Patient Modesty: Volume 7
To continue the topic of patient modesty, now Volume 7, I selected the graphic fresco by Masaccio from Wikipedia "The Expulsion Of Adam and Eve from Eden" (painted 1426-1428),displaying the fresco before and after restoration (ca 1980). The fig leaves were added (ca 1680)three centuries after the original fresco was painted, probably at the request of Cosimo III de' Medici in the late 17th century, who saw nudity as “disgusting”. During restoration in the 1980s the fig leaves were removed along with centuries of grime to restore the fresco to its original condition.
With this fresco, the various faces and nuances of modesty are suggested from the original painting in the different postures of Adam and that of Eve and then the reaction of Cosimo III to the nudity of the characters in the fresco. In a way, I see these different responses reflected in the different views expressed on these Patient Modesty threads. I would be most interested to read what my visitors see from these two views of the painting as related to the thread topic.
NOTICE: AS OF JANUARY 8 2009 THIS THREAD WILL BE CLOSED FOR ALL COMMENTS. DO NOT ATTEMPT TO WRITE ANY FURTHER COMMENTS HERE. PLEASE GO TO "PATIENT MODESTY: VOLUME 8" TO CONTINUE COMMENTS. ..Maurice.
..Maurice.
posted by Maurice Bernstein, M.D. @ 4:01:00 PM
116 comments
116 Comments:
lm wrote the following to Volume 6 today which is no longer publishing comments. ..Maurice.
I had previously mentioned 7 negative experiences with female providers,ie nurses and ma's. Out of the 7, 4 were privacy violations
and 3 were of unethical behavior
I personally consider any type of
privacy violation a form of sexual
assault. Based on my experiences I
don't consider female nurses as professionals. PERIOD!
lm
lm, alan here, I keep forgetting to sign my posts so I will start with it. I was the one suggesting most providers were good etc. I would like to ask you, and I do this in all sincerity, what did you do about your negative experiences. Did you tell them, follow up with a advocate, JACHO. I have had some success taking it up the laddder....what did you do in response to these issues.
Going with the original painting, I think it's interesting that Adam hides his face as Eve turns hers upward, as if seeking to deflect attention from her body to her spirit. Her shame of her body seems acute.
Adam does not seek to cover himself, but expresses detachment; he removes himself from the gaze.
I think these two different reactions can both be used to characterize the difficulty of modesty for patients--we are subjects (or objects) rather than actors of agency in this regard. While health care professionals may take an objective unemotional stance that we do not, while they may see similar cases day after day, each time the situation is relatively new to us and is humiliating.
We, too, seek Adam's detachment (pretending there is not a gaze while knowing there is) or to deflect the focus to the soul that illness affects.
The leaves do have the effect of softening the picture and its meaning, transferring the attention more to the grief of separation, although less so in Eve's case.
The icon I use on my own blog, Frida Kahlo's The Broken Column, depicts her without full clothing, but here she has agency and challenges the viewer's gaze. I've thought about changing it sometimes, or alternating between images, but I like it because it carries a lot of meaning about pain and subjectivity.
lm, I too feel a privacy violation is a sexual assault. I had a procedure in which I was NOT informed correctly who (what sex of personnel) would be doing a genital procedure. I felt sexually assaulted after the fact when I learned I was in fact lied to as to the policy and procedure and who on the team does genital procedures. In any event, after the toothpaste is out of the tube there isn't much one can do and little satisfaction to any complaint you make. I will don let this type of thing happen to me again or to my spouse. They intentionally fail to inform people. They think they have full rights to do whatever needs to be done without discussing this type of procedure with a patient. It is fully for their convenience and expeditiousness of the task. Evidently they feel a patient either 1. doesn't care or 2. they'll never know. Complete inconsideration for a patients rights. Plain and simple. JCAHO was the only agency that did anything.
LM Here. I did complain to the
joint comission. I complained to
my insurance carrier, the hospital
and the Dept of health services.
The state board of nursing is next. Yes, I was a male patient.
Yes, these things happen even to
men. It's disturbing! I have no
trust in nurses, particularly the
female type!
LM
LM did you get any response from any of the parties? ...alan
lm, if we may ask what was the general complaint involving patient modesty? Have you received any satisfaction in complaining to the agencies you listed? Just curious as we went through the same basic channels you are. Thanks. JW
RE: Frida Writes reference to Kahlo's Broken Column: Even with Kahlo's apparent immodesty of exposing her breasts note that she still keeps her disfigured legs hidden. The are her inviolate secret. Kahlo would probably agree that privacy is a very individual and subjective issue and deserves to be respected as such.
Complaint process
1) Ask to speak with the charge nurse. Ask to speak with the
house supervisor. Ask for the patient advocacy. They are on call
24/7.
2) Write a letter to the CEO and
the chief nursing officer.
3) Complain to your insurance providor.
4) Each state has a Dept of health services. Complain there as well.
5) Complain on line to the joint comission.
6) Complain to the state board of nursing.
7) Complain to the corporate board.
Thats who the ceo answers to.
These are just some of those entities I complain to when
some female nurse likes to
assume I don't care about
my privacy!
Annon dec 22 4:30 pm:
if you are lm in reference to the previous post I can tell you my experience, briefly.
1. formal complaint to the administrator, medical director
and surgeon (who had a financial interest in the facility= found out after the fact)
2. complaint filed with CMS in CA
3. complaint filed with the health dept.
4. complaint filed with Joint Comm.
5. complaint filed with the board of nursing (it was May and there were already over 1400 complaints filed-- case workers are overworked and underpaid and have little interest- overwhelmed!)
6. Finally complained to the corporte organization after it took nearly 2 years to find out who it actually was and then it had been sold off 2 times-- do you think anyone really cares?)
It took over a year for the so-called investigations from the BRN and the health dept. A call finally from the medical doctor in charge at the health dept. You know what he said...basically that is "who does" these things. And I quote, "the best thing is to stay out of a hospital!" No lie.
End of story..at the end of the day.. no one cares and NOTHING is done to right a wrong!
JW
That's when I initiate plan B. By
letting the public know. Successful
advertisement. That would have began by the second week. Had it been me. TRUST ME. They would be out of business in a month. You let
the public know that a facility and
their medical staff is careless
about your privacy! Then we see who
wins! All is fair in war!
JW,
What was your actual complaint if you don't mind sharing. Thank you.
But in Plan B..letting the public know.. wouldn't that open you up to a court suit by the doctor, nurse or institution of either slander or libel? That means that you would be hiring a lawyer and going to court. What do you think? ..Maurice.
Not really, what in order to slander it has to meet several criteria, and while I am not a lawyer I have posed this question to my attorney. Here is my disclaimer...I am not an attorney, this is my take on what he said not neseciarily law....had to toss that in. In order to be slander, it has to be 1. false 2. casue measurable damage 3. intent wieghs into this (ie. done for profit, malice, etc). If a person state and can document and facts they can not be held liable nor is it slander. Also a person who clearly states opinion within reason is protected so long as they state that clearly. The proof of liable and slander is a lot tougher than one would think. We had a person write an article to the paper stating that he wondered if what we did as a business did not violate anti trust or price fixing laws...not a thing we could do about it....and that wasn't even true...so there are ways to take it public without putting one at risk....and I agree, don't stop, be smart, but don't give up...pay an attorney to write them and tell them the obvious that you find their response unaccceptable and are investigating your options....they hate to hear from attorneys, it might cost you $75-100 for a letter, it will cost them 2-300 to pay an attorney to research and respond....JD
We have a right to picket. It's called the first amendment. BTW,
already spoke to an attorney about
it. Yes , I've done it successfully
and I've hurt some businesses
financially. But then maybe just
maybe they can improve their
service to patients(customers)
don't you think?
JW here, the complaint involved a violation of my privacy rights. Several issues were involved. I stated I preferred same gender intimate genital procedure to be done by a male and I was lied to. Also I was asked to sign a form which in small print states I was consenting to "others standing in observing me naked, allowing photos, and video filming." The signature for consent was signed when I had no adovate with me and no corrective lenses in order to read the form and I was told by the nurses that it was for something else. Other issues were also involved. Overall the entire experience was a pathetic mishap. Read just recently a man died in the same facility while there for outpatient surgery on his knee. The paramedics were called and they said they had been there several times prior but this was absolutely beyond words. I knew they would end up getting theirs and they did! You can't practice lies, deceit, falsified charting forever and get away with it.
You need to be careful going to the public with any complaint. I agree that it would be an effective way to get their attention; you just need to make sure you have your facts in a row before hand. Try to get your point across without naming any names/organizations. I say this because we had a case go to the court system a few years back where the doctors sued the local hospital for defamation of character. Why… just because the nurses/employees of the hospital wrote a letter to all the doctors and placed in the break room asking them to get the chip off their shoulder. They were upset with the CEO of the hospital so they sent their patients to different hospitals just to get their point across. It never went anywhere and I believe they dropped the suit but my point is that this was just a letter from the employees of the hospital that only reached the doctors (not the public) and it went to court. If you name names, you open yourself up to these lawsuits. I’d consult a lawyer to see what you can say legally. Jimmy
Along the lines of discussion here about patient modesty is:
A close friend just had hip replacement surgery and then spent 10 days in a rehab facility. When it came time for him to get a shower (at the appropriate post-op time) the RN told him: you know what tomorrow is?? We get a shower!
SSHE took him to shower. He stated how completely uneasy and embarrassing this situation was for him. Why is it this goes on?
Maybe Dr. B can explain this, maybe not. This could easily be handled with male orderlies, etc. There is NO reasonable reason that a healthcare faiclity cannot ask a patient about this and if they have a preference. IT is WRONG for them to shove this down everyones' throat. Of course there was one male that had to come out with filthy inuendos about how the nurse could scrub his privates for him. You see from a percentage of men carrying on like this ALL men then get the sterotype that males are not modest and don't care about cross gender personal care.
All I can say is that it shows a complete lack of respect and dignity for people.
JW
I had a hip replacement relatively recently. I chose NOT to use the patient controlled analgesia because of the increased risk of urine retention and having to be catheterised. I was in agony for the first 24 hours and the nurses were astounded at my refusal to use the PCA. I explained why I had decide to not use it, and they sort of understood. I was not prepared to be catheterised by a female nurse. YET, when i was told it was ok to take a shower the next day, a nurse insisted she would have to supervise me. Now, did they really think I would go through that agony of no pain relief for over 24 hours to protect my dignity and then just accept being watched in the shower by a female nurse? of course not. I stood my ground (on crutches, lol) and insisted i be allowed to shower in privacy. they eventually realised i was not for giving in and relented. I do understand that they may have responsibilities and have insurance worries, but do they for a moment think they would be comfortable having me watch them shower? - no way! Why not get some male staff who can do this sort of thing? the demand would surface if the service was offered.
Its about time people bring these
issues to light. Its discrimination
and trust me that I would be complaining big-time.
"the demand would surface if the service was offered."
That's why hospitals are extremely reluctant to offer the service, or even ask patients if they want same gender care. They know the demand would surface.
And I don't think it's so much that they wouldn't be able to accommodate patients. I think it comes down to two actions that hospitals would have to take to make it work.
1. In some hospitals, as in many "systems," the almighty schedule has attained a sacred status that is difficult to dethrown. To make a gender-choice system work, hospitals would have to place patient modesty and dignity on a higher level of value than the interests of the institution. For most systems, the schedule is designed to accommodate the system and its workers.
I must say here that some hospitals really try to schedule mixed gender staffs and they will tell you (and I belive them) that the can accommodate same gender requests same most of the time.
2. Even if the hospitals place the schedule below patient needs, they will tell you that they just don't have enough male nurses or CNA's. But then I ask, what are you doing to get more males into the system? What specific actions are you taking? Most of the time they admit they're not doing anything.
If hospitals really believe that this is an inportant issue and if they really want to make it work, they will do more than just give it lipserivce. They will actually try to recruit more males.
Regarding the other issue that's come up recently on this blog -- female nurses "supervising" male patients showering. I just interviewed two men who went through this. The wife of one man was extremely upset.
I find this scenaro fascinating. Why is this happening? What assumptions are behind sending a young female nurse to supervise an older adult man shower? What assumptions are being made about men in general and about that man in particular?
We all know that the "system" would rarly send a young male nurse or orderly in to help a female take a shower.
This is one of the best examples of the complete insensitivity exhibited by hosptials regarding men and their sense of modesty and privacy.
Part of the problem here, again, is the "almighty" schedule. Things run much more smoothly for the system if the schedule isn't disturbed. And in some hospitals, God help the patient who dares mess with the schedule.
In fairness, I do know that many hospitals do work with their schedules to try to accommodate both sexes. But they are reluctant to let this be known publically. They won't put it on their websites or include it in any pampahlets. They are afraid that, as someone posted above:
"the demand would surface if the service was offered."
And they are not anxious to open up what they consider to be a "can of worms."
This is where, I believe, honest, open communication breaks down. Hospitals that really try to make these accommodations, need to take the risk and let their patients know, publically. I believe it would not only make their patients feel better and relieve stress, but it would also be good for business.
I just have to step in and ask a pertinent question: "Can't we divorce sexual implications from the routine and standard work of a medical professional?" I just can't imagine that most or all female nurses find sexual excitement in the routine viewing of a man's genitalia or any other body parts. No matter what any "nurses" write on another blog, I can't believe that this sexual interest is regularly present or trumps the interest in performing the care necessary for a patient that needs assistance, such as taking a shower. It may well be that a male patient may be more concerned about being observed by a female nurse, but that is not necessarily true of all male patients who may be more concerned about their present and future physical disability than any worry about exposing themselves. Where are the sociological studies yielding reliable statistics that lead some of the visitors to this thread to their persisting conclusions? I am not, by this comment,suggesting to ignore the need for some men to be able to request and obtain male healthcare providers. That may be necessary for some men to be comfortable. But making sexual generalizations about nurse intent and behavior without studies is about which I am concerned. ..Maurice.
(p.s.-if I missed documentation of such studies in one or more of the thread volumes, I wish to be informed.)
Dr. Bernstein:
Per your last entry, I suggest
reading a couple of recent postings
on Dr. Sherman's, "Medical Privacy"
blog, under his "Male Modesty Violations,
A Special Case" sub-heading.
First is a link to a blog by a
patient named James Wallace Harris
on December 19th, 2008. The second
is a possible view inside the mind of this
patient and the young nurse assisting him.
(JASON, December 20, 12:03 AM)
I think it makes for a fascinating look into the actual dynamics of compromised modesty and shows that "sexual implications" can never really be divorced from medical routines because both patients and medical professionals always remain sexual beings.
I'd cut and paste them here but, for some reason, this does not appear to be possible on your blog. I do hope you have the capability for doing the same and will re-post here. I feel the two entries, viewed together, give some special insight in ways we rarely seem to understand.
- avram
Dr. B, I don't particularly think the issue is "sexual". Where in the diaglogue of the "showering" discussion was it elluded to or stated that the opposition had to do with something "sexual?"
It is the appropriateness of the siutation. My elderly mother was in a nursing home and a male nursing assistant was assigned to give her a shower. She reluctantly went along with it at the time. It was afterwards that I heard about it for nearly 20 minutes about how humililated and embarrassed she was and how that was NOT going to happen again. No matter how old we are this bothers people. Unfortuantely NOT all people "speak up." They need to focus on the fact that this is not a routine normal thing they are forcing on people in the healhtcare system. It is a matter of dignity and respect not necessarily anything "sexual."
If you're referring to my post above, with all respect, doctor, you're missing the point.
No where am I implying there is any sexual content to these encounters. For someone to be ashamed, embarrassed, humiliated --doesn't necessarily mean that they believe the observer has sexual intentions. It's more, I think, a question of power, giving up basic control of one's body.
I don't think that nurses get sexual excitment from, for example, supervising a man's shower. There have been studies about "Nursing and Power," and, for some, that may be an issue. The profession recognizes the power dynamic involved. And don't neglect power -- one gender having power of the other gender's naked body -- as insignificant. Just as rape isn't about sex, it's about power -- so too may be this issue, to some degree at least.
But that's not the point. As others have stated before, it's not about whether the nurse does or does not get sexual excitment. It's about the patient's feelings. Certainly an older, out of shape man, if he's sane, doesn't believe a young nurse is getting any sexual pleasure from seeing him naked. That doesn't mean he might not feel embarrassed and would rather have a male nurse observing.
It's not about sexual pleasure in most cases. It's about one's feelings of dignity, empowrment and the respect or lack thereof he or she feels involved. It's about how the patient feels.
And where are the studies? I've been asking that question through several volumes of this discussion. Doctor -- you have contacts within the medical world. Why is it that we haven't seen, to my knowledge anyway, any psychologists or sociologists log into this blog and confront some of the issues we're discussing? Of course, we don't really know who some of us are here -- but I haven't read anything suggesting it's from a medical professional, other than posts from you and Dr. Sherman.
Over the past few volumes I've mentioned some studies that circle around this issue. So have others.
So -- I ask you, doctor -- where are the studies? Why aren't they being done? Or, if they are being done, why aren't they more available? I think I have mentioned here how difficult I have found it obtaining certain medical studies.
You write: "It may well be that a male patient may be more concerned about being observed by a female nurse, but that is not necessarily true of all male patients who may be more concerned about their present and future physical disability than any worry about exposing themselves."
Your correct, of course. But who here is saying this for "all male patients"? I'm not.
But I must say, doctor, you're also looking at this issue, in your last post, from the nurses point of view. Try looking at it more from the patient's point of view.
And your correct, not all men feel the same way about this. Neither do all women. We're all different. And we need to be treated as individuals. Isn't that the main point of much of the discussion on this thread?
I note you didn't mention my comment about schedules. Unfortunately, in systems sometimes schedules develop a life of their own and begin to, by their power, control values systems. Remember, core values are great, but how do you impliment them? Schedules are one tool. Systems need to make sure the schedules match up with what the core values say. Frankly, in some cases anyway, hospitals that say they can't accommodate patient values due to scheduling -- first need to look at the scheduling.
