM

Anonymous said...
jsmd...'and they should be comfortable with it'....why? so its easier for staff. Some
people are never going to be comfortable with opposite gender care or even same
gender care when it comes to modesty. I am not comfortable being naked, wholey
or partially in front of anyone except my husband. This is my right. If I dont want
medical staff seeing my body that is my choice. Since sometimes it iss necessary I
will decide by who and how and no that doesnt mean I am comfortable with it. If I
could change it I would. Its an awfull feeling to feel violated in that way, but I and
nor can my husband help it. Its not that hard for doctors/nurses etc. to
communicate with patients after all the best medical outcome will come if everone
is happy.RM
Monday, October 22, 2007 10:36:00 PM

Anonymous said...
A big "thanks" to c.ray b. for two exceptional posts. These are just the kind of
entries this blog requires. We have dealt with sufficient amounts of anecdotal
evidence and patient reaction in the last 450 or so postings. We have circled all the
issues many times. Some- times, the debate here seems like a dog chasing its tail.
As Dr. Bernstein recently asked, "can we get down to the nitty-gritty..."
What's at the very core of what we need to achieve?"

As Amy Kapczynski pointed out, whether or not this privacy extension to same-
gender exposure is a valid interpretation of law, it currently exists. The true
physical or psychological "costs" are certainly real and acknowledged, even if
difficult to measure socially.

Before I get to my point, I think we need to agree that in order to make an
argument for same-gender care with any chance of acceptance, we have to stay
clear of the medical safety issues inherient in the emergency room and OR settings.
The first move for change must focused on regularly scheduled exams, testing, and
other procedures where life and death are not factors.

The prevailing OB-Gyn atmosphere
regarding gender privacy is now widely established. It is very important that women
have won this victory for their privacy
(modesty) rights. This blog, and other like it, attest to the fact that there is
nothing comparable for men in pelvic care. Indeed, it is this issue that has the focus
and power to drive the whole patient modesty platform.

Since the BFOQ has allowed the
privacy rights of females to be maintained in medical situations,
then our Constitution guarantees
males "Equal Protection Under Law". This leaves two options,
remove the BFOQ from Anti-Discrimination Law or apply it equally. The former is
not about to happen. The latter needs a
test case, elevated to class-action, and heard by the U.S. Supreme Court. Forget
arguments about practicality here. Either men do or they don't. A supporting verdict
from the court will set in motion all kinds of affirmative actions that lead to
compliance. This in turn will allowed for the developed awareness that is now being
surpressed by the medical community.

We can spend the rest of our lives posting here... but nothing will begin to change
without this upholding of equal protection under law. We need the case, the ACLU,
the challenge, and the Court.

Lets focus on the nitty-gritty of
making this happen. It's the ONLY way. ARA K.
Monday, October 22, 2007 11:37:00 PM

js md said...
c ray b, I meant to ask whether you differentiated male vs female preferences on
your study of gender preferences for different procedures. The ad hoc surveys I have
seen would suggest that men and women differ on how much they care.
RM, I never said that adults should become comfortable with gender neutral care. I
don't think it's easy to change. That's why I put the emphasis on children who aren't
born with our burdens of modesty and preconceived notions.
ARA K, I am not sure what you mean that women have won the right to privacy in
ob settings. A few cases have upheld the BFOQ in that setting, but I'm sure far more
have never come to the question. I'll bet more hospitals have male ob nurses than
hospitals who have barred them. The case remains far from clear.
Tuesday, October 23, 2007 10:16:00 AM

gve said...
c.ray.b is very accurate in his comments that men are very traumatised by modesty
issues and are strongly discouraged from addressing them or attempting to have
them accommodated.
I am currently awaiting tests associated with a prostate problem. I have made it
absolutely clear to my provider (in the UK, so choice is VERY limited) that I will
NOT undergo some of the tests in the presence of female staff. They have been
TOTALLY unsympathetic. Their concerns are solely that their female staff should not
feel slighted in any way and their jobs not jeopardised.
I have made it clear that if they are not willing to try and accommodate me, I will
simply avoid the tests. They are delighted with that response as they appear to
hope that means I will go away and trouble them no further.

And these peopel are supposedly health "professionals" what a joke!
Tuesday, October 23, 2007 12:17:00 PM

Anonymous said...
ARA K.'s point is well taken. The downside is the process could take as much as a
decade or more to come to fruition.

While perhaps this should be the ultimate goal, I'd like to suggest an interim
approach that might get quicker results.

As a prelude, let's look at some facts:
1. Simply put, medicine is a business.
2. Health care facilities provide a product (services) which generate revenue to
support their operation.
3. Patients are the "customers" who consume those services.

My suggestion is simply that patients become informed, responsible consumers and
take control of their own health care.

The first step is to recognize that doctors are paid consultants that work for you.
Their job is to provide you with analysis of your health conditions and advise you of
the available treatment approaches, with pros & cons for each. It is your job to
make the final decision as to what course of treatment, if any, you will pursue - not
theirs. Don't let them browbeat you into something that you're really not
comfortable with. They are a great resource - ask them where to look for more
information to help you make your decisions if needed.

The second step is to be proactive. If you have specific concerns or are
uncomfortable with some aspect of your care or treatment, speak up. The only way
they will know is if you tell them. If you have privacy or modesty related concerns or
preferences such as gender of providers, bring them up ahead of time if possible -
don't wait until the last minute.

Talk about things like the available options and your preferences for anesthesia
ahead of time - don't wait until the anesthesiologist shows up at your bedside in
SPU.

Don't blindly accept health care facility procedures because they are "standard
practices". Quite often they are done for the convenience of the facility, not the
patient, and often carry increased risks to the patient. For example, shaving an
area before surgery makes you ten times more likely to acquire a nosocomial
infection than if the area is not shaved. Likewise, the risk of infection from a foley
catheter is 10% per day, yet both of these procedures are commonly done on surgery
patients even though they're not strictly medically necessary. Considering that
80,000 people a year die in the US from hospital acquired infections, this is hardly
trivial. There are alternatives - ask about them.

Above all else you need to understand that you have the absolute right to refuse any
treatment or procedure for any reason, even in a life threatening situation.

The patient is the customer. And while the customer may not always be right, the
customer is still the customer. If a provider or facility can't meet your needs, they
do have competition. Vote with your wallet and your feet - take your business
elsewhere and let them know why you did. If enough people do this, they will get
the message.
TT
Tuesday, October 23, 2007 12:18:00 PM

Anonymous said...
Js md. The case is clear.

Find a situation in OB-Gyn regular testing and procedures where a woman requests
same-gender care and is refused it.
Woman are never placed in a no-option situation for non-emergency care. At worst,
they have to reschedule.

