Bioethics Discussion Blog: Patient Modesty: Volume 11

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Tuesday, March 10, 2009

Patient Modesty: Volume 11



We are starting "Patient Modesty: Volume 11" migrating from Volume 10. The theme continues and comes from male patients who are uncomfortable with female healthcare providers when dealing with particularly the male genital area. The argument is that the medical system arranges for women patients to have women healthcare providers for modesty sensitive exams and procedures if the woman wishes but the same opportunity to gender selection is not provided to male patients.

Volume 10 is now closed for comments there. The story will continue here. ..Maurice.


GRAPHIC: Cystoscope and Gender Selection. An ArtRage composition by myself.

115 Comments:

At Tuesday, March 10, 2009 10:00:00 PM, Anonymous Anonymous said...

In the brief time I have been here, Dr B has twice raised the issue of the "psychodynamucs of patient modesty" without much response. So I thought I'd make a stab at a contribution on this since "modesty" is a favourite discussion topic of every new naturist, and also one raised by nearly every person who finds out I'm naturist. The facets below may only be partially applicable to health care, but I'll try to capsulize the volumes written on "modesty" in naturist circles.

For new naturists, the "psychodynamic of modesty" tends to revolve around five issues: shame, sex, ugliness, uncleanliness and private parts. Shame is complex but in Western culture tends to have religious roots in Adam & Eve type feelings in oneself of lack of dignity especially vis-a-vis others. The sexual issue is usually a worry about personal vulnerability in the face of disrespect, perversity or imposition by others. The ugliness factor is what, more politically-correct, we refer to as "body acceptance" -- all of us seem to feel we do not stack up to idyllic media images of beauty so we are reluctant to bare all our deformities. Next, there is the childhood peepee-kaka legacy of associating certain parts of the body with unclean or unwholesome functions This pre-sexual idea sometimes gets linked by parents to the concept of private parts as a protective measure that later morphs into personal attitudes toward protective sexuality.

Clothing really has little practical value for any of these, but it has a powerful symbolic value. Dressed in a certain way, we feel more dignified. Clothing signals sexual unavailability (or in reverse, it can create erotic mystery to solicit interest). Some people think clothing helps hide physical flaws. It is likely that clothing originated for practical reasons of warmth and protection (perhaps later finding some utility for sanitation and health in populated settings), rather than for modesty. As a result, the relationship between clothing and modesty varies considerably by culture and over time.

The "psychodynamics of modesty" for naturists handles each of these. Dignity and respect are assured without reference to fabric. Sexuality is seen as a distinct activity and lack of clothing does not signal an invitation to intimacy. Our social compact to accept each other as we are is made easier by finding that people actually look no worse, and usually better, without clothing. Clothing for naturists thus is less emotional and more linked to specific practical purposes of warmth, ritual, decoration, etc. Finally, without the body being divided into sections by fabric, private parts lose focus and become just miscellaneous elements, along with noses and elbows, of the whole body.

Think about how hospital gowns assult all these things, and you'll understand why we prefer to be nude. A pyschological study by Martin Weinberg in fact found that naturists are not immodest, that like non-naturists we have norms regulating immorality, sexuality, and embarrassment, but just with differently constructed definitions.

Anyway, I am just speculating that the psychodynamics for patients with "modesty issues" may be based in or share some of these characteristics, and that for health care providers to respond appropriately, it might be useful to know which variation of modesty they are dealing with in a particular patient. (CSM)

 
At Tuesday, March 10, 2009 10:35:00 PM, Blogger Maurice Bernstein, M.D. said...

CSM, thank you so much for starting this new Volume with such a worthwhile education for us about the modesty views within your culture. I think you left us with what I think is an important point: "...for health care providers to respond appropriately, it might be useful to know which variation of modesty they are dealing with in a particular patient." Yes, instead of saying to the doctor "I demand respect for my rights and privacy and therefore I demand that I am able to select a healthcare worker of a gender of my selection!"..maybe a bit more personal description of the underlying basis for a modesty concern would be not only therapeutic by ventilation but also provide the doctor a better understanding of what is disturbing the patient. The former approach is like a patient entering the doctor's office and stating "I got this pain and I demand as a paying patient that you fix it." Surely the doctor needs the patient's description of the history of the pain and associated symptoms to make a diagnosis which could lead to effective therapy. The same with the modesty concern.

You know, I think the conflict between the patients who write here and their experience with their physicians and others in the healthcare profession is similar to those visitors here who are "textilists" (those who are not naturists) and those of the naturist culture. Unless you live the life of a naturist or unless you live the life of a physician you may not really appreciate or understand fully what the other culture is all about. And therefore your criticism must be tempered by an understanding of your lack of experience and lack of more intimate knowledge about that culture. Enough said. Again CSM, thanks. ..Maurice.

 
At Wednesday, March 11, 2009 12:09:00 AM, Blogger MER said...

The conversation continues to be quite interesting. Four points:

1. In your introduction, doctor, you write: "The theme continues and comes from male patients who are uncomfortable with female healthcare providers when dealing with particularly the male genital area."

It still fascinates me that we just accept the fact the some females prefer female intimate care. That's okay. That's just the way it is. And the system is set up, generally, to take care of that (with exceptions) But, when it comes to men, well, that's a different story -- we've got to really delve into this and find out why. The kind of answers one gets depend upon the kind of questions one asks.

2. Maybe I'm reading too much into this, doctor, but the language of your comment is revealing:

!"..maybe a bit more personal description of the underlying basis for a modesty concern would be not only therapeutic by ventilation but also provide the doctor a better understanding of what is disturbing the patient."

...suggests to me, again, this idea that the patient who feels more comfortable with same gender care is in need of therapy, and delving into it, getting the patient to talk, would be -- "therapeutic by ventilation." That way we can find out what's "disturbing" the patient. Let the patient vent. That's good therapy. Maybe that will help.
Actually, that's not a bad idea, to let the patient do some talking and have the doctor do some listening.

Admittedly, some patients with excessive modesty may need therapy. Similarily, patients with little or no modesty could probably use some therapy, too. In fact, patients who have modesty concerns but are to afraid to bring it up and even request it, maybe they need therapy, too.
Is concern for one's modesty a disease? A sign that the patient is neurotic? Let's not view this as a "condition," but rather as a value, a preference, a difference -- with the exception of extremely serious cases. I would say a patient who needs emergency treatment in an emergency room who won't allow that treatment due to modesty, could probably use some therapy.

3. Granted, people who are not naturalists or doctors don't know what it's like to be naturalists or doctors. But within the medical profession, too many professionals, especially the young ones (doctors, nurses, CNA's, med techs, med assts.) do know really know what it's like to be a patient. They've been relatively healthy, never been through the tests and procedures and exams they do every day, never really been in a gown, and lack the empathy that would really help them be better at their jobs. The evidence for this is quite large, memoirs, articles, essays written by doctors and other medical professionals who finally "see the light" once they are in the gown and on the table.

In the move "The Doctor" based upon the book "A Taste of One's Own Medicine," the doctor who has recently been through the mill as a patient -- requires his interns to dress in gowns and go through all the tests they have their patients go through. Nice ending. But I would have requird the young techs who do the tests to go through the same experience.