Dr. Bernstein, I think you are missing the point here on several levels, and coming from the medical side of the equation I understand your perception will be different than ours in some cases. But here are a couple of questions and observations I would pose to you and other providers:
1. Modesty is no strictly a sexual issue. There are many cases where exposure is embaressing without sexual connotations. If you were working out at a local gym and went in to shower, would you be completely comfortable with a female custodian coming in and cleaning the locker room while you showered naked in her view. Would you be fine with mothers bringing their young childeren in to shower or use the toilet and waiting in an area where they could observe you shower? If you were showering at home and the female neighbor needed to barrow some towels, any issue if she just walked in and got them. Medical personell have someone elevated themselves to a higher plain of moralit that them seeing members of the opposite sex is somehow different than in other scenerios of the same situation. No one said this was sexual...but it can still be embaressing.
2. When providers are placed in the patients roll they often speak of the embaressment. Some facilities even make special accomodations when staff members are patients. They get to choose staff, are provided special clothing etc...some try to justify it with its different becasue we work with each other...balony, if providers truely get conditioned by the repeated exposure that should balance or trump the fact that they know each other.
3. What about the double standard. There is an obvious consideration for females that isn't as prevelant for males. Why is this? If this truely isn't an issue, why do we accomodate females at a different level? Is it only female providers that have this ability?
4. The obvious answer for 3 is, it isn't about the provider, its about the patient. Why would anyone think it has to do with the providers emotions, its the patient that is in a strange environtment, the patient that is naked, the patient that is stressed...the provider is fully clothed in their natural environment. We don't care if the provider is having sexual thoughts or not, its still embaressing.
5. Concern for ones physical well being and modesty do not have to be a one or the other. We can have our physical health as the main priority and still care about our modesty.
6. Let me ask you, where are the studies that indicate men (and let me ask you..why do we restrict this to men and not both genders)don't care or wouldn't be more comfortable with at least the choice. Hospitals and providers are in the best postiion to gather this information. They have the patient contact to gather this information. I think the fact that such a study hasn't been done is an indication of the answer itself...don't ask if you don't want to hear the answer.
Why do providers always get defensive and make this about them? Why does the issue come back to what the provider is thinking rather than what the paitent is feeling. Modesty among members of the opposite sex is taught from a young age. In the medical setting sometimes we have to get over the years of condictioning to get care. That may mitigate some of that condictioning but it does not extinquish it. We seem to understand that for females but not males. The other part of this, it isn't an issue of can't, its a matter of don't or won't. What would be the harm of asking???? The harm would be then you would have to accomodate when it is easier to pretend it doesn't matter....until it is the provider who is the patient....alan
"Where are the sociological studies yielding reliable statistics that lead some of the visitors to this thread to their persisting conclusions?"
Sorry, Dr. Bernstein, but despite your obvious concern regarding the matter of male patient modesty, this has to be the most cynical, disingenuous statement thus far. Obviously, a medical establishment that thinks so little of male privacy as to have NON-medical personnel observe intimate procedures on males is not going to "squander" resources on a study of the sexual response of MEDICAL personnel in dealing with patient nudity (unless or until, male worker/female patient procedures become as common as the reverse). Further, any such studies would necessarily be self-reporting—so much for truth and accuracy.
The point of the matter is not whether or not the nurse (etc.) is stimulated, anecdotal evidence and common sense aside, the point is the psychological battering of the patient: e.g., a grossly fat, ugly woman that most men would rather tear their eyes out than see naked probably would object to being watched by a male non-doctor during an intimate exam or showering.
This denigrating of male modesty is ubiquitous in this culture, beginning in early childhood—IMO, responsible for much of male fetishism—and continuing from puberty throughout adulthood. It causes real psychological trauma. The exhibitionist bravado of certain men is evidence, not disproof, of this wound. Taught by mothers (and fathers) not to complain—believe it or not, in infancy by some—males merely acquiesce these indignities, not embrace them. It is a guarded secret on par with Freud's revelations, not an elephant but, indeed, a T-Rex in the room.
Though relevant, this is a VERY BIG topic better pursued in different forum.
What is germane, however, is effect these practices have not only on the mortified male patient but on male medical care in general. While it is documented that women in the U.S. seek non-gynecological medical care at twice the rate of men, the reasons for this disparity are speculative. Why, for instance, do men usually wait until a problem is dire before seeking medical help? Again, there are no "sociological studies yielding reliable statistics" for this phenomenon; still, is it beyond the pale to consider that most men would rather not subject themselves to this kind of humiliation unless absolutely necessary? If the tables were turned, would women? We're not talking about gynecological exams performed with discretion by male doctors. We're talking about intimate procedures viewed by, say, a male receptionist. But then we'd hear a storm of female protest, a storm of protest males are psychologically unprepared to make.
This is a self-reported sociological study that would have some validity if conducted correctly, maybe by non-medically affiliated men in a non-medical setting. For example: Have you put off seeing a doctor for reasons of modesty? I don't know, maybe a questionnaire designed by male patients themselves. In any event, the problem is larger than either men or the medical establishment is willing to admit.
Are we literally embarrassing our men to death?
—H.B.
P.S.: This is my first post. I've looked in on the discussion since Vol. 5, but my access to a computer has been sporadic until recently.
H.B. and others: If the concerns of those contributing to this thread is not one of healthcare providers desiring sexual arousal in their routine work, if it is not accusing the healthcare providers of sexual perversion or being sexual psychopaths or sociopaths then, of course, I stand corrected. Yes, I totally agree that there are both men and women who because of their physical modesty, by whatever its etiology, that this discomfort should be recognized, attended to and mitigated. I would agree, and as witnessed by comments on this thread, that such discomfort can be threatening to health if it causes patients to avoid examination, diagnosis and treatments. Certainly, just as physicians and nurses must be attentive to the physical ills of the patient, the emotional status should be recognized and dealt with.
I hope I have clarified my view of the discussions here. Now, as I have written previously.. go out and become activists for the change that we all agree is needed. ..Maurice.
Yes, I am too surprised by your comment Dr B.
It's ALL about the patients' concerns, and has nothing whatsoever to do with what the provider, nurse, or aide is thinking. Embarrassment and modesty concerns only affect the patient, not the provider. If the embarrassment is necessary medically, then the patient has to adjust, but most of the time that is not the case.
I'm sure the percentage of providers who are sexually stimulated by any of these encounters is very small. But that's not relevant to the patient's comfort level.
The question of how many men avoid medical care for these reasons remains unclear and badly needs to be studied. Everyone agrees that it is a factor. It would not be easy to study however as you'd have to survey men who don't seek care. How do you find them?
I hope, Doctor, that you don't misinterpret my comments. I have great respect for you and what you're doing. But I was a bit surprised by your last comment:
"If the concerns of those contributing to this thread is not one of healthcare providers desiring sexual arousal in their routine work, if it is not accusing the healthcare providers of sexual perversion or being sexual psychopaths or sociopaths then, of course, I stand corrected."
I'm baffled by the "ifs..." I came on this blog, I think, in Volume 3and have read all the past threads here. Although there are a few, a small minority, who seem to be bashing medical personal and suggesting sexual perversion, it's a really small number, maybe only one or two people. Most seem pretty rational about this issue. Asking for choice and equal consideration, I don't think, is irrational.
I have discussed this issue with several people, men and women patients, nurses and doctors, a few psychologists, one well-known sociologist. All have agreed that this is a valid issue, and the sociologist suggested studies be done -- specifically face to face interviews with patients leaving the hospital. He thought it would be a great topic for research, and couldn't refer me to any studies in the area. And his expertise is gender studies, so he would probably know.
I'm struck by my interviews with patients. Now, I'm not suggesting these are professionally conducted interviews with the necessary protocals. They're not. But I believe they indicate certain things. Here are some of the perceptions I read from the patient stories regarding what they consider modesty violations:
So much seems to depend upon what I'll call the "attitude" of the caregiver. Call it "clinical" or "disinterested" or perhaps "arrogant," or what might be called one of "entitlement." These words represent reality as the patient perceives it.
It's almost as if general manners are lacking in these cases, commen sense politeness -- like knocking on doors, introducing oneself, explaining what's going to happen, not allowing many people in the room, preventing people from just coming and going who are not connected with the patient's care. And letting the patient know more fully what's going to happen to them, specifically (if they want to know).
I've been struck, talking with couples, about how the other spouse, the one not undergoing care, is often most affected. Quite often the spouse being cared for is hearing some of these stories for the first time from his wife or husband -- because he or she wasn't completely alert or awake at the time. The one being cared for seems angry not just for himself or herself, but because the spouse was so hurt.
I've urged these people to write letters explaining why they were unhappy with their care -- but the impression I get is that they won't. They just want to forget about it and move on. And, they're afraid they'll be labeled as difficult patients. So, we all lose. Although they've been helped medically, they've lost trust in the system. The system has lost because it isn't getting any constructive criticism and assumes, because enough people aren't complaining, everything's okay. And we all lose because these incidents too often get pushed back into never never land as if they never happened, which increases the chances that they will continue to happen.
Again, this all comes back to what I've been saying on this thread -- open, honest, caring communication. Face the issue. Bring it up. Discuss it. Ask about patient attitudes and values. Not just before you're about to do a procedure. But long beforehand, so you know what the patient's values are and the patient knows that you know and that these values will be taken into consideration and respected.
I think the sociologist's comments about face to face interviews is well worth considering. Paper and pencil questions are one thing. Telephone or online questions are another thing. But actually sitting down and talking with patients who have had these negative eperiences would throw much light on the issue. Doctors and nurses need to do this. Is it actually being done anywhere? Perhaps. You need to look into the eyes of these patients, listen to their stories, acknowledge their feelings, try to regain the lost trust, see the tears and feel the frustration and powerlessness.
Face to face exit interviews should be part of the strategy hospitals use to find out about how they're doing.
And you're right, doctor. We all need to be doing things. But I'd like to see hospitals start working to get more feedback regarding modesty issues.
How many of you on this blog who have had surgery or procedures done, have actually be asked (face to face, paper and pencil, telephone on line interview) about your satisfaction with your hospital stay or treatment?
I've been asked by my doctors during follow up appointments, but never by the hospital itself.
Joel, it was reasonable for me to wonder and respond about the basis for the discussion when I read on this Volume but much more on the previous volumes statements such as "I personally consider any type of
privacy violation a form of sexual
assault. Based on my experiences I
don't consider female nurses as professionals. PERIOD!"
"lm, I too feel a privacy violation is a sexual assault"
Much, much more on the previous volumes including anecdotes. But I am glad to read now that there is a consensus here that the problem doesn't arise from the female nurses or orderlies themselves and is not related to sexual interests but is a emotional concern of some patients with lack of recognition of these concerns or adequate response by institutions and systems. As I have said, I now stand corrected. ..Maurice.
Aside from the thread on allnurses
regarding unprofessional nurses
peeking under the sheet at a male comatose patient. A crowd of them
no less. They were not even assigned to his care.
In which case not only are they perverted,but that is considered illegal in every state. Please don't leave out the sexual gratification in what these nurses
get out of this. I know better,i'VE
SEEN IT FIRST HAND!
I can't recall if I mentioned on these threads that my wife is a RN and has worked in med-surg units of hospitals for over 30 years. I recently spoke with her about the context of the comments which has developed over the past year or so that dealt with male modesty concerns and female nurses/orderlies.
Without prejudice, she told me that there never has been any modesty issues brought up by any male patients as she performed her usual duties including helping ill patients in a shower activity. She did say that some family of patients of other cultures such as Hispanic or Muslim will not allow a male nurse or orderly to attend their female relative. My wife has not heard from other nurses male patient complaints on this issue. She says that all of her patients are ill and they express concern about their illness and ability to function rather than modesty. Now, whether that is the result of patients feeling intimidated to complain or that the modesty issue indeed is a minor one is something we can't establish.
Nevertheless, in my opinion, even if it was, indeed, a minor issue in terms of the number of patients affected, it is not minor in terms of the solitary male patient who feels uncomfortable or even more upset when the patient's modesty is ignored by the healthcare team. That is why I am continuing personal interest in the subject and continuing this thread. ..Maurice.
I think modesty as it refers to patients feelings is archaic and
should be replaced with privacy.
To say that a patients modesty
was violated diminishes the severity of the act. It should always be referred to as a privacy
violation. In the grand evolutionary scheme I don't have
any concern about my body. I didn't design. I'm not
obese and certainly take care of myself. I really couldn't care what
other people think. What I find
extremely disturbing is why I as a male patient am not granted the same respect for privacy by female providers that female patients get.
It's discrimination,its a double
standard and double standards are illegal. What's the motivating factor behind this,perversion!
You tell me? I'm sure most female
providers won't tell you the whole
story. Why should they? Do you tell
everyone that the prestigous institutes of health published an
article in 2000 stating that 98,000
people die each year from medical mistakes. Do you tell other physicians about other incompetent
physicians. Why would your wife say
otherwise? If she had never encountered any issues, why so many
posts on this and other sites. I doubt were making this up.
PT
I have to agree with the doctor on this. The more I look into this subject, the more I'm beginning to believe that:
1. It is a minority (could be significant minority) of men who area unwilling to ever let a female caretake work with them intimately. Like the doctor, I still agree that their needs should be met.
2. Most of the intimate care in hospitals is not done by nurses (LPN's or RN's). It's done by CNA's and other assisting staff. Most patient I interview don't really know who is working on them, whether they are nurses or assistants. Although people frequently introduce themselves, it seems that they rarely state their job title/training and I don't often see it on the name tags.
I wonder about the training of these assistants. With the shortage of nurses, there are many programs designed to get more people into these jobs quickly. It's probably hard enough just giving them the technical training. How much time to they spend on subjects like patient-centered care and ethical issues like the one we're discussing here? I don't know. I do know that they're not licensed and, therefore, supervision andon-the-job training becomes an important issue, and we know how busy doctors and nurses are. Many of these quickly trained CNA's and medical assistants are young and female. I just bring this subject because I wonder if some of the problems we're hearing are coming from this group rather than the trained nurses.
3. I think we're sometimes mixing up very different situations. Critical care is one thing. I agree that people dealing with cancer and other serious diseases probably have many other things on their minds besides this kind of modesty. People in pain just want the pain releaved. These critical situations represent one dot on a continuum from critical to non critical intimate care. On the other end, basic phyical exams, opposite gender chaperones for non critical procedures, intimate prep for non critical surgery, etc. -- these represent other situations and modesty may have a higher priority in patient's minds. We need to realize that modesty concerns may vary with the same person depending upon what kind of situation they're in.
4. Although some academics with certain agendas don't like to admit that there are real differences between men and women, the recent brain research contridicts them. For example:
A. In a book such as "Just Like a Woman" by Dianne Hales, Bantam Books, 1999 (pp.65-67 and pp 241-244) you'll learn that women have fewer red blood cells, sweat glands, and take fewer breaths per minute. Men get hiccups more often. Women sleep less soundly and awake easier. Sounds minor and maybe it is...
B. But in books like Steven E. Rhodes, "Taking Sex Differences Seriously (Encounter Books, 2004), you'll read: "...neuroscientists have determined that men have fewer neurons connecting the left and right hemispheres of the brain. This difference may help to explain why women are better at talking about their emotins." pp. 27-28.
This research suggests that women generally have better communication skill, especially in verbalizing emotions; they generally judge character and moods better than men.
Now, I haven't mentioned the areas where men excel -- mathmatics, spacial tasks like map reading, etc. It goes both ways, and we're learning more and more about this.
(See Leonard Sax, M.D. "Why Gender Matters: What Parents and Teachers Need to Know About the Emerging Science of Sex Differences." Doubleday, 2005; Simon Baron-Cohen, "The Essentail Difference," Basic Books, 1999; Matt Ridley, "The Red Queen: Sex, and the Evolution of Human Nature, Harper Perennial, 2003.
5. It's, therefore, not surprising to see certain jobs and professions dominated by a certain gender. We tend to like to do what we can do well. I'm not saying that there are not and cannot be more crossovers. Most researchers use the word "generally" in their books. But maybe it make sense that there are more women in nursing than men or more of one gender in specific medical disciplines. That doesn't mean we don't need more men in nursing, but it may mean that most men don't have the kinds of strengths that do well in that job. What percentage of women are in our military? We're not necessarily going to get a 50 percent each in all occupations. The sexes have individual strengths that work better in certain fields. Why is that surprising to some people?
I got into this topic as an academic interest. I have no past with bad experiences. I've always been treated will in medical situations. But as I read blogs like this and did more research I had to confront my own attitudes.
Frankly, I'm not opposed to having opposite gender intimate care. But like much of this topic, my preference is situational. For me, gender isn't as important is my feelings about how I'm being approached and treated -- civility, professionalism, confidence, skills, good communication, empathy, concern. If I feel those things aren't there, from a male or female, I may asked for a different caregiver. I'd rather have a female who had all those characteristics than a male who had none of them. And vice a versa.
PT, you have brought out an interesting point that I think should be further discussed on this thread: modesty vs privacy as the basis for male patient concerns.
Yes, privacy, in terms of control of patient personal information is considered important by law in medical care and indeed the HIPAA regulations set the limits to the distribution of such information. But historical privacy is also a right that a patient has to give up as the patient's history is taken by a physician or nurse and physical privacy is also a right the patient must give up to permit a physical examination or procedure to be properly carried out. If a patient refuses to give up these rights to their care providers, they cannot expect to be properly diagnosed and treated. I see privacy as a legal property given to all patients but at times must be relaxed.
Modesty on the other hand is an emotional or personality status that is an integral part of each person and may not necessarily be expected to be given up. The way I see it, the degree of modesty may limit the extent to which privacy can be appropriately given up. I think modesty is the difficult condition which is disturbing some people as they are attempting to obtain medical care and the term most appropriate to what has been discussed on these threads. I do look forward to comments by those who agree with me or disagree. ..Maurice.
MER
On the first issue you mention that only a minority of men refuse
female caregivers. Are the others
offered an option? Why do you think
some of us refuse? Bad experiences
in my case. I'm sure others have valid reasons. Furthermore, you mention that cna's do the bulk of
personal care. You are incorrect
in this assumption.
Cna's don't provide level one trauma care. Cna's don't do pre
and post-op care. Cna's don't generally work in icu's,ccu's and
neuro-surg floors. Generally in most er's there are one maybe two
cna's at the most and usually one
of those are male. On most nursing
floors one cna to 3 rn's or lpn.
In my case I had more negative
experiences with nursing rather than a cna. In three situations ethical borders were crossed and two others were privacy violations.
Finally, Dr B mentions that "if
a patient refuses to give up these
rights to their care providers,they
cannot expect to be properly diagnosed and treated."
Sadly, for many that sacred trust was lost!