If hospital and medical facilities have not already staffed accordingly using the
BFOQ, it is only because they wish to avoid lawsuits when they can deal with the
male OB-Gyn nurse as an occasional fifth wheel. They also know that if they
continuously reach for the BFOQ here it will eventually focus the issue of no-choice
as it involves
males and the whole debate will find itself a matter for new constitutional law. The
Supreme Court has stayed out of this debate because state rulings have been
adequate in upholding the privacy BFOQ, as regards employment, but the issue of
"equal protection under law" as regards the BFOQ has never been tested.
This is actually bigger than Anti-Discrimination Law, where the contest is basically
between the
provider as employer and the potential employee. The new argument pits men's
rights vs. women's rights in the application of BFOQ law. The key
issue then becomes "equal protection under law".
That's the clear difference here.
Tuesday, October 23, 2007 1:07:00 PM

Maurice Bernstein, M.D. said...
As Moderator, I want to remind everyone: particularly in view of all the current
back and forth discussion, all Anonymous writers please be sure that your posting is
consistently identified by some kind of pseudonym or initials. This is very essential
for keeping this important discussion understandable. ..Maurice.
Tuesday, October 23, 2007 1:47:00 PM

Anonymous said...
Sorry, Dr. Bernstein. Poster of Oct. 23rd,1:07 P.M. was ARA K.
Tuesday, October 23, 2007 8:10:00 PM

Maurice Bernstein, M.D. said...
Thanks ARA K. Now back to the issues at hand. ..Maurice.
Tuesday, October 23, 2007 8:28:00 PM

Anonymous said...
"equal protection under the law" is anything but equal. There have been numerous
cases, while not ecactly on point, but close, where males are not provided same
consideration and still considered equal. For example, several states have ruled
male guards can not pat search female prisioners, but female guards can do the
same to males, none the less, if males do not start demanding like females have
nothing will change, kudo's to the females of our society who have stood firm and
not accepted what was handed to them as the way it is, guys, we can learn from
them. JD
Tuesday, October 23, 2007 8:28:00 PM

Anonymous said...
JD. Prisoners do not have full constitutional rights. Not really a valid comparison.
Tuesday, October 23, 2007 8:49:00 PM

js md said...
ARA K, I don't disagree with your last statement, but women really haven't won any
rights that they didn't already have. American medicine has always accommodated
women who had gender preferences. It was always easy except that 50 years ago
physicians were 95% male and now it's approaching parity. But the staff waiting on
women has always been all female. For men who care the situation is very difficult
as it is hard to get an all male team and not much 'progress' has been made there.
Nationally very few hospitals ban male nurses in L&D, though I have no idea how
many have just never had to face the issue. But 10% of nursing school students are
men and they all have to rotate thru L&D as far as I know.
I have personal experience with ultrasound techs doing exams on women where
their breasts are routinely exposed. We have had several male techs doing it over
the years at different hospitals and offices on literally hundreds of patients. No
gender choice was offered (and it was often not available) and not a single woman
ever complained or asked to reschedule. No chaperones were present either. That's
one of the reasons I questioned some time ago how big of a problem this really was.
Tuesday, October 23, 2007 8:52:00 PM

Anonymous said...
Dr. Bernstein, I think I did have a little dyspnea and a little mydriasis to boot.

Js md, alas, I did not submit either paper for publication. The first, conducted
almost 18 years ago, may have been worthy of publication but the second,
conducted a few years later, was not, although I included it as a small part of a
paper I presented at a professional meeting in Chicago.

The first, the research that began with testing the relationship between social
distance and dehumanization, involved telephone interviews of about 120 people at
randomly selected telephone numbers in Kirksville, MO, the home of osteopathic
medicine. I looked for the interview schedule we used to measure, among the other
variables, dehumanization but could not unearth it, probably because it was buried
or tossed in the three office moves I made since the study was conducted. But I do
recall some of what we did. We used factor analysis to whittle down the number of
items to a dozen or so, including length of waiting time in ambulatory care
facilities, failure of providers to introduce, leaving the door open during an
examination, allowing people to observe the examination without patient consent,
and the like. The structure of the items used was unique in that subjects were
asked how they expected to be treated and how they were actually treated. We did
no test of validity other than the factor analysis and did find that the instrument
had an acceptable level of retest reliability and internal reliability.

The second study I mentioned and from which I included figures used a convenience
sample of only 66 college students. I included it as a part of a triangulation
procedure I used because it was pertinent to the issue addressed, paralleled in
findings more methodologically sound studies, and added to these studies by
systematically tapping motives for same-sex intimate care. I introduced it as a pilot
study and used it to defend a request for financial and temporal support but was
turned down because, I was told, the study could be conducted without either.
However, I suspect the real reason was political.

Regarding your last question, there were only 10 males in the sample so I did not
separate them from the aggregate for analysis purposes.

You're absolutely correct, js md, "modesty is most definitely a product of
upbringing." It is also a product of personal experiences. A young man or young
woman may have been socialized to have little concern over the exposure of his/her
body. Negative experiences in, for example, a locker room, on a date, or even in a
health care facility coupled with the media-induced image that people have of what
kind of body is desirable can make one mighty "prudish" in a hurry.

Modesty varies cross-culturally as well. When U.S. women's bodies are suddenly
exposed they tend to cover their crotch and breasts. Women in some other
countries are more likely to cover only their breasts, only their crotch, or, in some
places, their faces. Among the Yonomamo of South America, women don't wear a
stitch of clothing. Neither do the men. But the men do put strings around their
waists and tie their penises to them (which anthropologist Napoleon Chagnon says is
mighty uncomfortable). However, even they have their modesty; if they are caught
with their string down, they become very embarrassed.

There are also subcultural differences in the U.S. "Blue bloods." "Boston Brahmins,"
and those of British descent are more likely than others to consider their bodies
sacrosanct. As has been pointed out in a previous posting, people from the Middle
East are even more sensitive about exposing their bodies to others. As an
illustration, according to a report I heard a couple of days ago, a convicted terrorist
housed in a supermax facility outside of Denver is content to remain in his cell for
the rest of his life rather than get a reprieve from his cell for an hour a day because
the latter requires that he be strip searched. I somewhere have a description of a
legal case about an Arab American who had coffee spilled on his lap by a passenger
jet stewardess. He was thrown to the floor and over his objections, his pants were
removed in front of others. As a consequence, he became impotent. He sued the
airline for battery and pain/suffering and his wife sued for loss of consortium. They
won their cases.