4. In pointing out the obvious, I don't mean to be presumptuous. Sometimes the obvious is so obvious it's invisible. Having written what I did in # 2 above, we need to also remind ourselves that, although most patients are not and will never be doctors or medical professionals, all doctors and medical professionals have been or will someday be patients.

So, when we talk about the psychodyanmics of modesty in patients, we're talking about everyone. With apologies to the toy store: Patients are Us.

 
At Wednesday, March 11, 2009 2:17:00 AM, Anonymous gve said...

Dr B,

you still appear to feel it is up to the patient to explain the reasons for their own "peculiarity". It is purely a matter of convenience for the provider that the issue of patient modesty is ignored (like playing charades with a child and pretending not to know who they are personating). We ALL know how we would feel if we were walking down the street and we suddenly became naked. I am sure you would feel no less uncomfortable than most of the posters in here. So WHY should we begin to believe that "professionals" don't even think about how uncomfortable the patient feels at having to be in a state of undress in front of strangers, (regardless of how "professional" they are). Would we feel less uncomfortable naked in the street if we knew everyone who could see us was "professional"? Of course not. The onus MUST be deposited at the door of the health "professionals" to ask, to raise the issue, to be proactive, NOT to play charades.

 
At Wednesday, March 11, 2009 12:11:00 PM, Anonymous Anonymous said...

MER is very much right on when he states that many a healthcare worker including doctors have never experienced procedures/surgery/tests that they prescribe for their patients. I have many times ask a particular provider if they have had a CT scan,ultrasound, colonoscopy, surgery, etc. I get a "NO" -99% of the time. Most of the nurses working in an endoscopy center are younger than 50 and they have NOT had a colonoscopy. Some of the doctors too.

In speaking with a friend, she and her husband have a colonoscopy scheduled. The facility is in Southern California. When making the appointment they were asked if they had a gender preference! This gender preference question was for both the physician and the nurse/assistants!! Too bad all facilities can't do the same snd offer the patient a preference.
JW

 
At Wednesday, March 11, 2009 2:59:00 PM, Blogger Maurice Bernstein, M.D. said...

Louisa attempted to post the following at 12:34 pm today but on the "Naked" thread which has been closed for posting. It does change the subject a bit back to the female concerns expressed in these earlier threads. ..Maurice.


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

I agree, there is no history of female doctors taking advantage of male or female patients.
When women reject male doctors, the argument is sometimes made, well, your Dr may be a lesbian...
There is no history of lesbian doctors assaulting patients either...
The problem when it arises, always seems to be male doctor, nurse etc and female patient.
I've certainly never heard of a case involving a female. (and I work in criminal law)
I see a female doctor and like that we're the only two in the exam room...
I wouldn't see a male doctor for anything invasive or highly personal anyway, but having another person in the room is another reason I'd prefer a female doctor...
I've been seeing female doctors for a long time now and have never felt the need for a chaperone.
Our male family physician was rejected by my sisters and I when we hit puberty...he wanted to examine our breasts when we presented for anything (we didn't have any breast issues) - we all refused (independent even then!)....but my poor cousin had her breasts examined on every visit for colds, sprained ankle, inoculations for travel...not surprisingly, this practice wasn't continued with his older female patients who are at MUCH more risk of breast cancer. (her grandmother, mother and aunts all saw this doctor)
I think this sort of Dr would be more careful these days - women are more aware...but I suspect the very young and shy would still be at risk.
The other question: Would a chaperone question why a male doctor is examining a young woman's breasts when she has a sprained ankle?
I suspect the question doesn't arise - doctors taking advantage wouldn't want a witness in the room.

 
At Wednesday, March 11, 2009 3:33:00 PM, Blogger Maurice Bernstein, M.D. said...

To MER and gve: As I have written before, physicians must look at the patient's concerns or symptoms through the all encompassing glass of the biology, psychology and social aspects of each patient. Therefore, if the patient is upset because of lack of finances, this social aspect carries with it clinical significance (a patient may delay obtaining a medication or reduce the dosage because of lack of finances.) And this may be in addition to the biologic and other psychologic factors.

If a physician finds a patient who is "searching around" and perhaps delaying an exam or procedure to find a proper gender provider or technician, this is an issue for which the physician should better understand the dynamics and how it may be affecting the patient's management of the underlying biologic illness. This "unified concept of disease" (looking at the patient as a whole patient and looking at each of the biologic, psychologic and social aspect)is exactly what we teach our medical students from virtually day 1. This is the way they should look at patients as a student. This is the way they should look at patients as a practicing physician. And remember, when this individual going to the doctor presents a concern to the doctor, this is not simply one person speaking to another person. It is a PATIENT speaking to a DOCTOR and the professional methods we teach students--considering all aspects of a patient's concerns, symptoms and behavior, we expect these methods to be followed.

As a teacher of medical students, this idea of physicians ignoring the dynamics and just responding to the bare requests is totally out of keeping with the "unified concept" and can lead to missing important issues that the patient has not brought out to the doctor's attention and even missing a treatable diagnosis.

Criticizing the doctor for wanting to learn more about the patient is not a valid approach but I can understand this action if the individual doesn't know how medical students are trained to become doctors. If you have any questions about this, you can ask me because after 2-3 decades of this duty of teaching I think I know how it is done and why. ..Maurice.

 
At Wednesday, March 11, 2009 3:45:00 PM, Anonymous TT said...

MER,

As usual, you make some great points.

I found point #2 particularly interesting as my reaction was very similar. Privacy/modesty isn't a disease or condition that needs to be analyzed or treated, but a personal value that needs to be respected. Whether or not you agree with their values, you need to respect that each person has an inherent right to their own personal values and that they are part of who that person is.

Now we're back to the issues of trust and respect, which are absolutely essential in a health care provider/patient relationship. It's been repeatedly suggested that patients need to speak up if they have privacy/modesty concerns, and I agree. Unfortunately, when they do so, far too often they are met with criticism or demeaning comments, as is evidenced by the numerous anecdotal incidents described in this thread. When this occurs the breakdown in the patient/provider relationship starts, and the mechanism is pretty easy to see. For a patient to place their care in a providers' hands, they need to be able to trust that person. When a provider denigrates a patient's personal values they are demonstrating a lack of respect for who that person is. If someone doesn't respect you as a person, it's a lot more difficult to trust them. Now emotions get involved - hurt feelings that can evolve into anger and the the "I hate all doctors, nurses, etc." attitude. The next time the patient needs care, they'll probably start with a chip on their shoulder from the last experience - it's a vicious cycle.

So what's the solution? I think it has to start with mutual respect and trust and intelligent discourse. Patients need to speak up about their privacy/modesty concerns to their providers, and do so in a calm and rational manner. In turn, all providers need to just accept that some patients have these concerns, recognize that there's nothing wrong with that and express that to the patient. Now you've got a place to start an intelligent conversation about what is or is not possible and why.

As Voltaire said in his Essay on Tolerance, "Think for yourselves and let others enjoy the privilege to do so, too."

TT

 
At Wednesday, March 11, 2009 3:45:00 PM, Anonymous Anonymous said...