PT
You state that your wife has not encountered negativity of personal care from male patients. It is no doubt because people (both sexes) do NOT speak up. The assumption should not be made that because there has not been verbal opposition of this practice that it does NOT bother people. Maybe it would be MORE thoughtful if a patient were ASKED about if they had a preference?? That is the key. It is the same thing that female patients have gone through for many years in years past having 95% male OB/GYN physiicans to go to for a check up or a delivery. So on that note because we did not hear from female patients that they did NOT like it particularly equates to ACCEPTANCE? NO. Clearly once women had the easy choice of going to a female OB/GYN they did so with enthusiam. NOT all women feel this way but many do and just like that not all men prefer same sex genital care but SOME do. Get the point? It is very individual and I don't think it is fair at all to say that just because RN's have not heard from male patients for 30years that this is confirmation that men don't feel uncomfortable and don't feel embarrassed with the situation. As a society it is a "given" that people know the majority of nurses and healthcare workers are female. So maybe nothing is said because they feel they don't have a choice.
JW
Wow that certainly revived the conversation didn't it. I understand now Dr. Bernstein what you were referring to. I agree with the above posters that the people calling providers perverts and accuse them of assult are a very small minority. I and others have urged those few to temper their comments to try to draw providers into the conversation as well.
Several topics have sprung out of this. One of course is the extent of the concern or issue. As stated above this topic has such a wide range of sub topics. Providers seem to often bring up the extreme the patient in the ER after a serious MVA, the cancer patient, the surgery patiient, etc...and while some people may have issues there...I would think these are a smaller segment of the group. I have problems with my care in several circumstances but have had several surgeries where I know females were present but really don't have a serious issue with that exposure at all, sending a female tech to do a scrotal ultra sound when a male was present, then witnessing them asking a female patient if she would rather wait for a female tech to be available..big problem.
And as far as patients expressing concerns, a patient not expressing a concern when they are already in the situation is not in my opinion representative of anything...what are they going to say. I and I am sure many or most of the people posting can all tell you we have been in numerous situations where we were humiliated by the exams-procedures and had big concerns....and never said a thing. I have stated this before but will say it again...I never said a word until I read this thread and realized...I wasn't alone and my silence was being taken as consent.
On the gender of staffing, while I have no doubt gender differences are to some degree part of the issue...however...the stigma or society labeling of nurses I think is more the issue. I teach a Junior Achievement Class to middle schoolers. It has to do with choices of occupations & education. One thing I started doing, again after being involved in this thread was doing a poll the first day of class. I ask them, how many of you would like to make $30 an hour, well of course every hand goes up. I then go through a series of questions of what kind of occupation they would be willing to do for $30/hr. When I ask be an X-ray tech, be a Dr., be an anesthisologist etc I always get a significant number of males rasing their hands, when I say nurse...hardly any...if any. When I question this, many of the boys say...you guessed it...nurses are girls. Our society has told us nurses are female, look at advertising, look at TV shows, etc. We promote the nurse sterotype as female. And while we may not have had official affirmative action there was a lot of effort in the medical and educational fields to provide a positive presentation of female Dr.'s. How much effort do you see to brak down that sterotype and bring males into nursing??/ alan
Most direct patient care is done by non-licensed help in todays world. These people have little training. Some are certified. Big Deal! RN's have other responsiblities and do not have the time or are no longer assigned such insignificant tasks.
How many people actually take the time to write a letter or even express themselves when angry or dissatisfied with a service. When people have a lousy meal at a restaurant to they write a letter or even confront the establishement? NO, most times they walk away and don't go back. People don't like confrontation. I'd guess only 1% would actually speak their mind and make an issue of something they no doubt figure isn't going to change anyway. So they just go along with the program and then get home and talk about it to friends and family. That is who hears about it not your wife!
I equate the level and discrimination of male patients to the degree of discrimination that
blacks recieved in the 60's,
rampant. At one surgery department
female patients are allowed all gender teams but when men ask they
are refused.
Why is it that at level-one trauma centers female patients are quickly covered but male patients are not? Why are there only female
nurses at urology offices? I could
go on and on. Discrimination is just that. But look further beyond
and ask why? What is the motivating
factor?
PT
PT, I am not posting the allnurses.com anecdotal portion of your last comment where you ended with "You say DR B that the number of people stating that female providers here on this thread are
perverts and that those are a small
number! Remember, the cross section
on this site is small as well and dosen't represent the big picture.
Most males that this happens to
are usually comatose!"
Please understand that I am not impressed by anonymous anecdotes especially coming from another blog. In a way, except for setting a tone for a discussion (and we have had sufficient anecdotes on these series of threads to set tones), these anecdotes without any documentation of the individuals involved and the full circumstances, beyond tone setting is otherwise without worth and in the negative extreme can be simply inflammatory. However, to make such documentation available on a blog without all the individuals able to consent is also unacceptable.
It is unfortunate that the "cross section on this site is small" and we have no understanding or proof of what sorts of visitors (patients or medical professionals)come here and whether they write for constructive discussion or for some other personal interest. Please accept my skepticism since on most blogs including this anonymity rules.
Anyway, this is my explanation of why I rejected the allnurses.com anecdote. Notwithstanding all that I wrote, lets go on with the discussion, especially one we have not concluded: modesty vs privacy as the primary source of concern. ..Maurice.
Dr. Bernstein. Would like to direct your readers to some interesting responses to James W. Harris' "modesty" blog entry that was referenced on Dr. Joel Sherman's "Medical Privacy" site, recently.
In my opinion, there are now a couple of well written postings that point out that Mr. Harris' willingness to accept compromised male modesty as status quo is a very big part of the problem.
The posting are signed "minutemoon".
I suggested a week ago that you post the URL to Mr. Harris' blog entry here and you didn't, so I am not going to list it. Should you chose, you'll find it easily on Dr. Sherman's site.
- avram
My instincts tell me that as far
as this discussion goes you are
in denial of the big picture.
This is not about a psychologial
emotional dispute, its about real
discrimination and privacy violations. If you can't accept the bad, you can never accept the good!
PT
PT, I am not ignoring privacy as a patient right and the right to physical privacy is a right as well as patient information. What I am saying is that, believe it or not, patients must give up a some of their privacy when they go into doctor-patient relationship for diagnosis and treatment of their symptoms. That would include right to physical privacy in certain regards. This does not mean that the doctor or his or her nurse should ignore the fact that the patient has given up some of that privacy and should be attentive to control this reduction in privacy. (Similar to the control that is required on the access to the patient's medical record or control regarding discussing a patient in a hospital elevator.)
That means attention to keep doors closed, curtains drawn, keep non-clinical personnel away from the examination or procedure and so on.
However, what determines how easily a patient can give up some of the right to physical privacy in order to allow an effective diagnosis and treatment will depend on the degree of modesty (the emotional component) that the patient carries. Obviously, there are some writers to this thread who have a degree of modesty which would prevent any invasion of their physical privacy and would avoid needed examination or procedures or would allow it only with medical care providers of a specific gender.
As far as "privacy violations" are concerned, yes, giving up of privacy is a decision of the patient and requires consent of the patient otherwise it becomes a legal matter and will be handled as such. And if privacy of a patient has been truly violated, there is certainly a civil or criminal legal consequence to that action. ..Maurice.
I personally do not believe the nurses or other medical staff are malicous in intent. I personally believe only a very small minority of the posters here beleive they are malicous. I do believe there are a very small number who are, those who enjoy the power, the embaressment, etc but they are a very small percentage. I personally believe the issue comes from several sources including commercialization where in scheduling means money and has taken a priority over patients emotional comfort. I believe it like most things of this nature started small and just kept expanding and the providers benefited from it and patients just accepted it. Now perhaps we are seeing the begining of the resistance that MAY start the penduleum back toward the middle. From my experience providers act more ignorant of the issue than acting like I was an idiot...that has been my personal experience and would lead me to believe it is not someting done with ill intent but more lack of sensitivity. I do believe the all nurse site is a good place for insight into the mind of the provider. The vast majority of threads there are technical in nature and job related. When it strays into this area it gets heated and gets cut off, so I do believe it is ligit compared to say voy which is more fetish. That said, none of these sites contain any of the analitical controls that would give us any measurable facts or data, so we take it for what it is. We should be careful not to take the extremes as the norm, the problem is who can define the extremes, I believe hating providers, labeling them all as perverts, saying in general they have mal intent, is extreme...but then maybe I am the minority or the extreme...I don't think so but niether do they....so it goes.
Dr. Bernstein
While we discuss privacy vs modesty..aren't we really just debating vocabulary. I think the vast majority understand we have to give up a certain amount of privacy/modesty in the medical arena, and most of us understand our decisions of what we are willing to give up in that area has the potential to compromise our care. Isn't the question(s) really who gets to determine what is reasonable accomodation. We are looking at the issue from two different perspectives. The providers are looking for efficency and to a large degree convinence for themselves, we as patients are looking for accomodation that provides us with as much comfort as possible. Isn't that what the issue is really about? The what (accomodation) is such a varied thing among patients. I have a different level of modesty and expectations than others. Some more, some less but it still comes down to who gets to make the decision of what accomodations will be provided. I had several surgeries and did not request a male staff...I felt that would be to hard to accomodate with multiple staff members needed for the surgeries I thought expecting them to manipulate multiple staff schedules to accomodate that would have been to much even if they were willing to do so. I also felt as long as I am out, I am ok as long as I don't know or have to face the people who were there when I was exposed. I kind of felt like I was just a piece of meat not a person to them with no personality or responses...and I got comfort from that...they didn't see my discomfort...so I was ok, now obviously others don't feel the same. On the other hand, scheduling or assigning a female to do a scrotal ultra sound when they had male staff that could have, and didn't even ask... I was really angry. That would have taken such little effort on their part to ask and assign accordingly. So who gets to decide what they will and won't offer or provide. Providers have elevated themselves to a level where they feel they have the right to dictate what level of accomodation they will provide and is adequate for patients, they have decided that we should be able to determine what they feel is ok for us rather than asking us what we need or want and making the decision from there. That I feel is the problem. WHO gets to determine the level, that is something WE need to take back. We have placed our trust in providers and our emotional well being is being determined by what fits the work model rather than what fits the patient. Assigning techs to patients randomly is easier than assigning based on patient preferences...so....alan
Alan is so correct with the last post. As with the showering incident in rehab for hip replacement I have to strongly say that there were male attendants available within this establishment as it was a large facility and connected with a nursing/ assisted living home as well. Therefore a male patient could be accommodated if they cared enough.
When Alan stated he was okay with the surgery because he saw none of the people, my expereince was not the same. My wife and I both chated with the female nurse who ended up (without our knowledge and consent) shaving and prepping my genital area. Having a full blown conversation with her and all made it even more angering afterwards, especially given the fact that I was lied to even after I expressed my feelings and preference. This iterates their domination and control to satisfy the ease of their routine with NO regard for the paying consumer.
I certainly don't dispute that some
privacy has to be given up,however,
it should be in the appropriate
context. My issue here never was about that. My concerns are privacy
violations and crossing ethical
boundaries. Modesty is too complex an issue to confuse with privacy violations. There is just no way
to extrapolate any kind of conclusion from the data on this site.
Concerning modesty issues,in 2007there were 347,524 female breast enhancements performed in the US
alone. That's up 64% since 2000.
On the other end of the spectrum
since 1990 there have only been
about 10,000 penile surgery enhancements and the majority of
these were for accidental trauma,
cancer,congenital abnormality and
war injuries during the 1st and
2nd gulf war.
You can see where I'm going with
this modesty issue. Additionally,
more at play here is the issue of
double standard. Wouldn't you
agree it is the drving force.
Core values within institutions
are already established and extend
to both genders. Why does this system discriminate against male
patients? I personally don't care
wether you published the thread
from allnurses, in the vast scheme
of things its irrevelant. There is enough articles on the web that anyone can find. They literally number in the thousands,however,
in your discussions they should
be talked about as they are part
of the problem and are not by any
means the minority.
PT
Dr. B you stated a short time back "sexual" connotation involved with this discussion. It received quite a stir. When "lm" stated he felt sexual assault with privacy and ethical violations from healthcare I am guessing that statement (I cannot speak for lm of course) is his 'feelings'. In other words it does not translate from the providers feelings but how it is received and perceived from a patient's point of view when they are not accepting of the actions (privacy and ethical violations).
It is like a RAPE. They say from the rapists point of view it is not "sexual" but an issue of "control". However, from the victims (and significant other) feelings and point of view it is a "sexual" violation.
So along those lines it is the feelings of the person harmed that is being expressed.
JW
Patients deserve a right to professionalism from the doctor, tech, or nurse. Patients deserve to have their privacy and modesty respected as much as possible given the constraints of the hospital system. However, I believe there is no such "right" to a same gender provider, whether it be a nurse, doctor, or technician. I believe this as adamantly as saying there is no such "right" to a provider of a certain nationality, race, or creed. Same gender provider is a privelege.
I'm an ER doc. At the hospital where I work, the majority of doctors are male, and the majority of nurses are female. If lucky, we may have one female doctor on at a given time. The next chart in the rack was a female pt with groin swelling and pain. After an interview, I needed to examine the area in question. The husband of the pt requested a female physician. My answer was "no," that if they want a female physician to examine her, they best leave the ER and find and pay for a female physician (which I knew they couldn't because of insurance), otherwise refuse the exam (to which I have no problem with, but that also mean I would discharge them as I have no idea what I'm treating or dealing with). They reluctantly let me perform the exam, after which I was able to order the correct test and admit her to the hospital. I make only one exception, and that is for a female pt who presents after being raped by a male perpetrator.
I knew this couple made this request based on either culture or religion. I know that the majority of women would prefer to be examined by women providers. Furthermore, I know that our one female physician (if we're lucky) would not appreciate having her day consisting of breast and pelvic exams passed on from people requesting "female physicians". This one pt's religion is not more important than another pt's preference. And in the end, there just isn't enough "supply" to meet the "demand".
I agree with those of you posted in the following aspects. It IS an infringement on your right if you were told that no females would be present but in the end there were. If an institution extends an option of male/female provider to a female pt, then they ought to do the same for a male pt. And disclosures about observation and videotaping should NOT be in small font.
However I believe to request a male ordelie or nurse even in "private" activities as foley placement or showering is unreasonable just based on the fact that one may feel uncomfortable. (Of course, if one calls the CEO of the hospital and offer extra $1000 cash to grant this privelege, I'm sure the hospital would be more than happy to oblige. This is in response to the poster who mentioned he was a "paying customer". What you are paying for is the medical care, and not the privelege to have who you want taking care of you...that's extra)
Put it this way. If an elderly African American male who was subject to the brutality of the KKK requested to be seen by an AA doctor, I think most of us would agree that the request is unreasonable. If the hospital grants him this out of compassion, then it's their privelege to do so, and not the pt.'s right. (This is just an example and not meant to spark another debate in this thread).
Chill, thanks for your comments particularly because you present your views from the doctor side of the doctor-patient relationship. And I have looked forward for the views of another physician besides Joel and myself.
I think that everyone writing to this thread and all patients should remember that in all of medical care there is operating the principle of proportionality.
It is a fact that diagnoses are made without exposing the patient to risks of any and every test or procedure. A patient with strong suggestion of acute pulmonary embolism who is not in shock does not need to have pulmonary angiography for a confirmatory diagnosis before starting treatment. That patient does not necessarily need to have pulmonary embolectomy to try to remove the clots in the lungs. The doses of anticoagulent for treatment of pulmonary emboli need not be started and maintained at some maximal dose but is titrated to an accepted monitored level of anticoagulation. Not all patients with phlebitis and emboli need to have an inferior vena cava umbrella inserted or permanently kept in place to prevent further spreading of clots. Medical diagnosis and treatment is delivered proportional to the clinical condition of the patient and the events which occur.
I think proportionality also applies to many other responses to the patient by the healthcare team.
It may also apply to those responses to patients wishes or demands. The healthcare team must decide how urgent or necessary or emotionally or physically important the request is to the well-being of the patient and then also consider the various practical logistical aspects of accommodating the patient. Proportionality in medicine: not everything, all the time, for everybody. Does this spark a debate here? ..Maurice.
Chill I have to agree with you in one respect. It is not the patients RIGHT to choose gender. Free choice is part of our society, the patient has the RIGHT to request, the provider has the RIGHT to decline, and the patient then has to RIGHT to either take what is presented, leave and find another provider, or suffer the consequences.
Your post however seems shows what many in this and other posts seem to feel. I am not trying to attack you on this, I understand facilities are limited by staffing numbers and the make up of that stff is even more challenging, I understand granting patient requests like this cause issues in scheduling. I also understand medicine is a business, it is about making a profit or your gone, granting requests for specific gender providers isn't as efficient.
I think the issue for me and others is what I would for lack of a better word call the hypocracy or perhaps the arrogancy of medicine. I know that sounds very judgemental and negative, perhaps it is but I use it for discriptive perposes not condemnation. The patient-provider relationship is like none other. Patients are by the nature of the relationsip asked to place a level of trust in providers that they do no where outside of the intamacy of close personal relationships. We are at times litterally asked to put our lives in your hands. To reach that level of trust one has to cross over the basic level of confidence in the providers skill and knowledge of the mechanics of a persons body. We have to completely trust that the provider has our best interest at heart. In essence we often connect being a good person with being a good doctor. The medical profession obviously understands this, when you see and hear advertising for hospitals they use words and phrases like "compassion", "compassionate care", "big enough to be able to provide, small enough to care", "treating the whole person" etc. look around find the advertisment that says, all we care about is your physical well being. A hospital posting we give you the absolute best medical care available but we don't care about your feelings or emotions would be like a ghost town. So when a person comes in they expect that their emotional well being will be also important, after all, you all tell them thats how it is. Modesty is something that isn't a basis of discrimination, it is a social norm that is ingrained in us early on. One of the supreme court judges made the statement some where along the line that shielding ones naked body from the opposite gender is one of the most basic reactions and instincts of people in our society. Most patients understand there are limitations in the medical arena, the medical institution has and continues to expand the can't provide to don't or won't provide for financial and convinence of the medical providers not for the benefit of the patient. We could certainly apply this to all areas of society. The owner of the fitness center would find it much easier to just have their staff clean locker rooms when ever they wanted with out regard to gender, same with the gas station owner, the local Y or swimming pool,.. locker room or restroom need cleaned, just send in who ever is available, if its a young female while you are showering you wouldn't have a problem? If a young male walked in while your wife, mother, or daughter was showering neither you or her would mind? After all they are just doing their job, are you discriminating by not wanting them do it?