Js md, I tried to get the site of Kapczynski's lengthy legal treatise to come up but
neither of my computers would or could accommodate me. I was able to find her
two page comment but would benefit by her elaborative statements in the longer
publication. What I did find interesting was her frequent reference to customer
preference as though the desire for same-sex intimate care was qualitatively similar
to male airline passengers' preference for attractive female stewardesses. Judge Roy
addressed the difference between the two by citing a paragraph in A. Larson.
Employment Discrimination Sex 14.30 (3d Ed. 1980): "Giving respect to deep-seated
feeling of personal privacy involving one's own genital area is quite a different
matter from catering to the desire of some male airline passenger to have . . . an
attractive stewardess. The correct simulation of this type of case is to the personal
restroom attendant example. After all, one could with equal logic say that the
decision not to be stared at by a member of the opposite sex while urinating is only
a matter of customer preference. Indeed the degree of invasion of peronal privacy is
far greater in the hospital case. The hospital attendant not only has to replace and
remove bedpans, but, if the patient is weak enough, may also have to bathe the
genital regions. It would be a strange doctrine that would decree that the sanctity
of the right to privacy in the performance of excretory functions, fully respected in
a public restroom, is forfeited by the fact of falling ill and becoming hospitalized.

Gve, I had a very negative viceral response to your description of how you were
treated. I shudder to think how I might have responded under the same
circumstances. Some 300 posts back, I thought I read that the UK had laws or
required policies enjoining hospitals to accommodate requests for same-sex
intimate care if available. My wife, who is a nurse/attorney, would advise you to, if
you cannot go elsewhere, make use of the facility's grievance process, if there is
one, diplomatically making your needs (as distinct from your preferences) known to
authorities at each status level. If that doesn't work find an attorney who will make
a phone call to the proper authorities on your behalf.

The dilemma in which you find yourself is not unusual here in the States. Our PPOs
and HMOs limit us to healthcare providers who are in their systems. There is one
dermatologist in the town in which I live. If he won't accommodate patients'
requests for privacy, they must drive two hours to find another, and there is an
even chance that none of the others will accommodate patients' requests. To simply
find another provider if we become disillusioned with the one we now visit is often
easier said than done. -- c. ray b.
Tuesday, October 23, 2007 9:42:00 PM

js md said...
"JD. Prisoners do not have full constitutional rights. Not really a valid comparison."

That is true, but the point is that male prisoners do not receive the same rights to
privacy as women prisoners, at least in many states and institutions. Some court
decisions have justified this due to society's feeling that women need greater
protection, but IMO it is legally tenuous.
Wednesday, October 24, 2007 6:46:00 AM

Anonymous said...
I, too, would like to thank c.ray b. for his wonderful postings.
Like ARA K, I hope we can stay focused on the "nitty gritty". But I would like to
leave some info that may help searchers online. I found the full 37 page Kapczynski
report at: http://www.yalelawjournal.org/pdf/112-5/kapczynskiFINAL.pdf I would
like to point out that she is a bright young gay feminist and a leftist activist. Her
opinion is shaded by this.
On another note, those looking for same-gender hospital/medical support should
print up the online statement of St. Michael's Hospital regarding all Pelvic care. It's
the gold standard for what many people posting here have said they are being
denied. The animal does exist. I suggest sending this to those "professionals" who
think otherwise or say it can't be done.
St. Michael's is clearly thinking pro-active and staying ahead of the change curve.
The URL is
http://www.stmichaelshospital.com/programs/imaging/ultrasound/exams.php
Now, back to the debate. Equal Protection Under Law, I find this a great new angle
for attacking the problem. KYLE
Wednesday, October 24, 2007 1:25:00 PM

Maurice Bernstein, M.D. said...
And thanks KYLE for presenting us with the two very appropriate resources to help
us with this discussion. It may be that the last URL may not be fully visible in some
browser formats, so I have created links to each of the resources:

Kapczynski report

St.Michaels Hospital

Again, thanks.. ..Maurice.
Wednesday, October 24, 2007 2:31:00 PM

Anonymous said...
AKA as jms md stated the issue was not the pat search, it was the issue that it was
applied differently based soley on gender. While I understand prisioners give up
certain rights when incarcerated, one would assume that deminished rights is
applies equally to both females and males. The fact that it was applied differently is
right on point to what we have said, offering more accomidation for female
inmates is a double standard.
Wednesday, October 24, 2007 3:17:00 PM

Anonymous said...
Jsmd, just because you have heard of no complaints does not mean patients are
happy and not everone is comfortable to object or complain. Patients are people not
products. How many patients go home feeling violated and angry with themselves
for not having the courage. I urge all teachers of the medical field to teach thier
students that not all patients will tell you they are uncmfortable particularly with
opposite gender care. Yes some people dont care but many do and suffer in silence.
Treat patients with dignity and respect we are not just 'a days work' we, patients,
are people. I have just found out I have two tumors in my brain and one on the top
of my spine so will have further investigations to see if there are more further along
my spine as I have only had an MRI of the brain so far. If I need to have them
removed I can assure you my underwear will remain and I will ask that a catheter be
placed with one nurse present and my husband will do my personal care.If my wishes
cant be accomodated personally I would rather go withour the op regardless of the
consequence. I mean lets be honest why cant underwear remain. The area to be
operated on will be draped so I cant see the problem. If for some extreme reason
underwear was in the way, a pair of sissors and 3 seconds and theyre off. Give
patients back thier dignity.RM
Wednesday, October 24, 2007 5:32:00 PM

Maurice Bernstein, M.D. said...
RM, I truely understand how you must feel. You are confronting a double anxiety
situation: concern about both your operation and pathology and treatment along
with concern about very personal intense modesty issues. I hope you will have made
your concerns perfectly clear to your physicians and they act intelligently and
constructively on all of them since I fear they are all interrelated and pertinent with
regard to your overall mental and physical health. My personal best wishes that all
concerns are resolved in your best interest and successfully. ..Maurice.
Wednesday, October 24, 2007 5:51:00 PM

Anonymous said...
Of course, offering more consideration to female prisoners than to male prisoners is
a double standard... but the whole matter of prisoners should not have been brought
into a debate regarding full citizen rights under constitutional law. When you lose
these rights as a prisoner, whatever you receive is
based on an entirely different system of judgements. The double-standard certainly
remains but it does not pertain to the argument being made here for "equal
protection under law". Let's not diffuse the issue with unnecessary sideshows. That
was my only point.
ARA K (not AKA)
Wednesday, October 24, 2007 5:55:00 PM

Plain Jane said...
Taking the emotion out of the issue of same gender care is like asking a husband to
not feel any emotion for his wife. One of the issues of same gender care is about
maintaining the intimacy of an individual or marriage. Violation of intimacy is
emotional and traumatic to the individual and/or spouse.

The rights of an individual to not be violated, or in a position where that may
happen, over the rights of a person to work in their chosen field is in my opinion
the issue that should never have occurred and same gender caregiving should be
established sooner rather than later. It has been a long standing tradition that men
are doctors. Doctors have taken birth out of the hands of midwives and brought
birth into the medical realm. This preempting of the primary need of females has
created a source of conflict for humanity. If women need to have medical care to
deliver their child, why not bring the midwife into the hospital? Why not train
women to treat other women?