The disturbing realization is that Louisa's experience seems so common. I have had friends say similar things regarding doctors wanting to examine breasts irrespective of what the patient went to see the doctor for. What is going on ??? It seems like the sexual misconduct cases are just the tip of the iceberg and there are plenty of incidents such as these that happen quite frequently on naive women. Maurice I cant see how you can come up with an explanation for these experiences. As much as doctors try to blame the patient for being irrational regarding their modesty, we the patient are more astute than they realize.
Jan

 
At Wednesday, March 11, 2009 5:15:00 PM, Anonymous Anonymous said...

The countless obese nurses who
don't portray a passionate image
about health to the patients.
Consider visiting a physician
who specializes in diabetes and when he or she walks into room
what would be your impression if
that person were grossly obese?
Would you think this person might
be sincere about the work they do and the old adage "just do what I
tell you".
Earlier I relayed the story about the male patient who pursued a testicular ultrasound 7 times.Apparently, he has a medical
fetish and how do you think he acquired this fetish? A fetish such
as this occurs from a single event
most likely occuring when at a young and impressionable age.
One can only imagine the kind of
medical exam that promoted such behavior lying dormant. Many young men who have experienced such humilitation from a medical exam shun medical care as a result of this. How many men die from an undiagnosed condition that was curable? All this because some female providers or worse even
clerks felt it important to be observers(vouyers)in some medical exam.
Who's to blame? I haven't even
factored unprofessional behavior
among female providers into the
equation. That'a a whole different
ballgame. Are the patients to blame
for their future behavior? I'm always curious as to why there are
nursing advocacies for nurses. What
about patient advocacy. Has that
become such a lost jargon. Who is advocating for the patient both
physically and mentally? How can
any organization consider themselves professionals when
discrimination is applied to one
gender?


PT

 
At Wednesday, March 11, 2009 6:16:00 PM, Blogger MER said...

Doctor:

You write: "Criticizing the doctor for wanting to learn more about the patient is not a valid approach..."

I'm not sure where you're coming from. Do you infer from something I'm writing that I'm criticizing doctors for wanting to learn more about the patient? If you do, you're mistaken.

This "unified concept of disease"
-- looking at the whole patient, considering all aspects of the patient, looking at the whole human being. I can't see why anyone would be against that.

Perhaps its a simantic issue -- your use of the word "disease" in that context. To me, it reads as if all these aspects of the human personality are considered, in essence, "disease." Are you saying that they are aspects of whatever condition the patient has? I would tend to call them conditions, situations, or, in the case of modesty, perhaps values.

You write: "this idea of physicians ignoring the dynamics and just responding to the bare requests is totally out of keeping with the "unified concept" and can lead to missing important issues that the patient has not brought out to the doctor's attention and even missing a treatable diagnosis."

Who on the blog is talking about ignoring these dynamics? Most of us are talking just the opposite. Are your comments in response to a specific post?

Could I suggest that when appropriate, posters extract brief quotes, especially if the poster is giving a very specific response to a very specific post. That way we know what the post refers to and puts it in better context.

 
At Wednesday, March 11, 2009 6:34:00 PM, Anonymous Anonymous said...

MER you speak my thoughts much better than I. So often when a patient, especially a male brings up modesty concerns, the efforts from providers have often been directed at how they can convince or get the patient to feel comfortable enough to accept what providers want to provide...not what the patient wants. We have discussed this before but "we are professionals", "we have been trained", "we do this all the time", are not really attempting to find what patients really want, the are trying to get them to accept what the providers have already offered. And while we as patients can not understand things from a providers side, as stated providers have to know everyone has modesty issues to some level, providers have modesty concerns in other areas, would they swim nude infront of nieghbors, would they walk nude on the beaches in Europe. While they may choose not to think of it, they may choose to place such a low value or priority on it, I have a hard time understanding how it could not be known at some level, it may not be important enough to factor into the day to day...surely every provider has had patients who expressed modesty issues if not verbally, at least with obvious body language. If they don't think about it, they can not lay claim to treating the whole patient, it would be better if they would just admit, we treat the physical being....sorry I meant to let that drop...but I think it is so telling that as stated, the issue keeps being pushed back to the patient by providers...this as stated earlier erodes trust and magnifies the issue....alan

 
At Wednesday, March 11, 2009 7:46:00 PM, Blogger Maurice Bernstein, M.D. said...

MER, the patient comes to the doctor with a disease, a disorder, a symptom. I am not referring to patient modesty as a disease. It is a concern all patients have to one extent or another. But the underlying dynamics of that particular concern may affect the outcome of the disease, disorder or symptom. Perhaps the modesty concern developed from a single emotionally traumatic experience in the distant past or by something recent or by learned custom or by worry about body image and so forth or by none of the above but by simply the concept that every patient has the right to select the gender of the healthcare provider of their own choice. Whether it is modesty or a right, I think the physician should be informed as part of understanding the "whole" patient who comes to the doctor with some disease. This is the "unified concept of disease" whether modesty is involved or not modesty but an autonomous desire to obtain a legal right. So the patient should say to the doctor "I want someone of the opposite gender to perform the exam and this Doctor is the reason why I am making request..." Then the doctor will be aware that the patient is not satisfied with accepting any gender and will also have an understanding of why the patient made the request. That is all that I am requesting of the patient. A good doctor will then use that information to try to provide the best outcome for the patient ..Maurice.

 
At Wednesday, March 11, 2009 9:52:00 PM, Blogger Maurice Bernstein, M.D. said...

By the way, you might find this UK Channel 4 website interesting and maybe pertinent to this thread. It is called "Embarrassing Bodies" and deals with illness and including self-examination of modesty sensitive areas. It is medically oriented but quite frank but seems supportive of the issue of patient modesty by its very context, though there is an instructional video showing a female ?doctor demonstrating how to examine a live male's scrotum.

Let us know what you think about the site if you take a look. ..Maurice.

 
At Thursday, March 12, 2009 7:02:00 AM, Anonymous Anonymous said...

How quickly this discussion gets deflected back on doctors and nurses! I still don't see any reflection on the various kinds of modesty issues of patients -- what causes your particular sense of modesty? What makes some body parts "private" or "intimate" and others not? For example, we all have breasts -- men and women -- do you consider breasts to be "private parts" for women but not for men? Why? What parts of the body can be "exposed" without you feeling "naked"? Are you only modest about genitals? Why? Is it the connection to sex? Sex is an intimate activity that is unlikely to be occurring in a doctor's office. Anyway, aren't lips, tummies, thighs potentially "sexual" too? But maybe sex isn't the "modesty" issue. Just being touched? Or does modesty come into play only for probing-type exams? Clearly, Dr B is not talking about modesty as a "disease" or "disorder" that needs "therapy" to be "cured" in a negative sense -- it is merely important for us patients to identify exactly what is bothering us so that health providers can respond intelligently and with sensitivity to our concerns. What is the "personality" or "spec sheet" of your sense of modesty?(CSM)

 
At Thursday, March 12, 2009 7:43:00 AM, Anonymous Anonymous said...

The "Embarrassing Bodies" site has some really useful, down-to-earth, practical information. The matter-of-fact tone speaks directly to this discussion. It also made me realize that, just as part of routine all-body grooming, I could add some routine medical inspection. It also looks like an area where spouses/partners could usefully help each other. In relation to modesty, it of course implies a certain level of body comfort. Routine inspection (by oneself, your partner or your doctor) becomes just that -- routine. (CSM)

 
At Thursday, March 12, 2009 8:15:00 AM, Anonymous Anonymous said...