I would guess you see these as totally different, after all you are medical providers...but they are more alike to your patients than the medical community would like to admit. We all know our society is very diverse, some care some don't.
There has to be a balance, we as patients need to understand we do not have a right to a specific gender provider, we do have a right to ask, and we have to be reasonable (lets not get into what defines reasonable here), you as a provider should understand there is a personality in the person you are working on, it isn't just the mechanics, they are not there for an oil change. We have the right to ask for consideration of our emotional being..you should not find that insulting. If what they are asking is reasonable and achievable, and you deny that on a won't or don't basis rather than a can't basis, you are making the statement that their emotional well being isn't important to you. You have that right, but don't try to present medical care as compassionate and caring if it isn't, you are just confusing the relationship. You don't have to be a good doctor, you can be a competent Dr, fix the bones, diagnosis the problems, do all the mechanics, but don't expect your patients to think you are a good Dr. if you aren't willing to atleast willing to make an effort to address the emotional side of the patient.
The second part of this is the what I called the arrogancy of the medical profession. The basis of this issue is that medical providers have elevated themselves to a higher level, that the nudity of patients to them is is not an issue becasue they are providers, therefore it should not be for the patient. As in the locker room example, because of being providers you are at a higher level than the janitor who might view a naked person. You have established that level and we as patients need to believe that to allow us to shed our natural inhibitions and trust you. That turst however does not in our minds mean that you have complete control and authority over us, we do not give up our right of self determination. Providers seem to forget that and see this issue from their side, it isn't about the uncomfortable feeling of the patient, it is about the feeling of the provider and their schedule. That is the arrogancy of the provider. It is similar to the female reporter in male locker rooms. Google the issue, all of the articles are about the feelings of the reporter, they have entered into what society has defined as a persons personal space, and yet have somehow become the victim. I have yet to see an article from reporters on how this is an issue of modesty of the athelte...its about the reporters rights and feelings period. A provider is entering the patients private space...and becomes the offended party when there is an issue. I also have to question why do you think respecting the emotional trauma of a rape victim has absolutely no similarity to considering cultural or religous concerns. While I agree the intensity of the trauma of a rape victim is much greater, expecting someone to abandon long held and deeply ingrained cultural or religous beliefs and has no validity just because the provider has a schedule to keep is perhaps the hieght of arrogancy. Not only is the provider saying their schedule or position is more important than the patients beliefs, they have appointed themselves to a position of being able to sit in judgement of the value of a persons belief's.
I guess when it comes down to it there are a couple basic issues, one is trust...can we trust you to take care of our physical being if you don't care about our emotional well being...sometimes we have no choice due to immediate need or financial status. Trust to a large degree depends on honesty, don't as an institution tell us you provide "compassionate care" or care about the whole person if you don't...that isn't honest. And second, exactly what level of control do you...or perhaps should you as a provider have over your patient....I have to be honest the fact that you seemed to feel her request for a female provider due to religious or cultural background was unreasonable and perhaps insulting to you, and the fact that you knew they couldn't go elsewhere due to finacial issues and felt justified in levering that seems pretty cold and not real compassionate. BUT, and I mean this, if you as an ER doctor feel your job does not include or should not include this type of compassion in order to be the best ER provider you can...that is the right thing to do. If you feel these requests and providing for these consideration will compromise the physical aspects of treatment...you are doing your best to do your job, physical well being is 1st priority. they then have to make the choice on their priority.
I do want to say again, I hope this was not taken as an attack on you. Your post was a great look from the other side of the gown. And just as I hope you know that those who accuse providers of being perverts, malicous, or deviant do not represent the majority of people posting...I do not see your post as being THE feeling of the profession...and again I am not saying you are WRONG WRONG WRONG, personally from my desk do not agree with you, but I am one person and I have no idea what it takes to be a good ER Doctor from your side, I only have my side for reference, which is why your post is so valuable and I really and truely hope you will continue to post here and encourage others in your profession to share insight with us...maybe we can learn from each other...and please don't take offense if some get a little confrontational, for some it is a very emotional issue...thanks again for taking time from your busy schedule. One of my friends is an ER doctor and his schedule between being there and on call is brutal...he sacrifices a lot of family time.....alan
It is pathetic and sad that if I go to the admin office and write a check I will then have a really great chance of maintaining my dignity and comfort level with regard to intimate care for elective procedures. I will probably do just that for future needs.
Thanks for the tip, Chill.
JW
Chill,
You state it is not the right of a patient but a priviledge for the provider to accommodate same gender care if requested. The "Patient Bill of Rights" that institutions/facilites "hang on the wall" and profess to provide a patient with states:
A PATIENT HAS THE RIGHT TO "RESPECT" FOR CULTURAL, PSYCHOLOGICAL, SPIRITUAL, AND PERSONAL VALUES, BELIEFS, AND PREFERENCES."
The "word" priviledge is not in that sentence. These core values are a part of the Joint Commission statement of rights to be given to all patients. (male and female)
JW
Chill's comments arr typical of physician arrogance and condescension, with perhaps a bit of prejudice thrown in, that many of us find so disgusting.
Also hope Chill is not as careless with his medical practice as he is with spelling!
CLW
Well -- we're certainly getting a perspective from the other side. I hope this doesn't represent how most doctor's think.
But, again, we're back in the ER and getting Chill's perspective as an ER doctor. That's fine. Most patients undertand that the ER has different priorities than a doctor's office or day surgery or a standard exam. I accept that, as I'm sure do most others on this thread.
Your comment, "The next chart in the rack..." bothers me. Now, in extreme emergencies I can understand that comment. You move quickly and do what you can. But apparently the womon you refer to wasn't a critical case. Later you give an exception to your "no" rule, and state that's the only exception. So -- it sounds like you just say "no" in these situations regardless of whether the case is critical or whether there is a doctor of the requested gender available.
Yet in this case, you indicate, you knew it was for cultural or religious reasons -- was there a female doctor available? I'm not clear on that. Sounds like there might have been because you say she wouldn't "appreciate having her day consisting of breast and pelvic exams passed on from people requesting "female physicians". I gratified that at least someone's comfort is being considered here, if not the patient's, at least the doctor's.
If there wasn't a female doctor available, that's one thing. If there was, that's another thing. If there had been a female doctor, would you actually have discharged them? Your comment that they could just pay for their own female physical (which you knew they couldn't afford) seems crass to me. It reeks of arrogance.
Your comment: "This one pt's religion is not more important than another pt's preference."
I question the ethics of that remark. That, of course, is your opinion. I think, or at least hope, that many other doctors would place religious and cultural preferences higher on their ethical scale. But, again, you've thrust this issue into the ER, which is often where doctors and nurse want to go when talking about this issue of modesty. It's not all about the ER. That comment is telling, especially in light of the next one.
"However I believe to request a male ordelie or nurse even in "private" activities as foley placement or showering is unreasonable just based on the fact that one may feel uncomfortable."
Well, of course. The last thing we want to be concerned within a hospital "system" is patient comfort. We need to just deal with the "next chart on the rack." That attitude is the "system" taking over, the schedule ruling the day.
Finally, your comment about the African American male, the KKK brutality, etc. is absolutely unbelieveable. I can't comprehend a professional seeing things like that. I would equate a situation like that with a woman's rape. You would inflict possible psychological trauma on this man?So -- it's all about us as patients having the privelege of being treated in your hospital the way you decide is approprite for us? Is that it?
I really hesitate to write this post. I'm sitting here reading it wondering whether to post it. I'm afraid this will be considered an "attack" on a medical professional who dares post here. At the same time, I have to be honest.
I challenge you, Chill, post for us the mission statements, the core values of the hospital you work for. Then, we as a group, can see how your philosophy matches up with your place of work.
If your attitude and belief system represents how most doctors think about this issue, then God help us.
No wonder our healthcare system is in so much trouble.
Dr Bernstein: You comment on proportionality is interesting and, valid within context. But proportionality in an ER situation is not the same as proportionality in less critical situations. And let's not forget, that the healthcare team includes the patient. And the patient isn't just "a" team member, but an important team member. The way I read your last paragraph, the healthcare team doesn't seem to really include the patient.
If I have offended anyone here, I apologize. But, frankly, I was offended by some of Chill's comments.
A bunch of great responses to Chill's comment! But I have a question with regard to the trust we must have in our airline pilot as we fly with him or her. Wouldn't this be an example where we expect trust in terms of preserving our physical existence but not necessarily our emotional state or "rights" at 30,000 feet. For example, do we have any right or ability to dictate to the airline pilot flying us and the 150 other passengers any personal requests or are we left to remain quiet on one side of the locked cockpit door and expect only to land safely at the location previously designated and at the designated time? Is there any similarity between the responsibility of the pilot to the passengers and the physician in an ER with a number of sick patients waiting to be seen? Or a physician in his or her office with patients waiting in the waiting room, all with specific appointments, needing to be attended? Is this analogy way off or is this worth discussing? ..Maurice.
Well Chill, thanks for the comments. I can honestly tell you that if that were my wife and you refused her request, we would’ve walked out. I can tell by your response that you completely missed the point that many have stated on this blog, you’ve strictly thought of taking care of yourself (and the facility) and not the patient. Sure, you ordered the correct tests and admitted her to the hospital. Great… I wonder how she feels today. I wonder if she completely avoids male doctors now that you FORCED her to consent to that exam. I wonder if her husband thinks of her same the same way? I guess all that doesn’t matter because you ordered the correct test and admitted her to the hospital.
If medicine and treatment were free, I wouldn’t have a complaint. Fact is, it isn’t and I PAY a hefty bill and I deserve the treatment that I want. Not the hospital or physician. Your constraints aren’t my problem. If you can’t provide the service that I request, step aside and let someone who can. It’s really as simple as that. I hope more people develop the same mentality as me because then you won’t have a choice.
Dr.Bernstein
I can’t speak on your analogy because I don’t see any similarity. If I go to the doctor or ER, I don’t have a choice (I never go to either until I can’t work). I can choose if I want to fly at all, if I had the same choice when it comes to medicine. I’d never get sick or see a doctor. That’s just me though…
Jimmy
Doctor: I think your analogy is valid only in a few specific contexts. For example, if I'm on the operating table and unconscious, then I have put complete faith and trust in the OR team. I have no control over what's going on. That would be like a passanger on an airplane. If I'm just sedated, the team may want some feedback from me (pain, etc.), so I may be asked or participate, or I may decide to participate unasked.
But as a patient, as long as I'm alert, I have some control which, of course, needs to be, within reason, negotiated with the doctor.
A comment on the difference between modesty and privacy. We have to look at these two words in context.
Let's assume I'm going into a hospital for an exam or operation. Before being admitted, I talk with my doctor and his staff. I say that I'm concerned that my "privacy" be respected. How will they interpret that word?
I think the first thing that will go through their minds are the HIPPA laws, that is, privacy as information. This would especially be true if the patient is clothed and doctor and patient are facing each other on a more equal basis. I don't think there would be any association with modesty in this context.
It's interesting to note that, if you examine hospital websites, you'll find "privacy" notices on every one. But what do they mean by privacy? They mean personal information. I have yet to find a hospital website where the privacy notice says anything about body privacy or modesty.
Now, if I'm in the hospital, in a bed, in a gown, about to have a bed bath from a nurse, and I say -- "I want to make sure my privacy is respected." How will that be interpreted? In this case, privacy doesn't equal information, but it may not mean modesty either. The nurse will probably make sure I'm draped properly and that the door is closed or the curtain drawn, but that may be all. Privacy may not mean that no one else will be present, unless I stipulate that. But in this context, privacy will move toward the direction of modesty.
Even if I use the word "modesty," with the above context, it's difficult to figure out exactly how that will be interpreted unless I'm more specific. Do I mean I want a male nurse? Do I mean I don't want anyones else, just one person doing the job? What do I mean, specifically?
My point is that "privacy" and "modesty" only have real meaning with certain contexts, and even in the contexts, the meanings need to be communicated more specifically.
Also, this only emphasizes the importance of communication. The word alone doesn't carry meaning enough to fully cummunicate. We, doctors, nurses, patients, must clarify what we mean by the words.
Anyway, that's my take on how those words differ.
I want to first thank all of you for responding, and apologize if I may have offended anyone. It is not often I get to hear the pt's perspective about issues such as these anymore. Alan, thank you for your comments, no offense taken at all.
To CLW, I understand you are probably frustrated with the medical system and my comments may have added insult and injury. Your right, I didn't know how to spell privilege and was too lazy to look it up (I just did).
In medical school, I met many pts who would prefer that I did not examine them based on my gender and/or my status (student). At the time, I respected their request and stepped out of the room. Obviously I have changed.
In our ER, it is not uncommon for the average wait time to see a doctor to be 4 hours or more. (4 hours in an ER. Horrid right? Until you realize that 4 hrs comes at an expense of a "go-go-go", "move the meat," "treat and street", "cut the pt off and just get the information you need" mentality. While this obviously isn't good for the individual pt., I believe this is necessary for the good of the masses.)
The triage nurse tries their best to first sort in order of acuity, and then after that, it is first come first served. Hence the charts are picked up in the order they are placed...when I mentioned "next chart in the rack", it is both for fairness to my colleagues as well as the pts that this is how it works. Otherwise the "fun" complaints like "fractures" or "lacerations"...stuff you can objectively see and fix would get "cherry-picked", and complaints like "weak and dizzy" or "vaginal bleeding" would be ignored until the end. (Unfortunately there was a study published that showed the average time to MD is affected by the chief complaint meaning a lot of docs out there are "cherry picking" charts). My point in mentioning "next chart in rack" was to illustrate that I did not choose that pt. to see.
True I have a responsibility to that pt. I'm seeing right now including their physical, mental, and emotinal well being. I also have a responsibility to all the pts I will be seeing and all potential pts. We all have experiences waiting in long lines. However, I can't imagine a worse line than the ER wait room. Imagine if you were the pt. WAITING to be seen, running to the bathroom every 20 min to vomit, or having severe pain, only to "look ahead" in the line and see a pt. requesting a female physician simply because they are not comfortable with a male, and knowing it is going to delay the line. I doubt anyone in THAT SITUATION would care to indulge in that woman's "emotional" or "moral" issues. Like Dr. B's analogy with the airline pilot, a provider has the responsibility to all the pts and not just to the one at present. Therefore I no longer accept requests for female docs.
Now there are always exceptions to the rule. I think this is what Dr. B meant by "proportionality". That is why I make the exception for rape victims. Because the emotinal trauma may be more damaging than that vomiting pt. in the waiting room. I feel I need to draw a line that is black/white...rape or no rape. Or else... let's say you are a female pt who is extermely uncomfortable with a male provider, but because of the lack of an alternative, find yourself in an ER with a male doctor. You request for a female doc but was turned down. Let's say you somehow knew that earlier in the day, this male doc granted that privilege to a muslim woman. Would you think your discomfort and preference is any less important than that woman's religion?
As many of you mentioned, the way the ER works is different than a clinic or an elective surgical procedure. I can only give my perspective working in the ER. If I were to choose and pay for a provider (electively) based on gender, and instead I got someone else, I would be equally frustrated.
I'm going slightly off-topic here to make a reply to MER's specific comment "So -- it's all about us as patients having the privelege of being treated in your hospital the way you decide is approprite for us? Is that it?"
My answer if it HAD to be YES or NO, would be "yes" (obviously nothing is ever just black/white yes/no). And before you guys start commenting on the "arrogance of the profession" allow me to explain. In medical school, I learned that it is about "the patient". Now, I realize that a doctor makes decisions on more than just "the patient". It's about the patient, the patient's family, the other patients, the community, the liability, the insurance, the money (or lack of). The doctor goes through all those years of training to try and make the best decision in consideration of all those things. If you were to ask just "the pt," it would be just about "the pt." Let me give an example to illustrate my point:
An elderly woman was admitted to the hospital after she fell and broke her hip. A few days later, the pt. was deemed medically stable for discharge by myself and physically stable for discharge by physical therapy. However, the family had concerns of their ability to take care of her at home. I then suggested that we send her to a skilled nursing facility (aka nursing home) to which the pt. started to cry and said she doesn't want to go because of many people she knew that died in nursing homes. The family and pt. pleaded with me to stay in the hospital a few more days. However, I told them that was not possible and they had to choose either home or SNF. Would this pt. be emotionally traumatized going to a SNF...perhaps. Was forcing the choice on the family in their best interest...probably not. Why then? Because of the responsibility I have to the sick patients waiting for her bed, to the (failing) Medicare system knowing that the more unnecessary cost that this pt. racked up (staying the hospital), it means someone else can't get the care they need. Obviously the family does not consider these issues, and hence it is up to the doctor.
Sorry again, this went off topic of "pt. modesty". I look forward to any further comments you guys may have. Perhaps there is some common ground to balance pt. modesty with the necessity of hospital/system efficiency?
Chill
Well chill,
perhaps with your antiquated mentality you might share with
us just exactly what er you work
so that I'll make sure I never
visit there. Too bad you never
stood next to me when I got my
military physical with the female
clerks standing there and leering!
Too bad maybe you've never had
the number of female nurses disregard my privacy and the times
ethical borders were crossed.
That piece of paper in my wallet
called an insurance card gives
me entiltement. The right to choose
and refuse who provides care to me.
It's also the card that pays your
salary. Maybe you had better get
with the times. The dinosaurs died
out long ago!
PT
PT, unfortunately your message was written before I published Chill's response that perhaps better explains Chill's view. Therefore, your message may have been premature. I was eating supper and missed a prompt moderation of Chill's comments. I apologize.
However, I want to add one important point regarding discussions of ethics in medicine on this blog. Let's all try to keep the communications civil no matter how distant one visitor's views are from another visitor. Civility encourages further discourse, the opposite may terminate it. ..Maurice.
Well, Chill, you certainly responded with a realistic picture of what it's like out there. Your answer puts your previous message into better perspective. You say when you were in med school it was all about the patient. Now it's about many other factors. One question is, of course, how those other factors are balanced out. My concern is that "the liability, the insurance, the money (or lack of)" often receives too much priority.
You point out the truth of many professions -- the difference between the academic curriculum and the underground curriculum; the differrence between theory and reality; the philosophy and the actual practice.