The long standing bias has been that women need to be under the care of a man.
This bias has its foundation in the Bible. It is only natural that men and women
want to preserve their most intimate areas for their spouse. Same gender care does
not prevent people from working in their chosen area of doctor/nurse/technician
however it does limit to WHOM they give that care. Unfortunately, this very simple
concept is being challenged? Why? Some people think it is because of equality and
equal opportunity. Others very strongly feel that it is because of the opportunity for
violation of the individual. If someone can prevent a crime it is considered prudent
to do that, which is why people lock their doors. Why is it such a difficult thing to
see that same gender care is a step in the prevention of assault?

Jane
Wednesday, October 24, 2007 7:03:00 PM

js md said...
RM, I agree with you that because I heard no complaints, does not mean some
would not have preferred same gender care if offered. But of the patients I referred
to, those who were my patients (most were not) could easily have said something
on follow up. I certainly would have listened. I'm sure you would have. My point is
that few people feel as strongly as you and you have to make your feelings known
proactively. As I've said before, patients with your degree of modesty concerns are
not well recognized in medicine except where there are religious reasons. Good luck
on your medical problems.
Plain Jane, I disagree strongly that same gender care is indicated for assault
prevention if by that you mean a forced physical assault. Assault is rare in a medical
setting. Few providers would risk years of study and their entire career. I'm sure the
streets of big cities are far more dangerous for assaults. And same gender abuse
also occurs.
Equal opportunity laws were put in place to help the disadvantaged and women have
benefited immensely. There would be far fewer women physicians without them.
Eliminating them would be a huge set back to women.
Wednesday, October 24, 2007 7:49:00 PM

Anonymous said...
Plain jane, I was reading your post agreesing with you until I got to the last
sentence 'same gender care is a step in the prevention of assault'. I think it is up to
patients to decide if they are happy with care from the opposite gender or not. I
personally demand care from the same gender. I dont for one second think that
most doctors/nurses of the other gender are out to 'assault' the patient. I would
hope that even if I am unconcious, in theatre for example I would be treated with
dignity but as we have read here and on other blogs that does not always happen
which is why I take steps to lessen the chance. I insist that if a foley is needed one
same gender nurse does that while I am concious and then I put my underwear ON. I
also insist that there are no students present and that only the staff that are
required are present. Either I attend to my own personal care and if unable to do
so, my husband does. The dissapointing fact is that i feel i'm looked apon as a freak
and a pain in the neck for such requests. But at the end of the day, this is my body
it is sacred to me and my husband, and its my choice. Yes it may take more time
but I am a person. In any other situation if I was left naked with a bunch of other
people it would be assault but in this case you are supposed to be happy. I am not
saying that you are being assaulted to me it feels like it. Each person has different
feeling that is why we are individuals. Healthcare should not be one size fits all.
Wednesday, October 24, 2007 9:21:00 PM

Anonymous said...
Thank you KYLE and Dr. Bernstein for the links. I still can't access Kapczynski's
piece. I'll track it down in time.

During the process of conducting research a few years back, I interviewed the wife
of a man who reported that her husband had an experience pertinent to RM's
posting and the postings of several others last month. It seems that he went to a
hospital to receive surgery for carpal-tunnel syndrome. He was told to remove all his
clothing and don the ubiquitous gossamer-like hospital gown. He asked why he had
to remove his underwear if the surgery was going to be on his wrist. He was told,
"It's policy." He did not accept this explanation as legitimate and kept his
underpants on. After he was anesthesized, his underpants were removed. A nurse
brought them to the waiting room and in front of other people handed them over to
his wife laughing as she proclaimed, "I think these belong to your husband."

I interviewed a physician who performed carpal-tunnel surgery, giving him the
above scenario. He defended the battery by suggesting that the fellow probably
signed away his right not to be battered and defended removing the pants as a
necessity in case something went wrong and the patient had to be catheterized.
"Well, doc, how many times have things gone wrong during the carpal-tunnel
surgeries you have performed that required catheterization?" I asked him. "Never,"
he responded. So, in spite of the fact that the best estimate that something would
go wrong for this physician was zero, his carpal-tunnel surgery patients would,
nevertheless, be required to doff their underpants.

I also asked the physician, "Among all carpal-tunnel surgeries, what is the likelihood
that something will go wrong requiring a patient have a Foley catheter put in?" He
didn't rightly know, but he did guess about one in one hundred thousand. "In case
something goes wrong, how much time does it take to cut off a pair of underpants?"
I asked. "A few seconds," was the answer. And, how much is a patient's dignity
worth? I, of course, did not ask this latter question, but given the evidence, the
answer must have been "not much" as far as this physician was concerned. What is
certain, the patient's dignity in the case described above was worth a lot more to
the patient than to the health care providers who removed his underpants over his
objections.

As an aside, given the mention of prison, our military has apparently exported to
Iraqi prisons the belief that people's rights not to be subjected to gender
discrimination trumps prisoner's rights to privacy. Iraqi prisoners, thousands who
have been released since we invaded the country, have been scrutinized by guards of
the opposite sex in the most intimate of situations. Such treatment is a sacrilege to
people from the Middle East and is profoundly ethnocentric. It has, unquestionably,
incurred the antipathy of many Iraqi citizens. According to Bilton and Sim ("Four
Hours At My Lai"), the only good way to win a guerrilla war of the sort we are
fighting in Iraq is to curry the favor of the civilian population. Our political and
military leaders can hardly hope to gain the favor of the Iraqi people by showing
such contempt for their mores. Maybe that's one reason why Scott Ritter (one of the
chief arms inspectors) proclaimed, "We've already lost the war," not long after
President Bush proclaimed victory. c. ray b.
Wednesday, October 24, 2007 10:18:00 PM

Anonymous said...
jsmd, my point is many people will not speak before during or after. Yes I would,
but many wouldnt and they may go on to suffer in silencev.RM
Wednesday, October 24, 2007 10:32:00 PM

Anonymous said...
c ray b. I'd like to mail you a copy of the Kapczynski opinion.
No charge. We can do this several
ways. I'll leave an email address
here and you can send your mailing address direct or, if Dr. Bernstein is willing, you
can give the address to him in an email and I'll email him to have
it passed to me. Your comments have raised the quality of blog postings by a good
country mile and I appreciate your special involvement. bbaldwin
Thursday, October 25, 2007 12:52:00 PM

Maurice Bernstein, M.D. said...
I will be happy to be an intermediate to maintain personal privacy on this blog as
desired. ..Maurice. DoktorMo@aol.com
Thursday, October 25, 2007 1:42:00 PM

Plain Jane said...
JSMD,

I was using “assault” in the context that any violation (improper touch, consensual
sex, rape etc.) of a patient is an assault to that individual. “Infringing” on an
individual’s intimacy rights is too soft of a word and not a correct assessment of
how the individual feels.