Dr B, for the men in this discussion group and just for the gender symmetry, you might want to add this link on testicular examination from the Embarrassing Bodies website. (CSM)

 
At Thursday, March 12, 2009 9:54:00 AM, Anonymous TT said...

CSM,

I agree that privacy/modesty is not a "disease or disorder", nor is it "something that's bothering us".

A patient's degree of personal privacy/modesty is purely and simply a personal value that needs to be respected. I think it gets reflected back on doctors and nurses because they are the "professionals". As such, it is incumbent upon them to put aside personal prejudices and acknowledge the patient as a person. If they want the patient to trust them, then they need to respect the patient as a person, which includes personal values such as privacy/modesty.

To be blunt, "why" isn't really anyone's business but the individual's unless they choose to share that information. Further, unless/until providers acknowledge and respect that value, it's highly unlikely that they will ever develop the degree of rapport or trust with the patient that would allow them to open up to the provider.

Dr. Bernstein,

I agree that the patient needs to let the provider know if they have modesty concerns. A statement along the lines of "I am a private person and highly value my personal privacy and modesty. As such, I am not comfortable with opposite gender caregivers participating in any intimate exams, treatments or procedures and ask that you respect that." should suffice.

The critical thing then becomes how the provider responds to that statement and how the patient perceives that response. If, as you have repeatedly stated, most providers are completely unaware that some patient's have privacy/modesty issues, their initial reaction may be one of surprise. I would hope that the majority of providers in that position would be astute enough to be candid with the patient & respond with something along the lines of "If I seem a little surprised, it's because that's the first time anyone has brought that up to me - but I can understand your concerns and assure you that we'll do everything we can to work with you along those lines." Something as simple as that can work wonders in getting the provider/patient relationship off on the right track.

TT

 
At Thursday, March 12, 2009 11:21:00 AM, Anonymous Anonymous said...

I just spoke to a friend who scheduled a colonoscopy and both spouses were asked their preference of gender for both the doctor and assistant. Guess they've gotten the picture. Maybe through patients speaking up!
Who knows why. Too bad all places can't be as considerate to accommodate patients by asking and providing same gender care if it is wanted by the patient. This place is in So Cal.

 
At Thursday, March 12, 2009 11:31:00 AM, Blogger MER said...

CSM: Your use of the term "deflected" is interesting. And the use of the ! at the end of that sentence is also interesting.

It's not a question of this issue being "deflected back on doctors and nurses." This is a relationship issue, a contextual issue -- it doesn't exist outside of this unique relationship. It's not one side of the other.

I've been pretty clear in saying that patients need to express their feelings, issue, situations to medical professionals. They need to be honest and trusting. They often aren't, for many reasons.

But do consider this -- the medical profession has much more control over the atmosphere, the context in which this relationship takes place. Maybe that's why it appears that the conversatin gets "deflected" back to doctors and nurses.

I will stand by my past opinions that the ultimate responsibility of creating a comfortable atmosphere where a patient will feel comfortable discussing uncomfortable subjects, exists within the profession. This can be difficult when the reality seems to be, as even Dr. Bernstein has admitted, that most physicians are oblivious to this issue of modesty, or don't considered an issue at all. And, when the gender neutral philosophy seems to be embedded within the professional and hospital culture.

You ask some good questions, CSM. This should be an area of study within medicine. Maybe it is. I haven't found the studies.

Despite some of my posts, I don't have extreme modesty issues. I'm not necessarily opposed to oppostie gender intimate care, depending upon the individual situation and context. I'll make a situational decision and when I do, I'll be confident and comfortable with it. So, I may not be typical.

My concern with this issue has more to do with it's hidden nature, and with the political, social, and legal aspects of the double standard. For example, in 1900, a particular woman might not have wanted to become a doctor herself -- but that doesn't mean that she wasn't upset that other women couldn't become doctors if they wanted to. She may have fought for those other women despite her own career goals.

My concern is more the with fairness and the discrimination involved with how the genders are treated. Beyond that, I'm concerned with getting this topic out into the open so that patients know what to expect and how to deal with it.

Isn't part of what makes nudism an attractive lifestyle to some is it's openness about the body? I've heard people who have visited nudist colonies say that they were very hesitant at first, but once they got naked with the nudist context, the felt more comfortable. Note the different connotations of "naked" and "nude." "Nakedness" implies a vulnerability and powerlessness, and "nudity" does not. Being more open takes away much of the hidden power of "nakedness" and turns in into a more neutral "nudity."

The "Embarrassing Bodies" website is interesting. I do like they way they confront the issue.

 
At Thursday, March 12, 2009 2:01:00 PM, Blogger Maurice Bernstein, M.D. said...

I shouldn't want to belabor my argument but I just had to respond to TT's declaration if it was directly to the patient's physician. If it was to a lawyer, businessman, hotel manager in some corresponding context then I think it would be perfectly appropriate and satisfactory as the statement stands. But to the patient's own physician for whom the patient went because of illness and symptoms, this statement is not good enough. Immediately I and hopefully other physicians would parse out "I am not comfortable" and say to themselves (thinking) "Whoa, my patient is telling me 'I am not comfortable...' and to promote patient comfort is one of my goals as a physician for a patient who is ill... I must listen further and sort this thing out whatever the source of the discomfort may be.." That, I am sure would be what most trained and conscientious doctor's mental reaction. That is the explanation why the doctor will be interested in following through as the patient continues "...with opposite gender caregivers participating in any intimate exams, treatments or procedures". But then the doctor thinks "but how important is this to the patient? It is very important since the patient continues "and ask that you respect that."
The doctor would then wait for a patient to then detail his or her "discomfort". If the patient says nothing further, the doctor should ask an open-ended question such as "Uncomfortable? Can you tell me why you feel uncomfortable?" And then the doctor awaits the response. All of this is just what we teach our medical students and I know that I am giving all my "teaching secrets away" to my visitors here. Now some non-doctor such as a businessman would and should not expect a customer to respond in intimate detail the explanation of a request but a doctor should since we have been given permission and responsibility by society to discover intimate details of the body as well as the mind and emotions of a patient. I hope I have clarified what to me is a so-called "no brainer" response to a patient who is "uncomfortable". ..Maurice.

 
At Thursday, March 12, 2009 2:04:00 PM, Anonymous Louisa said...