Granted, the academic curriculum, the theory may be idealistic. On the other hand, some of the underground curriculum you learn on the job may be based too much on the interest of the institution rather than the "masses," as you say. And if the system's sick, if it isn't working, that underground curriculum can get pretty rancid. The ideal should not be forgotten. Though I think it is often, if not forgotten, pushed aside as impossible. Perhaps it is in your situation. I'm in no position to judge.
I do want to clarify my position. My issues with modesty do not concern ER's. Not that those issues don't matter at all there, but they are secondary to many of the factors you mention. If my injury or illness is serious enough that I feel I must go to an ER (or be taken there), I want the best, quickest treatment by either gender. If I'm not that sick, then I can always go to another ER or wait to see my own doctor.
And you do have the ER point of view. In your job, you probably make quick decisions based upon many factors. It's not as much (if at all) a team decision involving the patient and his or her advocate.
You write: "If I were to choose and pay for a provider (electively) based on gender, and instead I got someone else, I would be equally frustrated."
So, for me, that's our common ground.
Busy, crowded ER's are different places than doctor's offices, clinics or regular hospitals where patients get elective surgery.
My perspective is that you're doing the best you can within a system that is broken.
This is great conversation. I feel we have moved from "bitching" to discussing and debating. Chill I understand your post a lot better. My experience with the medical profession has been totally different from the environment you live in. Yours is more like a battle field triage than what I am used to. The shear volume actually expands the concept of can't accomodate that I held. I think before any of us could say with any degree of certainty you were right or wrong we would have to stand in your shoes for more than a day or two. With a back log of patients waiting hours, time could become a matter of life and death. Time also can become a can't.....really have to think about that one for awhile. One has to consider the pressure on the providers to deal with the shear number has to be overwhelming.
Which brings another question to the table. I am reading a book called "my angels are come" by a man named Art Stump. It is chronicle about a mans journey through prostate cancer. It caught my attention because it happened near my home in South Bend, In. at Memorial Hospital. I have been to the facility and experienced the culture. The author writes of an experience where he was laying naked and exposed for a treatment, realizing there were "extra" people in the room. He over heard one of the nurses introduce one scrub clad girl as a high school student who was shadowing and was there only to watch....he talked about the extreme feeling of betrayal of his trust, his anger and rage. He then goes on to examine the difference between the business facility of he hospital and the providers. He talked about the different agenda's (my words) of the administration and the providers. His conclusion was the issue and issues like it are the result of the different reasons for exsisting, the business side was a culture of producing results in the form or revenues, sales, staff, etc to promote financial viablity for the hospital where the providers were focused on the welfare of the patients. He concludes often programs set by the admin. start off innocently enough without negatively impacting the patient but grow and expand and loose sight of the patient....it sounds like that may be the case where chill works. Certainly the Dr.'s don't choose to work in a system where "treat and street" is the case. I mean I can not imagine dealing with someone who has just waited 3-4 hours to see you while being sick...I would be less than civilized waiting 4 hours well. There is an excellent analogy of the patients side of this equation in the book, it is probably the best I have seen but is rather long...given my tendency to go long anyway, I would ask Dr. Bernstein if he would want this posted here or not rather than just do it.
It appears to me that Chill and the people he sees are both victims of a different sort to a system that is over loaded and causes the provider and the patient to compromise wants and needs. I doubt the life Chill envisioned in pre med is the one he is living right now.
This is an aswesome time for this thread, perhaps a high water mark. And Chill, I can't spell either and without spell check...yikes...I really am smarter than my spelling would indicate. Thanks again for being part of this forum. It really shed a new light on several things, including the ER and the choices providers give up as well...I imagine you would appreciate having time to interact with patients to improve not only the experience but the medical care, you have to feel like you aren't getting all the info you need from them given the time limitations...
Dr. Bernstein, if you feel posting the insert from the book would have "proportional" value (see, we learning) let me know and I will do so, it is a great read, very insightful.
Thanks again Dr. Bernstein, Dr. Sherman, & Chill...alan
Chill presents a fairly consistent picture of most people I have encountered from the medical profession. They KNOW they are right about everything. In his scenario, why not just ask the lady to wait in line until the female doctor was next available? How difficult is that to organise? Why would her sitting it out an extra few minutes or hours have offended him? Because he must KNOW best for patients. A lot has been said about tolerating opposite gender care in certain (usually extreme circumstances), I would not do so, he would have me die because i have my own values which don't coincide with his? The word arrogance is far far too moderate and polite for the first posting made by chill. Only he is in a position to decide what exceptions to make (rape). The patient is paramount in the mindset of the truly professional person, not their own convenience or "correct" set of priorities. Just because his values are different to those of some of his patients, does not make his values correct, it just makes them different. I believe he needs to stop, stand back and consider why people feel the way they do - just to be awkward maybe? or is it just possible that the patients who feel this way have deeply felt and fundamentally rooted anxieties about opposite gender intimate care. That they are right or wrong to feel that way is not his judgement call, it is theirs.
Alan, despite the attached "Fair Use" notice to this blog, I am shy regarding extensive reproduction of copyrighted text from a book here. Can you express in your own words the context of the portion of the book you wanted to place here and use in quotes significant phrases or expressions from the book in appropriate places or at most a brief excerpt paragraph? I realize you have good intentions regarding supporting your point of view. Thanks for your consideration.
By the way, I fully support the concept of debate and discussion in place of "bitching". ..Maurice.
gve I understand your thoughts and I have some of the same, but I do also understand his post a little better and have a little more tolerence for it. ER's were intended for emergencies in their concept. They often have become the dumping ground for uninsured and those who do not have a Dr. or ablity to pay. In our area we see insured use the ER for non emergency appointments becasue they get immediate attention. One has to consider when you have people backed up for 4 hours it means every minute adds to the problem. By the time they do history, get the patient in a room, work their way to them it isn't 2-3 minutes. Likewise, with one female Dr. it is a problem. That said, I have trouble with assigning priority to patients, it would almost be better to say no one gets a choice. A female rape patient may be no more traumatized than someone who has a long history of sexual abuse...and who makes that call. We don't give providers a chance to find out in these situations. But, our society considers rape such a traumatic issue that we make exceptions, a newspaper is not allowed to identify a alleged rape vicitm but they can the alleged perp. I understand taking the time to move people in and out without clearing a chart is probably a lot bigger deal than it sounds to us. I am not justifying the decision of who gets accomodated or not...but I understand it comes from more than just a "God Complex", there are actual physical limitations that play into it. I ask the question again, is it the provider or the system that jams people into the ER at an unreaslistic pace that is the problem. I sensed a little frustration in Chill's post the same as I do some of the posters here. Could be wrong....but seems like he is frustrated by it to, though perhaps for a different reason. And gve, I understand what you saying, but if a patient decides to walk out, they have also contributed to the situation and actually made more of that decision, each case has its own merit. The ER is a lot different than scheduled appointments...sorry I have to disagree with the intensity of your approach...
Anonymouses, please, please, please leave some consistent pseudonym or initials with your text identifying which Anonymous you are. This is especially important when an Anonymous writes repeatedly to this blog and responds to another writer. Remember a consistent pseudonym or arbitrary initials can still protect your personal identity and you still remain anonymous. ..Maurice.
Chill,
Your last post was much more insightful than your first. I agree that you do the best with the time that you have but I also feel that this has just become an excuse to just overlook the problems of your job. Perhaps it’s just where I’m located, but I see no shortage and nurses, I see no shortage for male or female physicians. Heck, each procedure that I’ve had it seems as though they are tripping over themselves. From my perspective, there’s a lot that can be done to address what we’re talking about on this blog but providers aren’t even making an attempt to change their practices. If they want to post patient values on their walls and use it to attract patients, maybe they should ask the patient what their values truly are. I’m all for fair play as you noted with patients waiting in the ER. So I say to any provider, if it’s hanging on the wall, abide by it or remove it and tell your patients that they’re going to get the care that they see fit, not the care that you think you deserve. Be honest with every patient upfront so it doesn’t do long term harm.
I’m can’t agree with you on it being a privilege for people getting your services. This is what you chose to do for your career; patients never choose to be patients. It’s a privilege when people come to your place of employment to get care. And, I guess it’s a privilege when some pay for the services that you provide but always keep in mind that it’s these same people (the few that pay apparently) who help provide you with the life you live. If these people stopped seeing you or the facility that you work in, do you think your going to continue employment? And just for the record, hospitals are reimbursed in some way shape or form for these non-paying customers. It may not be equal in value, but it’s still something that helps them keep their doors open and does bring in some revenue. My wife was a CFO at a hospital for 8 years so I know this to be true. Busy schedules, long wait times, and non-paying customers shouldn’t be used as excuses not to treat people as human beings. Nothing personal with you Chill, I think it’s great that you’re posting and hope you continue. I’m just sick of the patients always getting the short end of the stick. Jimmy
This topic has arisen before.
Any ER is supposed to be for urgently needed care. That means patients get triaged so that the sickest get seen first. Most especially big city ERs are like war zones and patients are triaged similar to a battlefield. The first priority has to be the sickest patients.
If your first priority is same gender care, an ER is not the place to go. Find a walk-in clinic or a private physician. I agree with Chill basically. If an ER can accommodate special requests, that is fine, but it can not be their first priority.
My response was not premature.
Chill said" I do not believe
that patients have a right to
same gender provider. That includes
physician,nurse,tech."
Before you make comments such as
this, walk in someone else's shoes.That comment is just riduculous.
PT
Joel,
Perhaps I should’ve been more specific in my last response but I was merely trying to point out that the excuses (as I call them) that determine how facilities run their ER are the same that I’ve heard in walk-in clinics, Physician Offices, or Outpatient Facilities. It seems that those reasons are above what the patient thinks of as important and they have become the normal response when people make certain request. I don’t have a problem with that. What I have a problem with is them selling to patients that all the needs will be taken care of knowing full well it will be within the constraints of their system. Give me a break….
Just remove the patient bill of rights from their walls and post something to the affect that we’ll take care of your needs within the constraints of our system, if your not happy with that, please feel free to find another provider. Why is that so hard? At least everyone is honest then and there’s no bitterness afterwards. That also gives the patient a choice to walk out and find another provider that can take care of all their needs outside the constraints of the system. Maybe that is just to simple for providers to understand? Jimmy
GVE that would not work. It sounds simple, to have her wait but there's more behind it. It's dangerous and a liability for us to check someone in and then have them go back to the waiting room. What if something emergent happens out there? Not to mention the necessary paperwork and documentation (time) the nurses and clerks have to do. Also we can't have her just wait in a chair in the ER as it violates the nursing to pt. ratio established by JCAHO. So the only way is for the pt to wait in that bed until the 1 female doctor becomes avail. Any way you spin it, it delays "the line". Now before anyone argues that the pt.'s emotional needs are more important than rules and liability, realize that all this (unnecessary) documentation and rules were put in place FOR PATIENT'S SAFETY in the first place. Ya can't have your cake and eat it too.
Also, just a brief comment on "doctors know everything". Of course we don't. But I know my thought process goes a lot further than the pt. In trauma, we use the ABCDE algorithm, with E standing for exposure...we cut off all the pt.'s clothes. I remember one young male that was very resistant to us undressing him with female providers in the room (it's understandable, in a trauma, there are A LOT of providers in the room...usually anywhere from 6 to 10). I actually heard the nurse say "it's ok, we're all professionals here"...to which many of you have talked about before. The pt. cared about modesty, I cared about establishing all injuries. GVE, if you were the pt., what would you have me do (let's just assume you are "stable" for the time being and not actively dying)? Keep in mind the pt. remains on a backboard and neckbrace and cannot move until his spines have been stabilized. If I missed a large gash around your privates because I didn't look, would you blame me? What if it resulted in an ugly looking scar? What if by the time we saw blood on the floor from your large pelvic laceration, it was too late to save your life? (BTW, kick all the females out of the room, or come back later is not an option...for many reasons). I just can't imagine standing in front of the jury answering the question "why did you not follow proticol?" with the answer "cuz I was protecting the pt.'s modesty".
I talked to a friend of mine yesterday who's an internal medicine doc and works mostly on the wards of the hospital. I mentioned about our discussion here and asked him what he thought. Without any prompting by myself, he started ranting the exact sentiments as I did in my first post that angered many of you. Some statements he made: "pts pay for medical care, concierge service [referring to same gender provider] is extra," "we can't satisfy every request by a pt," "pts don't realize that I have a ton of other pts I have to see," "pts think they know better than me but they really don't" and a whole bunch else I don't quite recall at the moment (keep in mind he does NOT work in the ER).
After my first post, a lot of people remarked that they hope my sentiments aren't shared. Unfortunately, I think they are for those that work in large hospitals. I think it's because as opposed to elective clinics, we're not trying to "attract customers". "Customers" come by the droves whether we want them to or not.
I've always used the term "beggars can't be choosers". So for the uninsured or Medicaid pts that no one else will see come to our hospital, is it ok then for the hospital to be more authoritarian in deciding for the pt? After all, they DO have a choice...1) if you accept to be treated here, then understand that we don't make special requests for same gender providers or 2) don't accept to be treated here. (That was my mentality in the first post I made)
Many of my doctor friends and I have the same sentiment. The disbelief at the degree of 'entitlement' that some pt.'s have, esp. those on medicaid or unable to pay. I see an ankle sprain and know it's not fractured. The pt. demands an XRAY (which then is paid for by taxpayers). They don't realize (or don't care) that I'm trained to determine whether more (expensive) studies need to be done. And unfortunately, no amount of explaining will work on some people. They think they know what's good for them...and in this case, it's an xray. Do I get an xray? (They are here as a last resort. Their medical care is NOT compromised. Now of course of it WAS broken, I would get an xray regardless of ability to pay). Obviously, I'm siding on the "beggars can't be choosers" side. What about from the pt. perspective, perhaps not as a pt. but as an objective 3rd party?
Of course, as an internist who had experience in emergency rooms as one who admitted my patients to the ward, I have always had the same understanding of the "mentality" and practice within ERs as does Chill. In terms of my office practice, as I have written to this blog many times, I have never been challenged by a patient regarding a modesty concern and was unaware of the intensity of concerns until I started "Naked", the first of the series of volumes on the subject of patient modesty here. I am hopeful that we get a few more physicians from an office practice environment, particularly general medicine but also urologists and OB-Gyn physicians, to contribute their experience and thoughts to this topic. I want to see what other office physicians have heard from their patients and what the physicians attitudes and responses have been. ..Maurice.
There is absoulutely no reason for
a trauma patient to be completely
nude. The patient is completely covered with a blanket. At the point of examination each area is only uncovered for the exam.
This procedure is a progressive
attitude followed by many facilities. Don't assume that patients who are unable to pay or
are on medicaid will not ever pay.
Thats a discriminative attitude,
selfish and judgemental. I've experienced that attitude despite
the fact that I have insurance and
in a high income bracket. The notion is readily appparent that everyone is lumped together, jaded
attitudes obvious.That's just one
of many disparities in healthcare.
Quality is certainly declining,
contrary to what you read about
increasing technologies. There are
no real improvements to speak of
yet its estimated that americans will spend more and more on healthcare. Er's are relying on pa's and nurse practitioners to fill the slots. The trend is to
order more and more expensive
diagnostic tests as diagnostic
SKILLS decline as well as respect
for the patient.
PT
Gee, Chill. I thought I knew where ou were coming from. But now you're all over the place. You move from a good, reasonable case in the ER to a regular hospital with an internest and then to the poor, uninsured and Medicaid.
You're mixing apples and oranges. No -- at least those two items are fruit. More like apples and hamburgers.
First -- A patient's emotional state is not "entitlement." Good medicine recognizes that the person you're treating is a whole person, not just a body, not just a disease or an injury. The patient is body, mind, and, dare I say, soul. Now, the ER has different priorities. We talked about that. But non critical elective care is something else entirely. If you don't believe that, or can't provide that kind of care, at least admit it to the patient. Which brings up...
Second -- Within the context of non critical elective care, there's the entire question of honesty. I've been harping on this idea of honest, open communication. Maybe our mysterious anonymous poster is on to something. He writes: "Just remove the patient bill of rights from their walls and post something to the affect that we’ll take care of your needs within the constraints of our system..." As I've noted before, systems develop cultures of their own, cultures that ultimately care mostly about the survival of and what's good for the system. We see that in our public school system, for example.
When I hear comments like those of the your doctor friend, I wonder how that doctor interprets things like A Patients Bill of Rights. Or the idea that the "patient is in charge." Or the idea of medical care as a "team" concept. Frankly, I'm not impressed with his excuses. So -- same gender care in his mind is "concierge service?" Really? Patient modesty, dignity and privacy are "extras?" Wow! Is that what we've come to? Your doctor friend says: "pts think they know better than me but they really don't"
Of course we don't know what he knows. But that doesn't mean that he knows it all and we know nothing. It doesn't mean that we don't know anything about our illness, our condition or our bodies. Good doctors ask the right questions and actually listen. Let me repeat that for your doctor friend. Good doctors ask the right questions and actually listen.
Let's all just be honest with each other. If the system is so broken that it can't or won't even try to or just don't care to live up to these ethical statements that appear on hospital websites and on the walls of institutions -- then just be honest with the patient.
What annoys, even angers patients is the healthcare system's apparent, call it "intellectual dishonesty" "equivacation," "unwillingness to communicate openly and honestly with the patient..." Particulary in areas of what we're calling here patient modesty. We are indeed a prudish society. We just don't like to talk about these things with each other.
Now, I'm not saying this happens all the time in every place all over the healthcare system. It varies from place to place, hosptial to hospital. I would imagine big city hospitals may have more problems. Some hospital systems actually work hard to live up to their core values. I've been impressed personally with the Providence system.
Third -- Now we're into the uninsured, the poor, and Medicaid patients. We've come to the point where we're using the expression "Beggers can't be choosers." Okay. If that's the case, state it explicitly, publically, openly. Make sure it's on the forms these patients have to sign when they enter the hospital so they know they will have no choices. Or that those choices are just "extras" or "concierge service" granted only if the system feels like it.
Make it clear that privacy, dignity and ethics only apply to those who can pay -- and even then, maybe not -- unless, of course, you're really, really rich. Because we all know, don't we, that, the rich can get whatever they want with medical care as they can with almost anything else.
Chill -- So, it looks like our common ground is limited to the ER. What you say about those conditions make sense, within reason. Otherwise, I don't think we see things the same way.