If a woman was in a situation that every tenth man she saw was a sexual predator
wouldn’t you advise her to avoid that situation?

JSMD, let me quote you so that I get it correct: “Few providers would risk years of
study and their entire career. I'm sure the streets of big cities are far more
dangerous for assaults.”

In going through some old posts on How Husbands Feel Yahoo group I found the
following:
“I wonder if your wife would be grossed out if she realized there was a better than 1
in 10 chance that the doctor examining her is a sexual predator? Look, at any given
moment, according the U.S. Dept. of Justice, some 200,000 men are incarcerated,
or on parole or probation for offenses that fall under the broad category of "sex
crimes". Bear in mind this includes everything from violent rape to exposing
oneself, to hiring a prostitute. Now let us suppose (and this is just a guess on my
part) that there are an additional 200,000 men who are guilty of a sex crime but
have never been caught, or have been released from prison, etc. The adult male
population of the U.S. is about 100,000,000. So, there is only a 1 in 4000 chance
that an average man is a sex offender. Why does physician sex offense occur at a
rate 25 times greater than the average male population, and more importantly,
why is it tolerated?”

The figures come from the US Census, US Dept of Justice and the Vanderbilt and
other studies on physician sexual misconduct.

I find that these statistics are appalling and are a disgrace to the medical
community and are beyond acceptance. No wonder many people are becoming more
and more insistent on same gender care. These statistics help cement my distrust of
the medical community and the integrity of the “system”.

Equal opportunity laws have been a huge leveler in the treatment of minority groups
such as women in the past. I have not said that men should not practice medicine or
work in medical fields. What I have said is that men should not be working in an
area where they will be in a position to examine, treat or care for women in
situations where intimacy can be violated. JSMD, touting the “Equal opportunity
laws” as more important than the rights of an individual seems to be a travesty of
justice. If equal opportunity becomes more important than the rights of an
individual, more and more people will refuse to receive medical care to preserve
their emotional and physical wellbeing over their medical care. Yes, even to the
point of death.

Jane
Thursday, October 25, 2007 3:05:00 PM

Anonymous said...
Jane, that's why male doctors work with female chaperones. Your problem is
already being well considered and your use of the word "assault" is offensive to men
in and out of medicine regardless of statistics. Being angry, unreasonable, and
illogical here only gives the whole patient modesty movement a set back. You
presently have or will soon have as many female doctors as male doctors to attend
to you. Until such time, you'll have chaperones and hordes of female health care
workers to watch after your point of view.
You stepped all over an important discussion of constitutional law taking place here
with a couple of recent rants. You, as a women,
have far more patient modesty rights extending from gender sensitive care in
initimate procedures. Given that fact, your playing on the status of supreme victim
here is a waste of this blog's space. Chuck McP
Thursday, October 25, 2007 5:23:00 PM

js md said...
Jane, I assume you’ve gotten the 10% figure from the Vanderbilt article that’s been
quoted here before. The article does quote many studies varying from 4% up to 12%
of male doctors in certain specialties admit to sexual contact with patients. In
psychiatry, one study gave 4% of male responders admitted to sex vs. 6% of female
responders! (Admittedly all these figures are submitted anonymously and voluntarily
so they are only guidelines.) But don’t forget that women are also transgressors.
Bear in mind that almost none of these encounters were criminal, which translates
into the fact that these were consensual relationships, not a legal assault in any
way. Medically improper yes, and grounds to lose a license, but not criminal in the
vast majority of states and locales. When you contrast those percentages with the
percentage of married couples who have had ‘illicit’ affairs, somewhere between
30-50%, it’s hardly surprising. It has no relation to incarcerated criminals who are
there for nonconsensual assaults (except when minors are involved) and comparing
physician sexual improprieties with criminal assaults makes no sense.
So in short you are in very little danger of a sexual assault in medical surroundings
unless it is consensual, which could happen in any surrounding.
Thursday, October 25, 2007 5:26:00 PM

Anonymous said...
Dr. Bernstein,

I must have missed something: I thought this blog was a discussion of patient
modesty, and the reasons for it, rather than a discussion of constitutional law.

JSMD, could you provide some documentation for your assertion that "almost none of
these encounters were criminal"? We have been down this road before. A fair
number of states criminalize "consensual" physician-patient sex. The idea is that
due to the power imbalance, the patient cannot give consent. In this sense the
power wielded by the physician is somewhat analogous to the power wielded by a
rapist wielding a weapon. I am offended by the way you try to minimize physician
sexual misconduct by describing it as "medically improper". The fact of the matter
is that almost all physician-patient sexual contact is harmful to the patient: "It is
now well established that a sexual relationship between physician and patient is
almost always damaging to the patient. The damage includes, but is not limited to,
sexual dysfunction, anxiety disorders, depression, increased risk of suicide and
dissociative behavior. Such a relationship also destroys both individual and public
trust in the profession." (Minnesota Center Against Violence and Abuse:
http://www.mincava.umn.edu/documents/bmprpt/bmprpt.html

CLW
Thursday, October 25, 2007 6:18:00 PM

Plain Jane said...
JSMD and Chuck McP,

Obviously, I have touched a nerve with each of you. Patient Rights vs. Equal
Opportunity. Does it threaten you as men that women object to men other than
their husbands seeing them in intimate settings?

I challenge you to do a daily Google alert for doctors, sex, physician, sexual
misconduct or similar words. You might be surprised how many hits you get. I have
seen articles on over 700 different doctors all current regarding these issues in the
past year. The most frustrating thing with all of these is that the majority of
doctors "get off" with nothing more than a token slap on the wrist from their
medical board.

I think you will be surprised.

Jane
Thursday, October 25, 2007 6:26:00 PM

Anonymous said...
JSMD...

According to many states, there is no such thing as consensual sex between a
physician and patient. If it is not consensual then it is definitely NOT a pleasurable
act and can leave mental and sometimes physical scars for years.

The "hypocritic" oath is "First do no harm". What happened?

JB
Thursday, October 25, 2007 6:30:00 PM

Anonymous said...
Also, JSMD, the Vanderbilt study figures you used for psychiatry are for residents;
another study cited by Vanderbilt puts psychiatrists right up there at 12% along with
male practitioners of OB/GYN, internal medicine, surgery, and family practice.

The Vanderbilt Study recognizes that a serious problem exists: "According to the
American Medical Association (2001-2002 Edition), 797,634 physicians are actively
practicing in the United States. If the survey data are accepted, the potential
problem estimates at up to 10 % of the physician population or 79,763 physicians.
This is a substantial number and should be considered a priority problem for medical
educators, physician leadership groups, and the Federation of State Medical Boards
of the United States. "

I believe Dr. Bernstein has indicated that he realizes a problem exists and has taken
steps to increase awareness of it among his students.