I think a lot of this starts with a bad experience (often in childhood)...
I was discussing this subject with some friends over dinner and I was surprised most have a horror medical story OR have been sexually assaulted in their youth (not rape, thank goodness)- these experiences clearly shape our behaviour into the future.
Many of the women who only see female doctors have trust or control issues with male medical providers. Sometimes it was a GP taking advantage (in my case, or trying too) another had a scary experience in hospital as a small child - standing naked for an exam in a room she said seemed "full of men" - probably medical students - she felt surrounded - and could feel their staring - she felt alone and fearful they would hurt her - she didn't know what was going on and her parents were not in the room.
She has never seen a male doctor in her adult life - her avoidance she believes goes back to this frightening day...when she was 7 years old.
Also, I was reading that one in 4 women will be sexually assaulted in her lifetime - 1 in 4...
A refusal to be exposed and vulnerable with a male may well be a response to previous trauma.
These women have simply lost trust and are protecting themselves mentally and physically...
I know a man who was sexually assaulted by a male priest - he won't see a male doctor...
So, I'm not aware of a history of male doctors taking advantage of male patients, but it certainly happens with other groups - priests, teachers, scout leaders...
We all have history, good and bad..
I think modesty can be an issue for men and women, but there is often a reason...
I agree a man's request for a male nurse etc might be fobbed off - I guess because there is no history of female nurses etc taking advantage...
I personally believe all requests should be respected as far as possible - we all have different comfort levels.
My sister-in-law received treatment for Hodgkin's disease a few years ago - she says the worst part of the treatment was being fitted with body protection before having radiation treatment - she was naked and had male attendants. She was early 30's at the time - she was very upset and felt like a slab of meat and that no one cared about her dignity and privacy. She told her specialist, who spoke to the hospital - they now use draping procedures (as far as possible) and are sensitive to the gender issue.
I'm sure these procedures could be carried out with more sensitivity - have you ever been to a Day Spa? The draping and sensitivity is such that no one walks away feeling violated even though you've been naked most of the day...(I know it's not the same thing, but I've rarely felt naked in that setting)
I think people should complain when they have an upsetting experience - so often we walk away saying nothing, virtually guaranteeing that the patient that follows us will be treated in the same unsatisfactory way.

 
At Thursday, March 12, 2009 2:29:00 PM, Anonymous Louisa said...

One last point - the concern for patient modesty seems to be better in private hospitals in Australia - most of the complaints seem to come out of the strained public system.
I suppose when you're a paying customer, you tend to get better treatment.
I think childbirth is now pretty much a medical experience - in private hospitals most women seem to have a reasonable/positive experience...
Take a look at the Birth Trauma website - there is an Australian and Canadian chapter, but the latter site is larger...
These women have been left traumatized...not by the pain, but more the total lack of consideration for their modesty and feelings - being left naked on a trolley, multiple people in the room making the birth more difficult, doors left open violating a patient's privacy, lack of respect...
It's hair-raising stuff...
Check your private health insurance before you get pregnant!
If that's the best they can do, I think more women will opt for a midwife centre or home birth...or forget about having more kids.
An elderly family friend gave birth to her kids at home (in the UK)- her birth experience didn't include indignity, lack of respect and callous disregard for her privacy - she labored in her bedroom with the midwife making tea and keeping the fire alight...
That situation could go wrong very quickly with tragic results, but I couldn't help but be struck by the difference - one gentle and caring, the other so savage...
I'll post the link to the Birth Trauma site if I can find it...

 
At Thursday, March 12, 2009 2:30:00 PM, Anonymous Anonymous said...

Dr. B,
I believe you when you say how you teach medical students. This is not news to anyone here but most are talking about the entire healthcare system not just doctors. I believe in what you say but medical students move on and become a doctor. I can not quote you exactly, you basically said that your third year medical students where nervous and slightly embarrassed when they where performing intimate care on real patients and not on models. Do you feel something traumatic may have happened to the medical students at a young age, or do you believe what they are feeling is normal? I believe what they may be feeling is normal but they forget that feeling. We are not taught how to be a "patient" we are "conditioned" how to be a patient. The social rules my parents conditioned me on where never followed by "except in a medical situation" The conditioned rules change with every doctors office, clinic and hospital. I have never had the same physical exam done the same, I have had some nurses grant me more privacy then others when experiences nudity in the hospital whitout me asking. Some doctors and nurses understand privacy and respect, which has nothing to do with modesty. So if some healthcare workers can understand patient respect why can not all healthcare workers understand that? I understand every doctor, nurse and tech is going to be differrent why is it so hard for them to realise every patient is different and every patient had differrent levels of nudity exposing themselves to the opposite sex.
Daniel

 
At Thursday, March 12, 2009 4:14:00 PM, Blogger MER said...

Thank you, Louisa, for reminding us that this is not completely a one gender problem. Note Louisa's mention of both Austrailia and especially the UK.

Don't misunderstand me. I'm saying the the only way to go is with a natinal health care system. But one thing a nationl system tries to do is standarize practices and behaviors. Note how Daniel says that you never really know from doctor to doctor, hospital to hospital, exactly how this modesty issue will be treated.

The UK national system has had and does have many problems, but they've been doing it since the late 1940s and have had practice fine tuning it.

Now, if anyone doubts what I've just said, go to the site I've listed below. It's run by the
Social Care Institute for Excellence (SCIE) -- established in 2001 to improve social care services for adults and children in the United Kingdom. The link below will take you to SCIE Guide # 15 -- Dignity in Care. Look on the right of that page and you'll see 10 items under Dignity challenge. Read those. Tell us what you think.

Now, if I'm making too big an issue of this UK thing, someone please find me a professional medical site from this country that at least attempts to face this issue head on and come up with some professional standards. I can't even find sites or articles from the US that seriously try to define what is meant by words like "privacy" and "dignity."

Also, books like the one I'm reading now -- "Sociology as Applied to Nursing & Health Care" by Mary Birchenall et. al. -- published in UK -- cover some of the topics we're discussing. So does Jocelyn Lawler's "Behind the Screens," out of Australia.

The problem isn't that most medical professionals don't try to treat people with dignity and respect. I think they do. One problem is that very specific standards are apparently not embedded in the system. And there are apparently no tools to evaluate how patient dignity and modesty is handled. For those 10 Dignity Challenge standards I mentioned, there's an evaluation tool available that can be used, a rubric or check list to determine that these challenges are met.

Here's the link:

http://www.scie.org.uk/publications/guides/guide15/challenge/index.asp

 
At Thursday, March 12, 2009 4:17:00 PM, Anonymous TT said...

Dr. Bernstein,

I wasn't specifically referring to a conversation with a patient's personal physician, but it really doesn't matter that much. Go back to my statement - the very first part, which you completely ignored, was "I am a private person and highly value my personal privacy and modesty." I deliberately worded that sentence the way I did with both malice and forethought. It is a clear declaration of both personal values and the reason for the following sentences. It also should indicate to the provider right away that this is important to the patient. If I made that statement to a provider and their first response was along the lines of "Can you tell me why you feel uncomfortable?", my response would be "I told you, I'm a private person and I highly value my personal privacy and modesty", followed by "and I insist that you respect that" (notice we've gone from request to insist). At the same time, what I'm thinking would be along the lines of 'Gee, this guy really doesn't listen very well - I'm going to need to keep a close eye on him". Now, had provider first simply said something along the lines of "I understand your concerns, and assure you we'll do everything we can to work with you along those lines..." prior to asking the follow up question, it puts a whole different spin on things from the patient's perspective.

My intent is not to belabor the issue or to be argumentative. The point I'm trying to make is that nuances and semantics are important. Life doesn't have a rewind button - you have to catch it the first time around.

As an aside on the whole open ended question technique, it only works if the person you're asking isn't aware of what you're doing. If someone tries it on me, depending on the mood I'm in I'll either shut them down by calling them on it, or take it as an invitation to mess with their head and proceed accordingly.

And while society may grant physicians limited implicit permissions you outlined, that does not override the need to get the patient's specific permission as well.

TT

 
At Thursday, March 12, 2009 6:05:00 PM, Anonymous Jackie said...

The comment about the US health system and lack of articles on patient privacy/modesty etc...rang a bell for me.