And Dr. Bernstein. It seems to me we've reached the essence of ethics here with this discussion with Chill. We've passed ontology and moved through epistomology. We're into ethics -- the place where the rubber meets the road.
So --what does this all mean and what are the implications for how the medical profession should behave and lead their professional lives? When systems are working well, it's easy to transfer your ideals into practice. When systems are broken, then it becomes a challenge. Sometimes it becomes a challenge not to just give up.
before I forget ot post it, this is alan. Chill I have to agree with the previous post, I thought I was with you after the second post. There is a big difference in the patients mind between can't and won't. I was begining to stretch my definition of can't to include work load. I was about to comment that the difference is attitude and purpose, I was about to make the comparision of a poster on the allnurse.com named witchyRN who basically indicated patients should just shut up about modesty and privacy, they are just lucky to get care. It was what I thought the hieght of arrogancy. Lucky, entitlement...are you kidding me, and when you walk into the resturant, are you lucky to get served, are you riduclously asking for the hamburger to be served with what you want on it. I hope I am not understanding your post. You all choose to be Doctors, you get paid very well to do so, and we your paitents are the one who pay you. You expect to get your hamburger the way you want if from McD's for 99 cents and you think a patient expressing concern about being naked infront of other people is ridiculous and an unreal sense of entitlement. I can't believe what I am hearing, who made Dr.'s at a higher plain than mere mortals, who put them on a pediastal that forbids mere patients to ask and make requests. And respecting a patients modesty and providing care does not have to be exclusive of each other. How about this for your ER patient. cut his clothes, place a modesty towel over his mid section and remove the rest of his clothes, move the towel when you need to look at that area. If he was alert enough to communicate, it sounds like he was at least at some level of stability. I would like to ask you these questions that I never get answers from providers. Why do medical and nursing schools have to hire practice patients because students are to modest to be examined when exposure is required. Read the nursing blogs and see how they protest being asked to wear swimsuits etc for bed bath practice....I understand many healthcare facilities have special accomodations when staff are needing surgery, the are allowed to where scrubs, choose staff, etc. And sorry I don't accept its different when you work with them, if your professionals it shouldn't matter.
I have heard numerous times one of the most important things in medical care is open honest communication between providers and patients...do you honestly think that kind of attitude and behavior fosters open communication. Do you think the young man who is obviously embaressed laying naked is going to tell you infront of a bunch of nurses that he has pain in his scrotum. I love my PCP because he is so sensitive of the issue. I can talk freely and openly about anything. I discovered a lump on one of my testicles, when I went in I didn't have to worry that his nurse would be standing there to make me feel uncomfortable so we could talk freely about it....
There is no way we can really understand what it takes to be a Dr., there is no way we can see completely your side of this and understand your motivation...but it doesn't appear providers have a clue what it means to be a patient in a vulnerable position and encounter an attitude like that. We are people not Honda's. The arrogancy of your co-worker to think that he is so important that the feelings of the people who are suppose to trust him are a sense of entitlement that annoys him...wow. I hope he ends up on the other side of the gown someday with someone who has the same attitude....one final question, if your mother was laying on the table...would you want her modesty to matter to the providers, or should they just let her lay the naked so they could do their job and not be bothered.
Chill I was with you for awhile there, but I really have to reconsider where you are coming from...appreciate the honesty...but man, scares me....alan
Chill,
we have a saying where i come form,"you can't educate pork, you can only cure it". Unfortunately that seems to be the score with your attitude.
You are clearly right about everything.
Patients (customers) deserve what they get.
Simple consideration is too much to ask.
That a patient only be exposed for as long as is absolutely essential is alien to your mind, your convenience trumps any patient concerns.
I doubt very much that you will still be in practice in 10 years time, dinosaurs like you will have been driven out.
Hypothetical scenario. A 16 y/o female and a 66 y/o male are both
patients in the er with the same
symptoms. Who gets the most respect
for privacy? You could invision this discussion in a nursing classroom or imagine it in reality. Imagine a male physician as a patient or say a male PHD scientist as a patient. Neither
would fare well in my experience as
far as privacy goes in regards to
a female patient.
I once saw an older gentleman
who was elderly,obese and very ill
and when the cna's learned that he
was a physician they smirked. He
was not treated well! In late 70's
early 80's I worked in a level 1
trauma center,county hospital while
going to college. I noticed that
male patients in the intensive care
units were nude in bed,yet female
patients were always covered. In the nurses restroom the walls were
completely covered with centerfold
nude men from playgirl magazine.
Can you imagine being a male patient on that unit. Do you think
they left their gender at the door.
Imagine you as a femle patient at
the ob-gyn office. Your husband steps into the physician's restroom
and the walls are covered with pics
of nude women. Would you want your
wife being seen there?
There are many learned experiences as to why people want
same gender care. In my case it took years for me to develop this
mindset. Frankly chill your attitude disturbs me. You no doubt
see the effects of managed care and
what the effects have had on group
salaries. In the coming years hospitals and medical facilities will have to adapt to an ever changing attitudes among patient needs.
PT
Is all our discussion simply about the Patient's Bill of Rights? I don't think so. Would you guys really be satisfied if we changed the Bill of Rights or remove it altogether? That simple?
I noticed that all the arguments made have stemmed from the concept of the "ideal" physician-doctor relationship, which is becoming more and more of a scarcity...except perhaps to the rich (or those with good insurance). There are businesses popping up of doctors catering to the rich, exchanging a high premium for individualized-personalized care.
I mean why not? Medicine is a business. The rich gets most of the comforts of life...why is it any different with medicine? (BTW I am NOT rich. I make the statement not because it's right morally, but rather it makes sense).
Just about every doc and nurse that works in a busy hospital complains of "the pts." Alan, as you mentioned, just go on nursing blogs and doctor blogs, and you guys will see what I mean. I know my colleagues have the same sentiment as me. Therefore, it's useless for me to talk to them...since we all agree! That's why I am on this site, because the pt perspective is obviously different. And I want to get a different perspective of all the biases that we/I have accumulated. Do you think doctors/nurses went into the profession to say the following (heard by my own ears):
"great, another drunk bum off the street...in the good 'o days, they would just hold them at the police station. But because a few died, now they ALL come to us"
"In room ** is a mom with her 4 kids, all coming with cough and runny nose. I have no sympathy for these people. They have medicaid and get seen for free instead of waiting for an appt. like the rest of us. It cost me $100 to be seen in the ER, and for these abusers, it's free for them paid by MY tax dollars"
"the pt is hungry and want something to eat. this is a medical facility, not a one stop shop for lunch and having your medical problem checked out!"
"that pain seeker is back again...can we just quickly get rid of him?"
Now the people who made these remarks are great people. And I think they are great at what they do. But these feelings come from what we've seen, heard, and experienced. And before you start remarking "nurses and docs should never make those comments," realize that the feelings are pervasive, which means that if you were in our shoes, you probably make one of these comments yourself.
GVE, I am FAR from alone in my views, and no matter what, the pts will continue coming. You keep referring to me as a "dinosaur". I've just begun my career. My generation of doctors it seems is more about money and lifestyle rather than the patient. If you look at specialities and how competitive they are to get in, there's a direct correlation to how good the "lifestyle/money is". No one wants to do primary care anymore. I'm sure you guys have all heard of the shortage of primary care doctors, and no one to fill the void, and we've resorted to training foreign medical grads who hardly speak English for those positions. Why am I sharing all this? Because all I've heard from you guys is this ideological doctor-pt relationship, and I agree we should strive for the ideal...but it's far from the truth now (at least from what I've seen). It's like the fact that check-in baggage at the airline SHOULD be free, but I don't think that will ever happen again. Overall, anyone can state what the "ideal" relationship should be. Practically, I don't see it actually playing out in a hospital (that has more pts than it cares for). My purpose is simply to find little tidbits and tactics that allow me improve pt. care while maintaining the same efficiency.
I think I'm discussing with the wrong group here...because it sounds like you guys are well educated with good insurance.
I think primary docs that work with people with good insurance in the clinic is different than a busy hosp. After all, you chose your doctor, and your doctor is happy that he gets paid by the good insurance. Furthermore, the issue of modesty may not be all that much of a concern in the clinic. 1) pts with good insurance mostly get to choose their docs and 2) all the rooms have doors and there rarely is a higher medical priority (ie unstable pt)
Find me a clinic doctor who openly takes pts with no means to pay (or even just Medicaid...as many doctors now refuse new Medicaid pts because the reimbursement is pennies on the dollar). Because I will gladly refer all my non-paying pts to that doctor! Chances are you can't...because they don't exist. Are these doctors bad for choosing on ability to pay? Next time you are at your doctors, as him how many patients he sees for free. Are these doctors worse than me because not only are they ignoring "modesty", they are ignoring the total patient?
Wait, I DO know of a clinic like that......the ER! I see the homeless, the decrepit, the indigent. We function as the safety net. And personally, I think our "system" as the safety net is more important than any pts personal preference or modesty. Yes it IS about those pts still waiting to be seen they may have a more urgent condition. It is about taking up too much time. But oftentimes I feel like saying "not happy? well just be thankful someone is even seeing you." Beggars can't be choosers.
What I have presented is more extreme perhaps so you may understand that it's not all about this philosophical doctor-pt idealism. Of course I ALSO see rich pts, or pt. with real emergencies. Of course we TRY to maintain dignity and modesty. In any private exam in a completely stable pt., only the necessary part to be examined is exposed. I always have a sheet for the pt. to cover as much as possible during a pelvic exam. That's standard practice! But it is not standard practice to get someone a specific gender provider. You can ask, but don't expect.
In trauma, there's a question of stability, and establishment of the stability takes precedence over modesty (again in my opinion), no matter how stable they may seem at first glance. All I can say is, unless you stand and observe how much (controlled) chaos and how many simultaneous events at once that happens, you won't understand why modesty is not at the top of the priority list.
Anyways, I think the discussion here has turned counterproductive...more to a "Chill suck" "Chill thinks he's all that" "how dare Chill" kind of tone. Anyways I imagine this is my last post on this thread 'less someone brings up a new enlightening perspective.
For my visitors, what you think you understand of what goes on in medical care and within the medical office or ER or OR is more what you don't understand than what is.
You have to "walk the walk" of a physician in these environments to truely understand. You have to be the physician holding the responsibilities and not the patient. You have to be faced with the mixed feelings, the conflicts involved in those responsibilities regarding what "ought" to be done for the patient and what "could" be done and then what "is" done in actual practice.
In addition, physicians face the uncertainties of making a diagnosis and the outcome of their treatments. They also face the unknowns of the intent, wishes and desires of their patient since often much of this is not communicated and especially in emergency situations but even in non-emergent conditions as amply written about on these threads.
You must "walk the walk" to truely understand. Physicians may, unintentionally, "walk the walk" of a patient when they are sick or hospitalized with some recognition of what is happening on the patient's side of the bed railing, particularly if the physician insists NOT to be given V.I.P. treatment (which is sometimes given to the detriment of the physician). Unfortunately, the other patients are not given a chance to intimately, personally review the burdens a physician faces.
On the matter of further comments to this thread, I would heartly agree with Chill's final warning but I would also add the advice to my visitors to "chill it!" What would be more constructive in further postings would be, instead of simply inflaming the concerns of both sides, for the commentaries to relate toward and discuss ways to work together to attempt to mitigate these concerns. ..Maurice.
Chill
I hope you do not leave the post, I was thinking about this last night, I respect that you have the guts to basically stand alone in the in face of all of the opposition you are bound to get here. I agree we kind of hit the wall a little, but rather than leave lets try to redirect or channel it. I would like to ask you a question, what do you and fellow doctors feel is your job. Do you feel that you are strickly treating the body, that is your job, and the emotional side of the person is not your responsibility? I don't mean that with a level of condemenation, I really want to know. That could really explain some things, maybe we are both approaching this from not only a different perspective, but from different objectives in mind. I gave this thread a lot of thought and while it was a bit upsetting to hear your thoughts....it was good because you are very honest and candid. It was upsetting because it wasn't what I wanted to here. But sometimes we need to hear that to start to see the other side. Perhaps you really touched on something with the different matrix of this group. As you said, my experience is from one of modest affluency. I have good insurance, I have the ability to pay the difference to go outside of plan. I can pay for elective surgeries. The facilities I have been to are not, the battle grounds you function in. And as much as it pains me to admit it, since you were so candid I will to. I do have a issue with the Medicad people who run to the ER for the least little thing, really ticks me off we are clogging the system with people who WON'T not can't take care of themselves. I work 60-70 hours a week, why should they have the same health care as me. So I guess if I worked there day in day out with it first hand, I might get really cynical toward them to.
Let me ask you, do you feel the other environments of medicine who deal with the insured, with the able to pay, with the more wealthy clients have the same attitude. Do you think what you and your friend expressed has as much to do with the type of facility you work in or do you think it is consistant through out the medical community? I have no experience with what you are dealing with.
On my end, I pay a hefty premium, in fact, I pay a hefty premium for the people that work for me. I feel I have the right a certain level of accomodation...or guess what, I will go up the ladder and I will go to another facility....but...that is different from the situation you are working in. And while your comments may seem brutal...they are probably brutally honest and I would say some of the basic sentitment is shared by more people than would care to admit it.
When you speak of entitlement, are you referring to gender requests in general, or more to the people who come through the ER for financial or convience reasons. Are you saying the request for specific gender providers made by a self pay (insured or other wise) is the same or deserves/gets a different level of consideration...and as much as I hate to admit it, I understand and agree to a certain level. I can't quite sort out what you are saying, when they young man came in and had to be stripped, it sounds like you did provide the basics, covered him with a sheet, exposed only what needed exposed, understood his concern...but didn't mean you would/could accomodate....I would be interested if you could clearify for me what you think here. I feel the medicaid patient does deserve to have the basic level of accomodation, but honsetly I understand that you may not be able or willling to go that extra step......I hate to hear myself admitting that...but your candid post would make me feel hypocritical if I didn't.
I want to tell you of a personal experience that plays into the physcology of this. My brother went to his PCP with pain in his back and scrotum, quick look Dr. says muscle strain maybe the start of kidney stones. He wants a second opinion, goes to the 2nd Dr. the 2nd gives him the cursory exam confirms the 1st Dr. He still doesn't feel right and asks for a referral, at which time he gets push back, starts getting treated like the difficult/needy/pyshco patient. Gets a referral from a 3rd party, the 3rd Dr. discovers he has testicular cancer and .....kidney cancer. One of the things that we learned as a family, is some Dr.s have for lack of a better word, have a God Complex, they don't like being questioned, they don't like the special requests. Now here is a the question, do you think in some cases Dr.s have to have some of that in order to deal with what they do? I mean you have to make decisions that will litterly save or cost a person their lives. I would think much like the pro athelete, self doubt is a recipe for disaster. If so, it would seem that personality would have less tolerance for what THEY feel is trivial. I am saving lives and you are worried about who sees you naked?????? I don't mean that as a condemnation....I just wonder of that isn't part of it. The provider is taking responsibilty for a persons very life in some cases, it would be easy to see how the concept of self determination that patients hold would become secondary or even bothersome. You tell me I have to have this surgery or I will die...I still have the right to decide yes or no...You say I have to be stripped naked to allow you to do your job, I still have that right to self determination, the problem comes in then that I should not be able to hold you liable for the results of my decision. So we have that catch 22, and especially in our society, with the clients you evidently treat, a lot of people would forget quickly the role in that decision when Dewey, Cheatim, & Howe attorneys at law come knocking.....
So if you haven't become to battered and bruised to give me a response I would appreciate some more of your thoughts, and I will try to understand you are being honest and got your teeth kicked for it. This discussion should not be directed at you, it should be about the system in general...heck, I don't understand why anyone would work the inner city ER when they could be doing boob jobs for a lot more money.
1. Do you think it is the feeling of providers that accomodations such as gender of providers or modesty are looked upon differently depending on the ...for lack of better words "economic level of the patient and facility.
2. Do you feel Dr.s and patients see the realtionship differently, you treat the meat, they want emotional comfort...which providers feel isn't part of their job?
3. How do you think providers see the issue of providers doing their job vs the patients right to self determination?
I am going to try, and i hope everyone else will do the same...to not make this as much a personal attack on you. I realize you are doing us a favor by posting here and its kind of hard regardless of who you are to take a constatn pumelling from everyone and you stand alone....It is obviously a emotional issue, but if we keep it about the issue in general and the profession in general rather than shooting the messenger, we might be able to extend this and really learn from it. And on your last comment, I don't think most people would argue the issue physical well being trumps modesty, its just a matter of degree's and perspective of reasonable...and some of that i think is just communication, it doesn't sound like you just cut the kids clothes off and left him lay naked, sound like you covered him up....that is a big difference...thanks and I hope we didn't run you off, Chill doesn't suck, both sides have an edge to their comments as it is a personal thing...but doesn't mean we can't attack the issue without attacking each other....alan
Chill
I would like essentially for you
to expand on what you said previously.
You said " Patients deserve a right to professionalism
from the doctor,tech,or nurse."
Do you think this happens in every case? Not all patients are treated
professionally!
You said" I believe there is no
right to a same gender provider,
whether it be a nurse,doctor or
tech."
Is this not a free country. How many women prefer female ob-gyn's
or female urologists. Are you
saying that they must all go to
male providers? That they don't have the right to choose?
That line of thinking is we must only buy american cars even though
I know I'll get a better quality
car with a european import.
Are you saying that despite the fact that we are paying for a service we have no choice?
If I needed to be a patient on a
nursng floor and I knew that the
nurses restroom had nude pictures
of men from playgirl magazine and
the nurses had no regards for my
privacy are you saying that I have
no choice of asking for a male nurse in any personal procedure.
BTW I have seen this!
Please enlighten me.
PT
Sorry if I've appeared to be going after Chill personally. That's not my intent. Dr. Bernstein is right. Patients haven't walked in a doctor's shoes.
But it seems there could be an abyss separating doctor experiences and patient experiences. Doctors do experience being a patient. But they never experience being a a patient, as most of us do, with no/little knowledge of medicine or the system. They're in a system, a culture that they know. They understand the basic language and routines. Most patient's don't. Those are really different experiences. I do realize that having this knowledge may make it even more difficult for some doctors. But they haven't walked in the unknowledgeable patient's shoes, either.