CLW
Thursday, October 25, 2007 6:57:00 PM

Anonymous said...
Dr. Bernstein,

I must have missed something: I though this blog was about patient modesty and
the ways it could be achieved, one of which is reviewed judicial opinion in
constitutional law.

CLW, FIND YOURSELF A BLOG REGARDING SEXUAL ASSAULT BY MALE DOCTORS AND
RANT ALL YOU WANT.
-- CHUCK McP
Thursday, October 25, 2007 7:18:00 PM

js md said...
Yes CLW and Jane, we have been down this road before and I personally have no
particular urge to go through it again. I have little tolerance for people who see
perverts everwhere they look. The solution is not to mandate same gender care for
everyone; there would still be perverts. Perhaps Dr. B. thinks it's worthy of a
separate blog.
But if you do have any statistics as to what percentage of physicians offenders have
received *criminal* sentences for sexual misconduct I'd be interested in hearing it.
Thursday, October 25, 2007 7:21:00 PM

Anonymous said...
Dr. Maurice. Yes, PLEASE find a new blog for CLW aka Plain Jane and JB so that we
might get on with somemore patient modesty issues here. Jane, I now have a
totally different view of the purpose of your recently opened "Patient Modesty" blog
of record and will not be posting there. ARA K
Thursday, October 25, 2007 7:58:00 PM

Maurice Bernstein, M.D. said...
As Moderator, I would hope there is no migration of the discourse into "name
calling" or worse since that behavior does not lead to further constructive and
instructive discussion. No, I don't see any value of a new thread into "medical
perverts" since that term and worse names have been used on my previous threads
on infant male circumcision until I put a stop to those uncivil and unproductive
descriptions. Think, based on somebody's statistics, if all the alleged vicious
pediatricians and all the alleged sexually abusive OB-GYN, surgeons, urologists and
general physicians were jailed or their licenses to practice shredded what would be
left for the care of the sick? Sure, some have suggested that society should take
medical diagnosis and treatment of the hands of doctors and given out to others,
technicians or maybe patients should have access to resources to treat themselves--
full autonomy.

I am not denying, as I have repeatedly stated here on this blog, that there are "bad
apples" in this box of fruit which makes up medical practice and let's get rid of
them through established legal routes. That means if any of my visitors finds such
an apple and can document the unwanted or unprofessional behavior then REPORT it
promptly to the state licensing boards in the U.S. or to the regulatory bodies in the
other countries. Don't keep it secret from officials and steam up about it on blogs
like mine.

Don't worry, as far as Dr. Bernstein is concerned and his first and second year
medical students, they, as well as the clinical faculty colleagues, are hearing from
me about the concerns regarding why doctors are hated, the deep concerns of
circumcision and patient modesty and have been suggested to read the threads on
my blog. And these concerns need to be mitigated and resolved.

By the way, does anyone know what is happening on the development of a formal
patient modesty activist group and a blog for the group so that the clout of numbers
can start to get some movement throughout the medical institutions and
government?

Again, let's keep the ongoing discussion including all new pertinent material civil
and with appropriate documentation (as already has been done in a number of
posts) so that we all can learn. ..Maurice.
Thursday, October 25, 2007 8:20:00 PM

gve said...
JSMD,

I think that you appear to have missed the point of the entire blog if you honestly
believe that "few people feel as strongly".
The reality is that most people feel stupid and silly to raise the issue of personal
modesty with medical staff and it is apparent that medical staff are MORE than
happy that this prevails.
If your assertion is so right, why not try asking every patient you see for a week,
what their preferrence is regarding gender of providers (I mean YOU actually raise
it) and see what response you get.

The whole "conspiracy of silence" about this issue by the providers is no accident,
everyone is looking over their shoulder about their own job, what if half the
population suddenly chose not to be seen by you?

It is about time that the providers were proactive and started to do the asking,
those that do so will see their practices flourish, while those who ignore the issue
will eventually be seen as being the dinosaurs.
Friday, October 26, 2007 1:47:00 AM

Plain Jane said...
Plain Jane is not CLW. Amazing isn't it? Two different people with the same
viewpoint. Interesting. I wonder how many more people exist that have similar
viewpoints that have not found this blog yet? Or are afraid to post on it because of
being insulted if they do?

The point that I have been making is that I have legitimate reasons for my
viewpoint and have told where I got my proof from. The numbers and the insistence
among doctors that the system is working are what have me so riled up with this
whole issue.

Dr. Maurice, as you full well know, it takes time to have enough information to
take to the medical boards to implement change. Rest assured that it is happening.

Plain Jane
Friday, October 26, 2007 6:14:00 AM

Maurice Bernstein, M.D. said...
Moderator’s Notice: Because of the need to meet the responsibilities to my medical
students which trumps the responsibilities to this blog, I want to inform the visitors
to this thread that I won’ t be moderating and therefore posting your comments to
this thread for the next couple of days. Therefore, lets have a brief cooling off
period and I will welcome your postings beginning on Sunday Oct. 28th. ..Maurice.
Friday, October 26, 2007 7:36:00 AM

js md said...
gve,
I'll defer to Dr. B to tell us what the point of this blog is. But the very title, "A More
Significant Issue ? " implies that its significance is in doubt given the question
mark. I certainly think it's valid to discuss all sides of the issue, both pro and con. In
fact, my doubts I believe have helped stimulate Jane to start a blog (which has not
gotten an overwhelming response I might add, though it can take time).
Friday, October 26, 2007 8:11:00 AM

Anonymous said...
Thank you bbaldwin and Dr. M. for your offers. I have asked my aide to track down
the article.

Js md -- Your 10/25 post seems to imply that, given the validity of research
conducted, sexual misconduct by physicians is relatively rare as evidenced by the
much higher rate of adultry. This comparison might be credible were one to assume
that those who commit adultry are in unequal power relationships and physicans
who commit sexual misconduct are married. These assumptions are, at best,
tenuous. To determine if sexual misconduct among physicians is relatively rare, a
more apropos comparison would be with those in other occupations in which there
are assymetrical power relationships (e.g., teacher-student, boss-secretary, etc).
Although I'm unfamiliar with research that estimates the rate of sexual misconduct
in other occupations, I think it is reasonable to hypothesize from opportunity theory
and by generalizing findings from research that tests this theory that the rate of
sexual misconduct among physicians and some other healthcare providers is higher
than among those in other occupations in which assymetrical power relationships
are the norm. One could also reasonably hypothesize that, within medicine itself,
those specialities which require the most intimate contact with patients (especially
those of the opposite sex) are those in which the rate of sexual misconduct is
greatest.