I work with some US women in HK...confident professional women.
They all receive health care in HK because of medical barriers in the States which insist on pelvic, rectal & breast exams and cervical screening every 12 months - or you don't get the Pill. Apparently Planned Parenthood MAY give you an initial script for 6 months, but then the pressure starts to "submit" (their words)
Even though informed consent is required for cancer screening as it has risks as well as benefits - and has been subjected to some serious criticism in recent years by senior medical people - they all say women have no choice as to whether they participate - the Dr accepts the risk on their behalf.
The information given to women about cancer screening is also, inadequate so, women are misled as to the risk of cancer, the benefits of testing and the risks...(this isn't confined to the States - this was challenged in the UK a few years ago and the screening industry were forced to issue risk information to all women - some say it's still inadequate)
Several had BAD experiences at student health centres at age 18 when women are supposed to start having full gyn checks every year (even virgins)...
They describe use of stirrups, having to undress before the Dr appears (like a battery hen) requests for female doctors ignored and male medical students imposed on them...
One woman said she was made to lie naked under a paper sheet before a male (she'd requested female) appeared - in that position, it was difficult for her to object - she was so traumatized that she has not seen a US Dr since that day - she and her partner used condoms to avoid doctors until she started working in HK and could access the Pill with a simple blood pressure check.
I must say I was completely shocked to hear all of this - they directed me to a website ObGyn.net - I was surprised to hear doctors telling virgins they needed all this annual checking and women with complete hysterectomies (for things other than cancer) need these checks to avoid vaginal cancer (VERY RARE - one in a million)

IMO NO Australian or English doctor would give this advice or follow these practices (if he/she wanted to keep his medical license)

The medical thinking is completely different elsewhere - all of these exams are considered unnecessary in asymptomatic women and can be harmful....
My Dr accepted my decision not to have mammograms when I turned 50 - after I studied risk v benefit information and made an informed decision.
My US colleagues tell me women have no choice in these matters unless they stay away from doctors.
It surprises me that US women don't challenge the need for these exams and tests and are not respected to make their own health decisions. Surprising no one has challenged these barriers in court...
I think this may be an example of lack of respect and lack of consideration for a woman's privacy and dignity.
I hope I don't come across as US bashing - NOT the case, just very concerned for my US sisters...

 
At Thursday, March 12, 2009 6:30:00 PM, Anonymous Anonymous said...

Dr. Bernstein..I guess I understand your point a little better. I guess part of the confusion is patients look at the Dr. as being in control of the interaction. As the doctor we assume you will lead the process, we are on your turf. The process usually starts with the Dr asking...what seems to be the problem, what are we here for, etc so it seems natural for this aspect of care to follow the same direction. While the realationship is evolving to a more equal partcipation basis we still look for prividers to lead us, provide direction. The side you present today is interesting and one I will have to digest. From a patients perspective its easy for us to assume the Dr. HAS to know modesty is an issue at least at some level from personal experience, from training, from previous patients, from a number of sources...another window of thought opened from this thread..

CSM, we have discussed origins of modesty, they seem to be different for different people and there seems to be no single cause for most people. For sure at least a portion is learned. The vast differences between and even within societies would support this theory. It has been asked why people have modesty, a valuable question in our society might be...why don't some people have the level of modesty that society has set as the norm....what drives, allows, whatever the term these people to not have the level society says is normal....

Louisa, I understand some women have had bad experiences with men. I also know that sometimes statistics come from a effort to back a predetermined thought. I really don't think the issue of abuse of women by providers is the main driver of the issue. Experiences such as the little girl happen all the time. Given the majority of providers are female the odds of a patient being subjected to exposure with the majority of providers being opposite gender are much greater for males. I have had several procedures and each time the there has been either one or two at the most males with multiples of nurses who were all female. I don't know that this has to be split on gender lines....but when one conisders over 50% of med schools students are female, over 50% of the techs are female, and
90+% are female...abuse by physicians is horrible, it is something that is unforgivable, the betrayal of trust is traumatic, but I truely believe physicans are trustworthy, compassionate people and to say a large segment of male doctors are perverted and abusers is really questionable at best. Physician abuse I believe is another issue..but that is just my personal opinion....alan

 
At Thursday, March 12, 2009 6:42:00 PM, Anonymous gve said...

Take a look at;

http://www.nursingtimes.net/primarycarenurses/Primary_care_blogs/2008/10/primary_care_blog_we_must_never_forget_patient_dignity.html

http://www.dbh.nhs.uk/Matrons_set_a_challenge_improving_dignity.asp

http://www.pickereurope.org/Filestore/News/resp_priv_dign_newsletter_feb03.pdf

http://www.dch.org.uk/docs/privacydignitypolicy.pdf

Just a few examples which show that professionals do realise how patients feel, they just choose to ignore it and hope the patient will suffer in silence.

 
At Thursday, March 12, 2009 8:06:00 PM, Blogger Maurice Bernstein, M.D. said...

Jackie, a most interesting posting. Do you think the issue you present deals primarily with inadequate or erroneous informed consent by the medical profession, patient's own private modesty concerns or degrees of forms of unprofessional sexual-based manipulation of practice or frank abuse delivered by physicians or all these and more? If it is all of these and/or more, there appears to be a lot of work yet to be done in the U.S. to rectify all this, don't you think? ..Maurice.

 
At Thursday, March 12, 2009 8:25:00 PM, Blogger Maurice Bernstein, M.D. said...

Alan, of course all doctors should know that patient modesty is an issue that they as physicians should be aware but I think this awareness is mainly in terms of protecting the patient from unnecessary bodily exposure towards the examiner and especially to avoid any exposure to others in the vicinity. What doctors don't know and which I have learned by these threads is that patient modesty (which I think is the underlying basis of the patient's "right" that has been emphasized here) may trump needed exam or procedure if gender selection of providers of medical care is not offered or available. It is that emphasis or result of patient modesty that is as yet an unknown, unrecognized concept in physician thinking. "Would a patient really avoid an exam or test because of the gender of a professional caregiver?" Well, obviously the answer is "yes" if the patient was aware ahead of time as to what was available. That is the concept doctors have to learn and accept in order to change the practice and provide the best for their patients. ..Maurice.

 
At Thursday, March 12, 2009 8:50:00 PM, Anonymous Anonymous said...

gve, interesting links. The SCIE Guide on Dignity in Health looks well-balanced. The RCN "Dynamic Dignity" campaign does indeed seem to be "a splendid affair" of the sort requested here, even though care giver gender gets little mention. The Dorset guidelines, in contrast, seem unnecessarily radical for my taste -- note to self: never get sick in Dorset County -- but I suspect, with my lack of modesty issues, that if I ever were hospitalized in Dorset, I would never be moved out of the temporary "mixed sex accomodation" area anyway.

 
At Thursday, March 12, 2009 8:57:00 PM, Anonymous Anonymous said...

oops! forgot (CSM) tag on last post re gve links.

 
At Thursday, March 12, 2009 9:03:00 PM, Anonymous Jackie said...

It seems a BIG problem - I'm not sure why this happens in the States.