And again, we seem to be focusing on critical, life-threatening, ER kinds of experiences. I'm willing to drop these cases from our patient modesty discussion. Not that modesty doesn't matter, but it's not a priority and I trust that ER doctors and nurses do protect patient modesty most of the time as best they can. We patients have to make leaps of faith situations like that.
Chill and his doctor friend seem to have the same attitude toward patient modesty running across the entire spectrum, from emergency to non critical care. This seems to be the "gender doesn't matter" syndrom, or the "gender shouldn't matter" syndrom. And there is a difference between "doesn't" and "shouldn't."
"Doesn't" suggests that there are few or no cultural taboos in this area. That gender doesn't matter out in the real world, too. This position, of course, can't be defended.
"Shouldn't" suggests that the system knows gender does matter in our culture, but it's not going to matter in the hospital culture for reasons that may benefit the hospital culture more than the patient. Of course, there is the attitude that anything that's good for the "culture" is good for the patient -- a premise I reject as a general principle. I think this is more common than the "doesn't" matter position. I think there's an embedded culture of resocialization going on in some hospitals and clinics. Modesty is seen as a pathology that needs to be fixed, cured, challenged. Not necessarily because it's bad, but probably more likely because it interfers with the operation of the system.
But as I read Chill's remarks, I can't help but believe that his beliefs are common in healthcare. And where is the attempt in our society to bridge the abyss that may separate doctors and patients? Blogs like this may help. But I don't see any attempts by the system to help bridge that gap. Some books like "How Doctor's Think" help give laypeople an idea of what's going on. But consider, that book not only explains how doctor's think, but it is also quite critical of how some doctors think.
If we haven't left topic, and if we're still talking about treating the whole person and dealing with modesty issues, I think we need to clarify where we are when we talk about this.
If we believe that patient modesty:
"isn't" an issue across the board...or
"shouldn't be" an issue across the board...or
If we believe that this is a situational issue, where context makes a significant difference in our attitudes and perceptions.
I read that most laypeople on this board are not extreme in this position. But I'm getting from Chill and his doctor friend, that they do take the extreme position about granting patient requests for same gender care in nearly all cases. They just don't believe in it.
I'd like to know why they believe they shouldn't grant this type of patient request. Is it because the system can't cope with it, or is there another basis for their belief? Is it the "doesn't" or "shouldn't" matter position?
I agree with MER's questioning. If there is a failure of the system or profession, in order to correct that failure it is necessary to get the facts in order to restore the system. Again, using the airline analogy, after an airline crash, you hear on the news no accusations. What you hear is the responsible air safety agency is looking at the "black boxes" and beyond for the facts related to the crash. I think that if a system or professional failure is what is being discussed here, we must first start with facts.
Let's start with the premise, which I certainly can accept, that patient modesty is NOT the number ONE issue on the minds of physicians or other healthcare providers or institutions. Those who find that this is a failure, a system or professional defect which could lead to a "crash" of some sort (perhaps trust) and those who recognize that degrees of not attending to patient modesty is an issue but not number ONE, unlikely to lead to a crash, but an issue that should be resolved should take the airline crash investigation example.They should work together to gather, display and analyze the facts and together sort out a resolution from the understanding of the facts.
I hope all my visitors understand clearly that patient modesty, though not necessarily considered by physicians as the most critical issue on the plate when faced with a sick patient is nonetheless one to which they (as I know from my teaching) have been clearly alerted to in their training. They know it. One question is why to some patients they seem to ignore it. Chill has given some facts regarding the ER environment that may suggest an answer. Let's look at other aspects of this issue and get more facts. ..Maurice.
PT: any professional or public institution that have pornography in the bathroom is morally reprehensible (IMO). I think your choice however is whether you goto that institution or provider, and not a "right" to have a same gender provider. If I want a car, it's not my "right" for me to get a car - car dealers shouldn't have to just give me a car because I want one. However it's my "right" to pursue the means of getting a car. Just as it's your "right" to request a same gender provider, or to find yourself another provider, but there's no moral obligation to have to provide you with one.
Alan: thank you for your comments. And I seriously would enjoy discussing more of low-income "free care" pts and how their medical care may be different than someone with good insurance (I do think it ought to be...although I suppose some would consider this immoral). Maybe there's another thread that we can talk about that on. I do give my perspective some of your other questions below.
Dr. B, excellent framework for discussion. I have to agree on your 2 statement: that modesty is not foremost issue of providers, and that all medical doctors have been alerted to pt. modesty sometime in their training.
One question that I have for you all - do you think there is a difference between one person's preference vs another's religion? A better way to ask is, for those of you that have felt humiliated or had your modesty compromised, do you think your desire to avoid that humiliation (perhaps by having a same gender provider), is any less important than another person with a religious background that dictates so?
I tend not to think so. To me, it all falls under the category of "patients' preference". Surely there are gradations of preference. A pt. asking for 5 meals a day because that's what he's used to at home is certainly not the same gradation of preference as the pt. asking for same gender provider because of previous sexual abuse. Nevertheless, it's all "preference" to me as a provider. And the only question I have to answer is 1) what's the grade of the preference and 2) how far am I willing to inconvenience myself or the system to satisfy the preference. I feel a rape victim has a high grade preference, and warrants a same gender provider. Obviously different people will have different answers to the 2 points. In thinking of what has been mentioned before, "why do I get to decide for the pt then?" I suppose my best answer is just because I am the decision maker in that scenario. In the hospital, I get to make decisions for the pt., not just the medical stuff, but even stuff like "can the pt. eat?" "can the pt. go out to have a smoke?" "pt takes ginko at home, can he do that here?" Take the example of the pt. smoking - I hate smokers, therefore I always say no. Another doctor might smoke himself, and let the pt. go smoke. Is it right as the decision maker to prevent that pt.'s preference of smoking? I don't have an answer to that.
Unfortunately, a lot of "inconveniences" from stressed or overworked doctors fall short of the ideal. For example, take a delirious pt at 3am who is agitated, screaming and wants to pull out lines and get out of bed. The correct answer on a test question is to go talk to the pt. try to reorient that pt. Chemical sedation and physical restraints are last resort. When I started as an intern (1st year out of med school), I was on call and on my 23rd hour working. The nurse called on a delirious pt. requesting for me to order 4-point restraints to keep him in bed (and prevent injury to himself) and chemical sedation (probably because the nurses were tired of hearing his screaming). I knew the right answer, but I honestly didn't care...all I cared about was if they would stop calling me and I had hope of getting some sleep. I ordered the restraints and sedation.
The question Dr. B posted, of why providers sometime ignore pt.'s modesty - My first thought is because of learned behavior. In training, hardly any trainee is punished for not taking the effort to provide for patients' preferences. Instead, the focus and pressure is about medical pathophysiology. In the example I depicted above, I know I will not be castigated the next morning for sedation/restraints, but I WILL be questioned on my "medical" decisions.
Unfortunately, despite the exposure about pt. modesty in training, with no punishment/reward system...it ultimately fails. What you have left is personal provider biases...the 2 points I mentioned above. A colleague who has been humiliated himself might go to extreme lengths to provide for the pt., whereas a provider like myself may not.
Alan asked "Do you feel Dr.s and patients see the realtionship differently, you treat the meat, they want emotional comfort...which providers feel isn't part of their job?"
I think the job of the doctor that both doctor and patient can agree on is to treat physical illness or "meat". I think a lot of doctors feel anything above that is extra, and many don't take that extra step. Furthermore, doctors are punished when they make a medical mistake (ie lawyers) but I have yet to hear a lawsuit about "I'm suing my doctor because he doesn't listen to me" (this goes back to the punishment/reward system I talked about).
One last thought to my previous post.
Going with the whole punishment/reward system theory, not only is no real "punishment" in not addressing pt's emotional need such as modesty, there's no reward.
The ER doctor is paid simply by number of patients per hour. The clinic doctor may alot 15 min per pt. If the pts medical issues takes 14 min, then that leaves 1 min to address everything else.
Now take a doctor that really invests in a pt., and instead of 30 pts a day, he only sees 15. (this is assuming no one fires him as he is hurting the system's bottom line). The pts probably would love him, but at the end of the day, he works just as hard, makes half as much, and takes twice as long to pay off his student debt. Ask yourself, if you sacrificed years of your life with over $100,000 in debt, would you still choose to make less money to be the more "complete" physician? If you question your ability to do so...then is it fair to expect more from your doctor?
(let's just assume managed care is here to stay and not have a discussion whether managed care is good or bad)
Chill
I hope this isn't your last thought or last thought. There are a lot of questions and realizing your schedule may not permit you to, or you may not feel inclined to,,,answer them you are doing some good here.
To this point we have only seen one side of the equation. Your thoughts are honest and frank and while we may or may not like them they are valid.
We forget there is a business side to this, and as much as we would like to say this isn't a money thing...of course its a money thing..for everyone. A question I posed after starting to read "my angels are come". Do you think we have a seperation here where they system (admin) has created a situation that is economically viable at the expense of what we are discussing here. If Dr.'s were not pressed, if reimbursement was at such a level to allow a different approach, would it make a difference. Are providers and patients both victims or causualties of a system that right or wrong is focused on the bottom line, customer service (in this case modesty) is a price they are willing to for go, and patient satisfaction is measured on the impact it will have on that bottom line. Is the business side looking for that sweet spot where they can get the maximum income at the minimum cost, if they cut to deep it could effect the bottom line if patients go elsewhere? In essence both provider and patient are getting what admin hands down? You can't provide same gender becasue physically you are so over loaded it isn't reasonable or possible....if providers had the luxury of a case load that would allow providers to take time and move schedules...would they consider request for gender for intimate procedures/exam reasonable?
Chill, do you think this thought has any validity at all?
An for my part, of course you deserve to be highly compensated for what you do. Not only the cost and time to get there, but the awesome responsibility we put on providers, we expect them never to be wrong, bat 100% when NO BODY is capable of doing that in any job. We pay a baseball player 250,000,000 to play a game and insurance companies and the government (medicaid) want to discount providers pay for saving lives....how screwed up are we as a society...so on my part, your compensation should be a given, you deserve it, now how do we get you the compensation you deserve and the accomodation patients deserve....that is a question....the question is where are we starting from???? where are we right now??? is this a provider, administration, or patient issue or what blend of all three....alan
Excellent post, Chill. You certainly seem to be telling it the way it is. I respect that honesty.
Now -- a question. You've described the reality as you see it.
How do you feel about the ethics of that reality?
We can talk about situational ethics, that is, within the confines of this "system," broken or not, do you agree with the ethical choices you and other doctors are making?
What about looking at the overall ethical situation, not making it completely situational? What about the ideal? What's best practice? What ethical choice provides best for patient dignity?
Within an ideal healthcare system, would support patient requests for same gender care?
Chill
As expected I disagree with your
responses. True, car dealers don't
have to provide me with anything.
It's a market and the dollar is
king. You seem to have forgotten
where you paycheck comes from!
PT
Chill
I sense the falacies with each
of your responses are on the assumption that you work within a
perfect system. Healthcare is far
far from perfect. Personally, I
think Target is better managed than
most Hospitals and physicians offices.
Arrogance is and has been the
golden rule. Double standards stacked against men in regards to
privacy issues has been the standards at least since I began
working in healthcare in the mid
70's.
In many institutions change
takes time, sometimes generations
of employees for the better. I would venture to say that since you
don't feel that people have a right to choice when it comes to
gender then we don't have a choice
to choose between the best and the worst. Am I correct? Are you assuming that I have to be seen by
the incompetent or say the perverted?
That is why most physicians don't report the incompetent or
impared. Fortunately, many states
have a medical board site to help
me wade through the jungle and it
is a jungle. People are afraid to
admit the truth. How many unnecessary deaths are there each
year in healthcare? You know the
number. The prestigous institutes
of health in 2000 told us that
number. Fact is, that number is
underestimated.
How many women would you say have
been molested by physicians since
1980? Do you know that number?
Would you blame a women if she
choose not to see a male physician
or a male nurse. How many female
nurses would you trust with your
life? How many female nurses would
you trust to hold confidential any
private information about you if
you were a patient. I didn't think so!
If you knew what happened to me
as a male patient would you blame
me for requesting same sex provider. You mention that institutions have no moral obligation to provide me with one.
You are right, they don't have to
come out and say it. But it's my
choice and I have a right to request. It is NOT your right to
decide and force anything on anyone. This is not a communist
country. The trend will be within
medical institutions soon to accomodate these kinds of patient
requests happily. You can buck it
if you want but you don't and won't
have a say. Remember, its a free
market system. Its not about you,
its all about the patient.
PT
PT,
I've been monitoring this thread and it has been fascinating. I urge you and others however, to cut out the personal vitriol against Chill. It is in everyone's best interest to keep this discourse civil. PLEASE. Unfortunately, there is much in the health care system that is stacked against the pt. It is, in the end, mostly all about money. Let's move forward with the assumption that Chill is not a bad guy. He is however a product of his teaching and environment. It is the latter that is the issue, not Chill. I totally see his point of view.
Chill,
I want to thank you for your honesty, candor, and eloquence. I have found your blogs to be thoughtful, and well constructed.
For your consideration: While my wife was in the hospital dealing with breast cancer, her plastic surgeon , and all of the residents, and interns seemed to be concerned with her modesty, careful to expose only that which was needed at the moment. There was an occasion to discuss with her doc about his attitude toward his pts modesty. I remember him saying that when he was younger (he was about 40 at the time), he wasn't so careful, but he learned that it was important. I also remember one morning after one of her surgeries, he came in and "asked" if he could see her new breast mound. It was but a moment, and it meant something that he had done so. I remember tears welling up.
More on this later, but I think it is a product of the environment a doc finds themselves in. You are dealing with time constraints and resources, and an overwhelming stream of pts. Which you most likely will never see again in your practice. In the PS case (associated with a large teaching hospital in Los Angeles) he is dealing with the emotions of his pts (and body image) as much as the disease. He has learned that it is important to consider the wishes of the pt. (And he still has a heavy schedule to keep.) He also knows that the relationship might well last through several procedures. So he knows he needs to establish a trusting relationship if he hopes for the pt to return.
At another of her surgeries, she needed to be almost fully exposed in order to be marked. During preop (and very hectic time), he allowed our request for privacy (so that her modesty could be respected), by kicking everyone out of the cubical (at our request), so that the 3 of us could participate in the markup without "distractions".
The economics surrounding medicine is making it difficult on everyone.
Chill, again, thanks for participating. I hope it continues.
Dr. B: You have a long road ahead of you. If Chill is right, and I suspect that he is, your teaching about modesty becomes meaningless almost as soon as your students leave your classroom. It is the case, I hope, that as some docs mature in this current generation, they become more like my wife's PS.
--amr
Chill,
Thank you for the time that you’ve taken to post on this blog. I’ve learned a lot from your responses and appreciate the honesty. One of the main issues that I was concerned about going into this election year was all the talk about healthcare changes, mostly from the democrat’s side of things. I honestly think a universal healthcare system wouldn’t be the best thing for this country. We have a problem with people taking advantage of our system now; imagine what I’ll be like for all of us if it becomes a free for all. That’s a different subject though. Truth is, I think if the proper people just spent the time talking to the actual patients and getting honest feedback from them, they’d recognize this problem we’re discussing. I just don’t understand why it’s getting over looked. I posted a link earlier on this site about the number of paramedics that we’re on trial or have been indicted this year. My point was that if you work in an environment where modesty isn’t respected, and you witness this every day. Why does it really surprise anyone on the number of sexual abuse cases in our healthcare system? These people witness this day in and out and what’s really sad about it is the number that has probably got away with it. If that was any other profession (say a cop), there would be changes forced from our government but for whatever reason, nothing has been done in the healthcare system to date (at least nothing that has worked). I also think a person can get the care they need with their modesty intact. When I went through both of my shoulder surgeries, the first surgeon that I went to wanted to put a tube in every opening in my body. No Thanks… I found a surgeon who did the same procedure with only an IV and my underclothes on. That’s one of the biggest issues that I see. Exposing a patient just because of your SOP even though keeping some clothes on won’t interfere with the procedure. If that body part isn’t needed, don’t display it. That doesn’t take funds to change, that just takes common sense. Other examples that users have posted. Colonoscopy shorts, there are such a thing and they aren’t in the way of the procedure, why aren’t they provided to all patients. These are simple things that don’t get addressed but can go along way to ease the mindset of patients. I guess I’m one of the lucky ones who reads in advance about the procedure and have the insurance to find the provider of my choice. I just feel it should be an option for every patient. Jimmy
A few more responses to Chill's last post:
Chill writes: "I feel a rape victim has a high grade preference, and warrants a same gender provider."
I'm glad to hear that. But are you talking about a current rape victim who comes into your ER for treatment? How about a past rape victim, or a past sexual abuse victim who may be in therapy or hasn't told anyone about it. Does this individual have to explain to you that he/she is a rape/abuse victim before asking for same gender (or perhaps opposite gender) care? And how will you respond?
Gets complicatged, doesn't it?
Chill writes: "I am the decision maker in that scenario. In the hospital, I get to make decisions for the pt."
Of course. But, yes and no. The patient ultimtely decides what/she is going to do, including whether you do become the decision maker. Of course, it's easy in a hospital environment to use intimidation to get the patient to do what the system wants. And, indeed, that may be in the best interest of the patient.
Chill -- you seem to hold on to the "Doctor as all knower" epistomological stance. I believe that's an old paradyme being repalced by the "team" model, with the patient an essential member of that team. In the past, doctors have experienced great stress and shame from being expected to have all the answers. It was part of how they were taught. Dr. Bernstein could explain this idea better than I.
"I knew the right answer, but I honestly didn't care..."
I really don't know how to respond. That happens to all of us in various professions. Problem is, in medicine, the stakes get about as high as they can get -- unlike many other jobs.
Chill writes: "why providers sometime ignore pt.'s modesty - My first thought is because of learned behavior. In training, hardly any trainee is punished for not taking the effort to provide for patients' preferences. Instead, the focus and pressure is about medical pathophysiology. In the example I depicted above, I know I will not be castigated the next morning for sedation/restraints, but I WILL be questioned on my "medical" decisions."
This, it seems to me, is the "patient as machine" attitude. Let's look under the hood and check things out. Some patient preferences can be outrageous and the system has every right to reject them. Other prefereces are elemental -- an essential aspect of the psyche, the soul. You call these preferences. I prefer to call them values, maybe core values. You're comparison of smoking and eating preferences is a false analogy. Those are not core values. But Chill's next statement gets right down to what we as patients need to do about this problem:
"Unfortunately, despite the exposure about pt. modesty in training, with no punishment/reward system...it ultimately fails."