Second, the studies cited by the Vanderbilt article seem to all be self-reported
studies. Self-reported measures are notoriously invalid for tapping rates of
victimization, or, if you will, the likelihood of being victimized. The validity of
victimization reports has been shown to be far superior to the validity of self-
reports for estimating the likelihood of victimization. Unfortunately, we would still
have a unique problem using victimization reports to tap the rate of sexual
misconduct among physicians and other health care providers because some, if not
most, of it occurs when patients are anesthetized.

Third, I submit that battery is more common among healthcare providers than is
assault. Tell me if I am mistaken, but I do believe assault refers to the threat of
battery; battery refers to unsolicited and offensive touching. When a healthcare
provider, without patient consent, whips off a sheet covering the patient thereby
exposing him/her, that's battery, not assault. When students practice unnecessary
pelvic exams and prostate exams on anesthetized patients without their consent,
that's battery. To label these sexual battery would require evidence that there was
sexual intent. Generally, that would be difficult to establish because we can't get
into a person's mind to determine motive.

Fourth, I am always skeptical about the "bad apple" assertion. The same thing was
said about Enron, Tyco, and other companies and their CEOs. Nobody who studies
the evidence, however, could ever reach this conclusion. Corporate crime is
institutionalized in the U.S. (see, e.g., David Simon's "Elite Deviance"). By
institutionalized, I mean it is commonplace and defended by those who are part of
the corporate culture. I would also hypothesize that battery is institutionalized in at
least some healthcare facilities. For example, the practice in some teaching
hospitals of allowing students to conduct pelvic exams and prostate exams on
anesthetized patients without their consent is well documented. Those who sanction
and defend this practice do so with impunity and respond with moral indignation at
any suggestion that it is inappropriate. And, I hypothesize that were one to
aggregate the many anecdotes in which battery is described, the same conclusion --
that battery is institutionalized in some healthcare facilities -- would be reached.
Let me give you one illustration that I propose represents a pattern. In effect, what
I am doing here is asking you to see the general in the particular.

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 she and
several other nurses were preparing an anesthetized man for surgery when one of
the nurses lifted the man's penis, pulled it out, and commented on its length and
size. The class responded in the same way as the other nurses who were preping the
patient; they broke out in laughter. I asked the professor if she reported the
incident. Her response was "no." Following the class period, several nursing students
who had been practicing LPNs for some years, approached me and defended the
battery as being a legitimate response to stress.

I wrote of my early findings to Dr. Gott, a medical columnist, after he published a
column on chaperones. Following his publication of my piece, he received what he
described as an "avalanche of letters from readers who had either experienced such
harassment or were aware of it." He also received numerous letters from outraged
nurses accusing him of "yellow journalism," publishing "smut," "unprofessional
behavior," a "gross injustice," and demanding that he violate his code of ethics and
give up my name and address. In defense of his choice to publish my letter, Gott
countered that "this type of harassment . . . is clearly a problem in some parts of
the country. If pointing this out constitutes 'yellow' journalism, so be it. I willingly
place myself in a class with Sinclair Lewis, the writer who first exposed unfair labor
practices and was unfairly labeled a 'yellow' journalist for doing so." -- c. ray. b.
Friday, October 26, 2007 8:22:00 AM

js md said...
c ray b,
I did not say at all that sexual misconduct by physicians is relatively rare. I have no
reason to doubt the frequencies given by the Vanderbilt article though as I too said
the methodology is severely flawed. It's hard to come up with a more feasible
methodology though. My only point of contention is the use of the term assault (or
battery if more appropriate). No one has defended any sexual contact between
physicians and patients as being appropriate. Different states handle it differently
but criminal prosecutions are rare as they should be 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.
I'm not sure by the way that your assumption of misconduct is greater when
intimate exposure is present is correct by the way. There is evidence that the
incidence of offenses is greatest in the field of psychiatry where there is no
exposure.
Sunday, October 28, 2007 11:05:00 AM

amr said...
C Ray B. - It would be very much appreciated if you could re-post your article here
or provide a link

This blog still remains one of the only places on the web where this discussion is
taking place publicly, but it is clear that these discussions are taking place within
the healthcare community. And given the ubiquity of the internet this is
bothersome.

Even after the pelvic exam issue came to national attention, only an handful of
states created laws against it, and there hasn’t been any attention drawn really to
it since 2003 when it came into public focus. It has since faded from public
discussion. Thus bringing these issues to national attention shall be equally difficult.
However, taking a cue from Ubell, a starting place could be a study from the
“inside” that documents the battery from the perspective of nurses who participate
or are witness to the battery but do not feel empowered to report it. This could
lead to Congressional hearing….

To add to the discussion about nurses and/or health care professionals having “fun”
with patients, I submit the following allnurses links. I was in contact with the nurse
that reported the problem, and she reported that nothing came of the incident and
she eventually left the hospital. At the time I originally read these entries, they
turned my stomach.

whoa inapproriate

whoa inappropriate continuation

Of late, I have begun to wonder though how truly prevalent the problem is,
especially in the ER or OR.

However, in the above allnurses entry nurse Tri does state: “The patient was not
harmed in any way. This type of behavior has been common in every OR, ICU and ER
I've worked in for the past 21 years. You need to pick your battles. Set a good
example and others will respect you an others may follow your lead.”

Pragmatically speaking, there will always be some level of abuse; human nature is
not going to be changed. So, beyond continuing to site examples (like I just did) ;-)
, finding out the scope of the problem I believe is important. Such a study as I am
calling for would help to calibrate us all.

Some areas of interest to me would be:

1) Location in the hospital or clinic (such as xray, mri, urgent care)
2) Who involved (nurse, doctor, other health care professional)
3) What was the event (touching, comments, exposure, pelvic or dre exams not
consented to etc)
4) Was it reported. If so, what was the result. Was there blowback?
5) Is it considered by the reporter as “business as usual” and common or is it rare
(rank the findings)
6) How often are events observed by a reporter
7) Is this institutional, regional, or national problem.
8) Did other patients observe the event
9) Did a pt report the event.

This could start out in one city just like the Ubell study did.

Unfortunately, abuse in an unequal power setting, since it is common in other
places in society, I am postulating that it would be at least as prevalent in the
health care arena..


Another one of my personal issue is with cameras being used (especially in the OR)
with the forced consent of the patient, meaning you must sign the release to be
videoed or photographed as a condition of being treated by the hospital. This is
truly institutional abuse. Someone recently rationalized it to me (who is a Dr.) by
saying essentially, what can you do, it is done by every teaching hospital.