They tell me that girls are brainwashed by their doctors, mothers and others that they MUST have these exams from age 18 (if not earlier) "to be healthy" - it seems to be a totally unnecessary thing that has become gospel. It's become entrenched in medical thinking and practice and heaven help anyone who questions or challenges it...
One of the women was told by her doctor at age 18 that it was part of being a woman, so she should get used to it - really - I'm 45 and have had ONE pelvic exam in my life - if I were an American woman, I'd be up to 28 or so by now....(more with pregnancy - US doctors usually do internal exams every visit throughout a pregnancy - in Australia, you'd have one at the beginning, whatever is required during the delivery and one after the birth)
I'm told women are called immature or considered reckless with their health if they don't want these exams and of course, if you want birth control, you must submit...
In this case, IMO...consent is not really possible, as you're "required" to do something or you don't get birth control...
I'm told doctors "hold onto" repeat scripts until you come in for your exam.
It seems the medical profession does not consider consent or informed consent all that important.
I also, wonder whether this a profitable scare campaign to keep the doctors busy - and the pathologists etc...
Certainly, some of the advice on the ObGyn.net site is intended to scare women...

Many doctors in the States are female, so the concerns about care was more about a total disregard for a patient's needs and feelings.
In Australia, stirrups are only used in the operating theatre or during a forceps delivery...
Women are not asked to undress before they meet the Dr...
No flimsy paper sheets or gowns...thankfully, I'm not an expert in gyn. exams, but for my one exam, there was no flimsy paper sheet or gown - I was given a fabric gown, a proper sheet and blanket...
Ignoring a patient's requests for a female/male doctor and no medical students being present may be due to a breakdown in communication, disregard for a patient's wishes or a system strained and under-resourced...I know free clinic's are often so busy that individual requests get lost.

It seems the system that's in place in the States, may suit the doctors, but not the patients.
One colleague described the set-up as dehumanizing...and leaving you feeling powerless.
If you google this subject, all sorts of health clinics appear (many University health clinics) - all screaming that women SHOULD be having a gyn exam every year from age 18..."it's vitally important to stay healthy"...
So, it seems this NEED is widely accepted and doesn't seem to be questioned by most women. (although certainly dreaded)
This group are highly intelligent and successful women and they couldn't make the US health system work for them - what hope does everyone else have to safely negotiate the system?
Certainly these women believe the system is abusive and relies on keeping women controlled, ignorant and afraid...
http://www.managingcontraception.com/qa/questions.php?questionid=635

 
At Thursday, March 12, 2009 10:24:00 PM, Anonymous Anonymous said...

There is a history of female nurses
and female physicians taking
advantage of male patients both
physically and sexually! These cases are documented in the courts.
I personally saw a 2nd year female surgery resident assault a
male patient. She was fired from the residency program. I spent 2
intense hours being interrogated in
risk management. Even they couldn't believe it at first.
This resident somehow relinquished her medical license
for 5 years. The conclusion as far
as a lawsuit I'm unaware of. The
hospital hushed everyone as in
many of these cases.
Lately, it seems that even female
teachers can't be trusted with their male students. Late last year
3 female teachers in the same county in florida were arrested for
having sex with young boys.
Many organizations don't consider
nurses as professionals and neither
do I. The reference to being a
professional is useless. I certainly don't trust female providers based on my past experiences and if I had to place
a trust value I would rate nurses
as the least trusting,female physicians second and female teachers first.
Many female physicians entered
medical school on a quota. Min
gpa requirements are 3.2 and most
white males were 3.8-3.9. Thus,if
a white female had a 3.2 and say a
white male had a 3.5, then the white female attended.
I will reiterate what I've said
before. How can any organization
consider themselves professionals
when within that organization, Male
patients and male employees are discriminated against.


PT

 
At Thursday, March 12, 2009 11:10:00 PM, Anonymous Anonymous said...

Jackie has made some good points. We’ve hit on the point of providers using humiliation as a tool of control over the patient. And just in the situation described by her, you can scan many procedures/surgeries performed by providers were they require the patient to bare all for no other reason than that it is SOP. Why is there such a variance between the States and Australia? I’ve always felt that if it works and doesn’t cause harm, then it should be allowed. It just doesn’t seem that there is any kind of quality control in healthcare; I guess that’s why there are so many unsatisfied people here in the states.

Interesting website you linked Dr.Bernstein. I for one don’t really see the relevance but that’s me. I don’t question nor care why another person doesn’t have modesty concerns. It’s all about the comfort of the patient and treating each person how they want to be treated. The fact that there are so many different view points on this subject should bring light to providers not to try to treat each case the same.
We’re all made (as you can see on the website) and think differently. Jimmy

 
At Thursday, March 12, 2009 11:29:00 PM, Blogger MER said...

I just want to remind everyone that the link I recently gave, and the ones gve gave, all come from Great Britain. None of them are from the US. I still challenge anyone to find similar web publications coming out of the US.

So -- I'm still trying to discover the why of this. What is there about the medical culture in Great Britain, Australia and Canada that brings this issue of patient modesty and dignity and respect out in the open, and incorporates it into the public forum?

Is it any accident that these counties have at least one thing in common -- a national health care system. If that commonality is a factor, why is this so?

 
At Friday, March 13, 2009 8:02:00 AM, Blogger Joel Sherman said...

I have recently commented on my blog about the claim that 1 in 4 women have been assaulted, just repeated here by Louisa.
The claim was made by radical feminists who rated the replies they received on their own. Basically any woman who had sex that she regretted or under any external influence such as alcohol was considered to be assaulted even though the woman herself thought the sex was consensual and did not consider it an assault. Few of these 'assaults' were criminal or could be tried in a court of law.
This 1 in 4 canard has permeated our culture and been taken up by federal agencies, but it is mostly fiction and feminist propaganda.
Anyone who wants to look into this further should go to Christina Hoff Sommers The War Against Boys.
None of this is to deny that sexual assaults are a problem, but it needs to be seen in context. I believe that sexual assaults against children may be as common against boys as girls, but there is no information about this that I have discovered.

 
At Friday, March 13, 2009 8:16:00 AM, Anonymous Anonymous said...

I am not sure exactly what is being said here. There are many suggested screenings that both genders are "subjected to" for their own benefit. Testiclular exams, DRE's, breast exams, etc are all in that thread. Sports physicals include hernia exams for boys....is it the way some of the exams are conducted or the fact that the medical community suggests or even suggests to strongly that is an issue?

The difference between us and the UK may come from different area's. Perhaps a national health care system takes away choice to a higer degree so the issue becomes more important..I read an article where mixed gender wards were a problem in England...don't see to many mixed wards here, or it could be they are more intune and concerned about patiints...interesting question. I would think a national health care would be more prone to not worrying about the issue since the I will just go elsewhere would not have any effect on their bottom line.......but I know nothing of how they work...you always hear about people from other countries coming here for health issues...maybe that is just a misconception...alan

 
At Friday, March 13, 2009 8:35:00 AM, Anonymous Anonymous said...

This discussion keeps coming back to misconduct, intimidation, control, and "the system." Modesty issues seem just entangled in general distrust. Political science distinguishes between crises of rules, authority and legitimacy. Rules are sliced into individual choice, community norms and global mutual guarantees. If modesty is a matter of individual choice, then individual health providers adjust. If community norms are involved, then one changes, for instance, local hospital procedures, but there will be differences from one town to another. Mutual guarantees operate through broader professional ethical codes and legal rights and obligations. A crisis of authority involves who has the power to set and revise codes, rights and obligations.