Like most human beings, doctors respond to the threat of punishment and reward. If patients don't speak up, if they don't let doctor's know their needs and values, within reason; if they don't remain polite and civil yet firm, if they don't file complaints to the right authorities -- if they don't do these things -- the "punishment" motivation won't kick it.
That's what Chill seems to be saying. I can't imagine getting into trouble for ignoring a patient's preference (read, modesty), Chill is saying. Who's going to complain? And if someone does, my supervisors and the peer boards will just laugh. They've got more important things on their minds. Perhaps that's true. But, as we can see with Chill, it seems to me that deep down he knows what's right, what's ethical. So do the peer boards.
Keep in mind that Chill is coming from an ER perspective. For me, that perspective rests on one extremen of this discussion.
But again, I really want to thank Chill for being so honest with us. And as one other poster commented, Dr. Bernstein, as a teacher of doctors, sure has his work cut out for him. Chill shows us that, in a broken system, the underground curriculum quickly takes over, making the academic curriculum, the ideal, seem unattainable.
Patient modesty can't be just side topics in medical education. They've got to be part of a hollistic approach to treating the whole person -- body, mind, spirit (soul). Chill seems to be saying that is taught as an intellectual concept, but it isn't modeled. And nothing seems to be a stake in not complying with patient modesty during training.
I don't know what's being done in medical education. Perhaps Dr. Bernstein could comment.
As I see it healthcare in this country barely adresses the physical aliments let alone the
mental ones. There is no concern
about your mental well being.
There seems to be a disconnect
with the patient. You are only a
number in a room. Fact is practioners have lost the subtle
art of diagnosing,whereby,its left
to the radiologists who make the
interpretation via a cat scan,pet
or mri.
Its shown now that pa's (physician assistants) can do the
jobs of physicians in emergency
rooms. If a male patient needs
a foley catheter what does it
matter to the er physician who
inserts it. If the patient requests
a male nurse or a female patient
requests a female nurse is not the
end result achieved. Who cares, why
not try to make the patient comfortable. If er physicians are
so "busy" why would they care who
is doing the personal care as long
as it gets done.
Most er patients are not real
emergencies anyway. Most patients
use the er as their doctors office
and if they are a level one then thats not your job. That falls on
the trauma team. If you get a
patient with say cp you'll probably
request a vq scan or an angio ct,
admit the patient and let the
attending do the rest. There IS
plenty of time to take care of
the patients mental, emotional
needs. Few have the patience for
it. Most simply don't care and it
never enters into the equation.
I don't believe anyone here is
picking on anyone per se. This is
a very sensitive issue with people
and I'd venture to say that people are on this board because they at
one point or another were victims!
With being a victim comes anger,
guilt and resentment. Through this
hopefully comes empowerment. Empowerment takes time and knowledge is power. To me it's
disturbing to have anyone visit
this site and flat out say all of
your concerns don't matter. I've
seen entire physician groups fired
over the attitude of one physician
in the group.
The patients well being will always TRUMP anyones idealogies!
PT
MER, our instructions about patient modesty in the first two years of medical school degrades due to the "hidden curriculum" which starts in the 3rd year. The students are no longer having the leisure to take a history and perform a physical on one patient every week or two, taking up to two hours without any formal patient responsibilities. They begin and continue into their 4th year and intern/residency to be responsible for attention to multiple patients each day, limited time for history and physical, practicing procedures, trying to understand therapeutic protocols and being supervised by superiors whose interests are far away from patient modesty and would be less likely to be critical of a student missing a modesty issue then missing the significance of a elevated serum potassium in a trauma patient.
And then, as I have written here many, many times---we, including me, have never gotten feedback by patients regarding their modesty concerns. "Out of sight..out of mind." So that is what happens to the results of our modesty instructions and supervision to the first and second year students. Degraded. ..Maurice.
Chill
You asked if I consider requests based on religion at a different priority than personal preference...while I never thought about it or at a minimum never tested it...I would say no. That may not be a popular answer, but to me the psyhic of requesting gender is the same, comfort or dicomfort. If the athiest asks for accomodation becasue he/she was sexually abused as a child, taught as a child, had life expereinces that make exposure traumatic...is that less important than someone who feels that way because of religous reasons. Who and how do you measure intensity. How do we make those calls which I guess is what we are asking providers to do.
I understand this in the ER much better from this discussion, getting the other sides perspective as Dr Bernstein said...a key point, we haven't told them how we feel, they haven't told us, and we just let it grow.
Chill, one thing I would like to point out, while a lot of this paticular conversation is about Dr.'s, alot of the issues that were brought up had to do with other providers and or proceedures rather than Dr.'s.
And MER has a great question, how do you feel about the ethics of the issue vs the actuality. In a perfect world, if the system allowed it, should it be different, if the system provided enough resources...would it matter? Do you feel discounting or dismissing modesty concerns while required now due to paitient loads...is right or a nesecary evil...and I also would urge, please lets not attack the messenger, we kind of unloaded on Dr. Bernstein awhile back and he obviously is on our side....alan
Chills coments are not a revelation or "eye-opening". It was basically the same back in the '70's at general hospitals which cared for so many indigent patients off the street. Yes, it is a zoo. The posts on this blog from people who have had bad experiences concern more of the elective procedures/treatments/surgeies that have found to be offensive with no regard from the providers for modesty, decency, and respect. I agree with Jimmy's post about the shoulder surgery and colonoscopy shorts. It is not difficult to take into consideration the patient. I think providers really don't give a hoot about the patient and how much is exposed or who is assigned to do an intimate procedure or treatment. I personally am sick of it and completely offended. It is unnecessary. The "Patient Right" document that so notoriously hangs in healthcare facilities does NOT state : "We deserve the right to extend or not extend these rights based on patient load or over burdened exhausted physicians/nurses." No it is posted for all patients at all times. I recently had something done and actually received a one page survey letter following. One of the questions addressed "patient modesty" and wanted to know if my modesty needs were met!
Medicine, imaging, pharmaceuticals--- All about money. It is big business. Only two things make them change protocol: a) LAW enacted 2) Monetary damages inflicted. PERIOD.
Not all patients request same gender care, so "chill" why not provide it for the few that request it?
JW
I ran across a short article written by a registered nurse about simple things that can be done to protect patient modesty. Go to this page:
http://www.albme.org/Default.aspx?Page=ArchivedNewsletters
Then scroll down and click on the "Volume 10, Number 4" link. The article is down the page a bit and entitled "Hospital Patients Have a Right to Privacy."
CLW
PT, you asked how many women have been molested by physicians since 1980. Any luck finding an answer to that question?
Dr. B usually allows an occasional plug for our discussion group "How Husbands Feel."
Here's the link:
http://health.groups.yahoo.com/group/howhusbandsfeel/
PT, if you're interested, mention who you are in your application and I'll see that you get right in.
CLW
With regard CLW's reference to the RN's article in the Alabama Board of Medical Examiners Newsletter (here is the more direct link), I ask where is the editorial by the Board ccommenting on their view and possible actions regarding the behaviors described in the article? The fact that the Board published the article must have found some merit in what was written. I would have expected it to respond in the same edition of the Newsletter. To me this seems like evidence of a "ho hum" attitude. ..Maurice.
I hope you all read carefully the link CLW provided above. Along with Chill's comments, this link suggests to me the following:
First, nurses deal with modesty issues all day long. That's what they do. They are trained more in this area than are doctors because it's more a part of their mission; and their mission is not only of patient comfort but also patient advocacy. The vast majority of nurses are more in touch with this issue than most doctors, and most nurses do their best to meet help the patient. I'm not saying they all meet their goals every time. And I'm sure there are a minority of nurses who either don't care about this or act abusively. But most nurses are with us on this issue. We need to remember that as we work to improve conditions. They are not the enemy. They are the best allies we can have.
I'm not saying doctors don't deal with this issue at all. But, as Chill has taught us, they are trained differently. I'm surprised that first and second year med school students are trained along side nursing students in some areas. They should learn some things together and learn to communicate better with each other and have more respect for each other's skills. I think Dr. Bernstein mentioned to me a one point that there's little his teaching of doctors and the nursing school.
But Dr. Bernstein is an exception in terms of acknowledging not only the existence of this issue but it's importance, but advocating for it. I think Chill respresents the more standard opinion out there.
I've also come to another conclusion. Most doctors and nurses who are truly concerned with patient modesty, are committed to modesty for both genders. For them this isn't a gender issue. It's a human dignity issue. They do the best they can for both genders.
Those who don't care about modesty, don't care about modesty for either gender.
Your last comment, doctor makes an interesting point. Why didn't the medical board respond to the nurses comments about patient modesty? Notice that the article was reprinted from RN Magazine. Is the the medical board made up of doctors only? Do they consider this to be a "nursing" issue if an issue at all?
The fact that there seems to be so little group training of doctors and nurses, at least in the early stages of their education, suggests there may be a disconnect that makes it more difficult for them to work together and inhibits good communication.
CLW
I did not ask if he knew. I know
he dosen't know. Why should he care to know? These issues don't
concern him. I do know the number
and it is based collectively with
data recieved from police department complaints nationwide.
The numbers obviously don't reflect those who did not complain,
additionally there are some who only complained directly to the
various state medical boards.
PT
MER
I strongly disagree with you.If nurses (female) do such a
great job with respecting patients
privacy,modesty issues we probably
would not have so many complaints.
Is this just your personal
opinion. Most female nurses will
only respect female patients modesty, privacy. I'm not a male
nurse but perhaps you should ask
male nurses who tried to work in L/D for years and ran against a brick wall.
Why do many surgery centers
alow for all female gender teams
for females but not for males.I
recommend and I'm certain you surely must have read many of the
threads on Dr Joel Shermans site.
Please elaborate!
PT
PT
Jimmy here. I’m not going to try and debate this issue with you but I can tell you from my experience that female nurses do try to maintain a man’s modesty if he speaks up in advance. Each time that I’ve brought the request up with the nurse (only a few times, leave underclothes on), they’ve acted completely shocked. One told me that most men don’t say a word and she’s had to ask a few to keep it in their gown. I think that’s one of the obstacles for all of us who actually care. Getting to the point where it’s common for a male to ask not to be displayed for any reason. Again, this is just from my experience. I worked with female staff through all four of my surgeries and all have been kind and very professional. Most of the flack that I’ve dealt with comes from doctor offices. But it’s easy just to hang up on them and go some place else. Just my two cents…
Jimmy
Therin lies the flaw. You had to ask them. You had to bring up
the issue. Should privacy be an
automatic, isn't it just the golden
rule. Treat others like you would
like to be treated.
The comment you made, she's had
to ask them to keep it in their
gown. Sounds to me like a rehearsed
excuse. Makes US look like the perverts. Sorry Jimmy.
I've seen your posts and I am
with you on this believe me,however, I've many years experience in healthcare and I've
seen the worst in them. I've been
at the recieving end of it.
Patients should NEVER have to
ask for privacy,it should be granted.ITS THEIR JOB!
PS Always enjoy reading your posts!
PT
I think Chills comments are applicable for several reasons, not the least of which is they give a glimspe into the mind of a provider. While the ER may not be typical, may have special circumstanes there are some similarities. The example of the young man in trauma. They saw the medical need to expose, we saw what we percieved as lack of reasonable accomodation. I say percieved because we don't know the details, was he covered with a sheet or towel, was he left exposed for an extended time, etc..I also got some new thoughts of can't vs don't.....
I also think there is a 3rd party to the equation that we are not recognizing. The administration of the hospital. While Nurses and to a lessor degree Dr.s are in the trenches, hospital administration sets policy or standards on things such as gowns, apparel, personel, scheduling, etc which have a big effect on the issue. If the policy was to offer each person going through intimate exams gender choice, if the policy was to offer each patient colonoscopy or surgery shorts, etc. what would be the effect. Now you can set all sorts of policies and it is up to the providers to apply them, like wise, in the absence of policy a provider can still provide for a patients modesty. I have seen both ends of the spectrum. I watched a nurse leave the curtains open in a ICU unit and whip my fathers gown up and check his foley with people visiting the patient next to him in full view. On the other hand, I watched a nurse lay a gown over my fathers gown and pull his dirty one off under it so as not to expose him and only she and I were in the room and he was unconcious...so I don't think it is an issue of a single segment of the industry. The policies are so different between hospitals. If we want change we have to make it clear to all levels of the system.
And great points, why do males have to ask, why do nurses act surprised....you hit it on the head. Becasue they assume women need and want accomodation becasue they have asked, complained, screamed, and sued...in short they made themselves heard...and we males, we took it, said nothing, and are angry and surprised they don't treat us equally. Silence is consent to them and we have allowed the occassional to expand to the ususal. Its up to us to speak up, at all levels until they hear enough to assume the right path is to ask us or provide.....alan
I would like to post a qoute from "my angels are come" by Art Stump. He wrote a book actually a diary of his experience with prostate cancer and his treatment in Memorial, South Bend, Indiana. While not the focus he does go into the privacy issue in several aspects...here is one qoute that while directed at outsiders has a lot of application to the right to self determination and who decides what is and isn't acceptable:
"Merriam-Webster tells us that privacy means "freedon from unauthorized intrusion". Logical inference tells us that the only entity who could legitimately authorize such an intrusion would be that person or party or legal proxy for that person or party whose prvacy would be compromised as a consequence of the intrusion..
It follows that insofar as patient privacy is concerned, a caregiving institution that does not have gauradianship cannot autonomously authroize intrusions upon the privacy of its own patients. Therefore an instance wherein an institution has presumptuously sanctioned incursions by outsiders into an area ostensibly reserved for patient privacy, such as an area designated a "Treatment Area Waiting Room" might credibly have demonstrated that instituions failure to respect to one of its most basic fiduciary responsiblities, namely the duty to keep safe the privacy of its patients"
While this is in reference to a physical area, does it not have application to all aspects of our treatment. While providers may contend there is an implied consent when one enters the facility, I would argue that when patients requests and desires are ignored or they are coerced as is sometimes the case...we have the same situation. Our right to self determination is not signed away when we enter, we have the right to determine degree of exposure and compliance and have the right to change out minds. We also have the issue of passive coersion providers knownly conducting proceedures with full knowledge that the patient is not in agreement but to intimidated to protest....thoughts....alan
I agree with both Jimmy and PT about the modesty, privacy issues. Both make good points. The problem lies in the fact that many men don't particularly care and the others for the most part do not "speak UP!" They are compliant. NURSES are very wrong to assume anything. Some women are not modest either. But then 90% of nurses are female. If 90% of nurses were male what would happen?
Unfortunately the male gender is and has been sterotyped of not having modesty, privacy issues. What gender "flashes", what gender rapes, what gender uses rest rooms with no partititons, etc. etc. ??
JW
PT,
I'd be interested in the data you have about the number of women sexually abused by physicians. If you don't want to discuss it on this blog, I'm sure Dr. Bernstein would be happy to act as an intermediary to pass our email address to one another. I might have some information you'd be interested in as well.
Thanks,
CLW
Alan, I was disgusted to read your post of the nurse that whipped your fathers' gown back to check a foley. First of all it was unnecessary to whip the gown back to fully expose a patient (male or female) and certainly all curtains should have been pulled. She should be fired on the spot for violating administrative and patient policy. I don't know how you reacted but I would have lost it and she probably would have ended up picking herself up off the floor. Admin would have been notified immediately. This type of action by healthcare providers is rude, unethical, callous, and unprofessional behavior. She needed to find another line of work ASAP.
JW
I have seen female nurses insert a
foley on an unconscious male patient in full view of female patients without closing the curtain.
Would they insert a foley on a female patient in full view of male
patients. I'd bet you not. How often does this occur? Frequently
I'm sure.
I don not think its an issue of
us speaking up at all. Everyone
and I mean everyone in nursing school are taught about respect
and privacy but male patients
don't count!
PT
ps CLW I will provide that as well
as other date provided that DR B
dosen't mind.
ATTENTION: I am planning to close down further postings to this Volume 7 after today and begin Volume 8 tomorrow,January 8 2009, in view of having reached over 100 comments within this volume. Again, my concern is if we continue more here, we may suddenly lose postings as we had in the past, but also it is also may be easier to scroll to a posting with a volume containing a smaller number of lengthy comments. I hope everyone agrees with my continuing decision in this matter. I haven't heard anything from my visitors to the contrary. Thanks to all for keeping these volumes active and interesting. They are clearly the most popular and often represent 10-15% or occasionally more of the visitor's initial topic selected from the over 650 topics already published on this blog. It is obvious that far far more folks are reading these patient modesty threads than writing. Whether they come out of intellectual or prurient interest or out of sincere personal experience or concern, I can't tell.
I hope and have strongly suggested that if this blog is to have any value in this topic beyond simple ventilation, that discussion continue to include emphasis on how to proceed further toward the education of the patients, professionals and institutions, changes within systems and final resolution of the writers concerns. ..Maurice.
I don’t disagree with what anyone has said. I’ve been fortunate to have had the care that I received; I get that now after reading this blog for so long. But, I’m still in my early thirties and I know that chances are one day; I may have to have some sort of procedure done that compromises my modesty. That is why I’m asking today, so the nurses and doctors I speak to can make a note of it and maybe that will help the next person after me. I hate that I have to ask considering what I give up (family time, long works hours, we’re not immune to that stuff either) to have the insurance that I have but it does mean that much to me. I also do it for my son who is pretty much built the same way I am even at his young age. I want him to have the choice/options one day and not have to ask, not because he deserves it but because it’s just the right thing to do.
Alan
Actually those policies are normally administered by that department’s supervisors, who was usually at one time, or another a nurse or doctor. All the department heads at our local hospital (as in surgery supervisor, etc…) were nurses at one point. Truth is, doctors are the only people that can make the exceptions if the patient asks. That is what I learned with the Orthopedic Surgeon I went to. That’s just in my area; it probably differs from hospital to hospital. Jimmy
NOTICE: AS OF JANUARY 8 2009 THIS THREAD WILL BE CLOSED FOR ALL COMMENTS. DO NOT ATTEMPT TO WRITE ANY FURTHER COMMENTS HERE. PLEASE GO TO "PATIENT MODESTY: VOLUME 8" TO CONTINUE COMMENTS. ..Maurice.
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