JSMd- The internet is overtaking the hospital (and the OR). There is a long history
of medicine taking advantage of patients in a hospital setting (and OR setting) in
the name of furthering education. The scope of the patient violation is truly making
the OR a public room in the hospital. This is an issue that is being advertised on the
net all over the place, but the public in general is oblivious to the ramifications of
what is being advertised. Recently UCLA gave an introduction to their new hospital
with Nancy Reagan in attandance – LA Times article June 5, 2007, California
section. Also there is a big promo video piece on the UCLA web site boasting about
how surgeries can be viewed anywhere in the world.

In a weird way, cameras in the OR might reduce the abuses that we have been
speaking about in this blog, but at what cost to the patients privacy?


JSMD – October 28 11:05am – If you are referring to “consensual sex” then I would
agree that it is wrong and I would have difficulty calling it criminal. I might discuss
however in this case loosing of the license. If on the other hand you are referring to
a health care professional taking advantage of a patient in a totally unwelcomed
manner or after the patient is under the influence of sedatives, then without a
doubt this is a criminal act, and there is no excuse for it. The example given of
grouping the patient’s penis in the OR in my mind constitutes criminal behavior.
Non-consensual pelvic exams I believe is battery and there is a legal brief on the net
that speaks to that issue. But even in the California law against non-consensual
pelvic exams, I do not believe that the law speaks to any penalties. So although CA
has law, I believe that it would be a civil dispute. Non-Con Tort

If by “transgression” you mean the former then I have said my say. If you mean the
latter, then I believe you would be creating a protected class of individuals that
would be above the law. Put another way, it would be ok for the nurse to play with
the patient’s penis in the OR with the patient “under”, but not ok if she did the
same thing, let’s say, in her apartment after she administered a date rape drug.

-amr
Monday, October 29, 2007 12:29:00 AM

js md said...
amr,
Thanks for the allnurse reference. Tales like that are always disturbing. We have
talked about this before as well. I don't know how common incidents like this are.
My guess is that they are restricted to a few hospitals or even nursing stations
within an institution. I have never heard of anything like this at the hospitals I've
been at. There are stories like this on voy, but allnurses is much more believable
and professional. I'm sure most nurses would be shocked at such behavior. The
hospitals have a lot at stake here. If the family heard of this or walked in there
could easily be a lawsuit that the hospital could not defend. Suits like this have
occurred.
My comments about physician sexual misconduct were in response to Jane claiming
that male physicians are mostly criminals. There is nothing protected about sexual
misconduct and many physicians have lost their licenses to practice, but few go to
jail unless their conduct was repeated and egregious with some element of force
involved (either physical or mental). This is no different from the nurses where a
charge of battery could be entertained, but I've never heard of a case that went to a
criminal trial.
Monday, October 29, 2007 1:28:00 PM

Anonymous said...
Wow a lot going on here, 1st off I would say if male physicians were as bad as has
been alluded to here we would read it in the paper constantly as in today's suit
happy society it would be a paycheck to retirement. While I have no doubt it
happens, to say it is widespread or most physicians are guilty.....I question that.
Second definition can give you the results you are looking for if you try. I read a
study by NOW that something like 70% of women were abused by their husbands,
abuse ended up being defined as raising ones voice, looking at them in a menancing
manner, etc. That being the case I would be surprised it wasn't 100%...of both
genders. If we apply that same scenerio to the medical community, how many
nurses are abusers...Applying such generalities to a gender is a slippery slope indeed
and I would bet a majority of people have a lot higher opinion of our providers than
that.
I also read the allnurse blog, and while I found not only the act sickening but also
the fact that such comments as "no harm to the patient" or "not reporting it so as to
fit in" were used to justify...I also found it encouraging that it was a minority and
the vast majority were appauled by the action. I still think a majority of patient
feel providers are compassionate and moral by nature with a few bad apples. It also
highlights another problem, the different viewpoint providers have on the issue of
modesty, the no harm theory is applied to less severe cases in compromising patient
modesty...but it is always applied from the providers viewpoint, not the patient,
harm as in beauty is in the eye of the beholder, and in this case, the patient is not
seen as having valid opinions...why is the example of showing the patient's penis to
other nurses different than a voyer lurking in the alley by a bathroom
window...becasue it is in a medical setting and...we are asked to trust providers...
The other thing we have battered around is sexism, since the other blog on sexism
is not about modesty, I would address it here. I believe that many of the issues
where we have a double standard that cuts against male modesty arises from our
early beliefs that females need protected more than males. We are still hesitant to
send females into combat, the different standards for pat downs at prisions were
issued by a judge that felt it was more tramatic to females and they needed
protection from male guards. The all nurse incident, if it was a group of males and
a female patient heads would roll....our society feels the need to protect females,
whether it is justified or antiquated thinking....regardless it is sexist.
Monday, October 29, 2007 2:54:00 PM

gve said...
jsmd,

thank you for confirming my supsicions about the medical profession. When in doubt
prevaricate.

If you are SO certain that this is a minor issue, why not do as I suggested and ASK
each of your patients for a whole week (hardly a life threatening burden on you)
what their preferences would be.

Is it really so difficult to understand what is being suggested here? Patients are like
animals caught in headlights, they say VERY little about what is going through their
very troubled minds regarding modesty, if invited to do so I am POSITIVE the
outcome would be different. Why not prove me wrong?
Monday, October 29, 2007 4:17:00 PM

Maurice Bernstein, M.D. said...
The last Anonymous and every other Anonymous, please..please remember to
identify your comment ending with some pseudonym or initials so that readers will
know to whom specifically to reply and make the discussion all that more
understandable. Should I prevent posting of those comments without any consistent
identification? Please, it doesn't take much time to think up some arbitary initials
that are unique and place the same ones consistently at the end of each comment.
..Maurice.
Monday, October 29, 2007 4:46:00 PM

Anonymous said...
There have been a lot of good points lately. I definitely agree with the point that
the patient’s perspective of what acts are harmful is very important. For many
patients, the harm from the inability to maintain their dignity outweighs the harm
that would come from declining the medical procedure. The tragedy is the fact that
this should not be the choice. The medical profession should be more focused on
maintaining high professional standards including intolerance for unprofessional
behavior. Even if there are only a few perpetrators of the unprofessional acts, they
are not being held accountable by their peers or the administration. This is clear
from the cases named in this blog by the ethicists, and the examples brought in
from outside blogs. In each case, the health care provider who defended the
vulnerable patient was the one who ended up leaving their job at the hospital. In
addition, many doctors who have been found guilty of misconduct do not lose their
medical licenses, and are not required to inform future patients, as illustrated by
reports from state medical boards. Recent posters have opined that there is a broad
problem that goes beyond isolated offenders, and 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.
KCM
Monday, October 29, 2007 6:07:00 PM

DO NOT ATTEMPT TO MAKE A NEW COMMENT ON THIS MISSING COMMENT SITE. IT WILL NOT BE PUBLISHED. ..Maurice.