But it sounds like what we have here is almost a crisis of legitimacy in health care, where the whole system is in question. If that is the case, then nothing short of a national conference of all the actors -- from patients, to doctors, to hospital management, to insurance companies, to politicians -- will ever be able to renew legitimacy through explicit agreement on how the system operates from top to bottom, from values to governance to individual rights, including the issue of individual modesty. Maybe we need to move this discussion to Obama.gov? Countries with a "national health care system" of course have a built-in monolithic forum for debate and establishing norms. (CSM)

 
At Friday, March 13, 2009 9:00:00 AM, Blogger Maurice Bernstein, M.D. said...

In response to what Jackie wrote and later comments, I think that one possible explanation for why examinations of the breasts, pelvic organs and more possibly excessive testing is carried out in the United States is not out of perversity but out of fear of missing a diagnosis which could easily lead to a malpractice suit. Wouldn't that also be a reasonable explanation and perhaps explain differences between countries? ..Maurice.

 
At Friday, March 13, 2009 9:52:00 AM, Anonymous TT said...

Dr. Bernstein,

Fear of a malpractice claim may indeed be part of the reason, and I'm absolutely convinced that major tort reform needs to be part of any discussion on changes in or health care system. At the provider level, it probably leads to the practice of more "CYA" medicine versus evidence based medicine. That still doesn't explain the significant difference in standard of care between the US and similar developed countries when there is no significant statistical difference in disease rate or outcome.

The other factor I see in play here is that while the goal of a national health care system is to provide uniform safe and effective care to all citizens or residents, the goal of the US for profit health care system, at least at the management level, is to generate as much profit as possible by maximizing billings while minimizing expenses. On top of that, it is essentially self regulating with little or no government oversight. In Jackie's scenario, you can bill a whole lot more for a gym exam with all the associated labs than you can for a simple blood pressure check.

CSM make a good point. I do think there is a almost a crisis of legitimacy in health care in the US.

Why are there more than 100,000 unnecessary coronary catheterizations performed on stable angina patients in the US every year? Why is the hysterectomy rate in the US so much higher than other developed countries? Why is the rate of c-section, inductions and other childbirth interventions so much higher in the US than in other developed countries with no positive and some negative results?

The only answer I can suggest is: Follow the money.......

TT

 
At Friday, March 13, 2009 10:02:00 AM, Blogger MER said...

First, I want to make a correction. In a previous post I noticed that I forgot to put in a "not." What I meant to say is that "I am NOT necessarily in favor of a national health care system for this country."

Having said that, I'm not outright opposed to it either. I still think we need a national conversation or forum as CSM has suggested. As we reinvent or rebuild or repair our health care system -- I don't see why we can't save the best of it, and look at socialized systems like UK and take the best from those.

Mixed gender wards were a big problem in the UK. They still may be to a lesser extent. Complaints mostly came from women. But the system reacted to the complaints and, as I understand it, now things are better.

I agree with Dr. Bernstein -- the motivation for all these extra exams is not perversity, but an example of defensive medicine. I wonder, too, if some of it isn't connected to doctors who have ownership interest in the companies who own the equipment and do the tests. Do you have a thread, doctor, about the conflict of interest invovled in doctor's sending patients to have tests at clinics they have investments in?

Regarding Joel Sherman's comment, I have some detailed information on a neglected topic -- the sexual assault on boys. I don't have access to the website as I write, but I'll post it here later.

I think the "trust" issue is important. I believe that most of us still have trust in our individual personal doctors. It's as we get pushed into the system that we begin to lose the trust -- when we move from our personal physician, someone we know, to a clinic for tests, then to a specialist, then into the hospital. It's not that we don't meet some wonderful, caring people. It's that we loose more and more of the personal touch as we enter deeper into the system.

There was just a piece on the network news about how pregant women getting ready to deliver, are sometimes faced with a surprise -- their personal doctor doesn't do the delivery. There's someone on staff to do that. The women were surprised and disappointed. They were not told ahead of time that this would be the case. Another breakdown in communication.

During that network report, they interviewed a female doctor, a hospital staff member who did these "surprise" deliveries. She said something like this: "All the patients really care about is having some who is caring and qualified to do the delivery."

Interesting comment. Of course, we all want someone who is caring and qualified. But, as we've discussed on this blog, the dynamics of patient emotions go beyond that, too. But this doctor didn't see a problem. The female patients interviewed did.

One other comment. I know that Dr. Bernstein has said he objects to TV series like "ER." I've heard mixed reviews from other doctors and nurses, too. But I do like the way it covers the emotional issues patients and doctors face, and the ethical challenges. I mention this because, as the series ends, one of the main characters, Dr. Carter, is undergoing a kidney transplant. This crisis is pushing him into the system he has worked in for many years. One sees him observing the system from a different perspective. On a recent episode, as he's on the operating table getting ready to have the kidney transplanted, he says in an annoying voice: "Will someone cover my crotch?" On this series, and on other medical programs like it, it's rare that this issue of patient modesty is addressed. I found it interesting that this doctor makes a comment like this. He's noticing things now, as he undergoes surgery, from a very different point of view.

 
At Friday, March 13, 2009 11:12:00 AM, Anonymous gve said...

All the links I posted were indeed from the UK.
i posted them not as examples of good practice, but to show that the "professionals" in the Uk are clearly aware of the issues. They are in fact not one jot more considerate about patient modesty than the postings from the US.

That they clearly recognise the issues but still just ignore the elephant in the room, shows contempt for patient modesty.

 
At Friday, March 13, 2009 11:36:00 AM, Anonymous Anonymous said...

The real point of my poli-sci musings was that if modesty is always raised to the level of "the systemic crisis", there is little hope for modesty issues to be addressed any time soon. Raised by groups of patients at the health care facility level, modesty becomes a procedural issue, with cost-benefit readily understood by health care management. Define modesty types, propose responsive procedures, solicit feedback and support of doctors/nurses, management puts in writing -- voila! Facility managers learn "change management" in business school. Then, organize "modesty committees" in a standardized way across the country, and change "the system" bottom up. While you are at it, could you please make sure to include "Modesty Type #0" so we naturists aren't forced to submit to high-end swaddling procedures -- thanks! Any reform should benefit all patients, and maybe we naturists can help offset some of the potential extra modesty costs. (CSM)

 
At Friday, March 13, 2009 1:27:00 PM, Anonymous Anonymous said...

Yes, MER, it is so easy for a doctor or nurse to say, "why would this bother you (intimate care or exposure) when we have seen a thousand bodies and we are professional. Easy to say as they stand there fully clothed! Just depends on who is standing fully clothed and who is lying naked.

I have asked many a provider if they have had the test or surgery or procedure they are ordering and 99% of the time they say, "NO."
JW

 
At Friday, March 13, 2009 2:46:00 PM, Blogger MER said...

gve:

Assuming you're correct, that the practice doesn't follow the theory in UK -- here's what seems to be the difference: more professionals seem to be aware of the problem in UK and are willing to discuss in publically, try to come up with standards, post it on websites, make the public aware. At least there seems to be an attempt to recognize the issue and address it -- publically.
To my knowledge, we don't see that same concern in the US.

 
At Friday, March 13, 2009 3:13:00 PM, Anonymous Jackie said...

You're probably right Dr Bernstein - defensive medicine must play a part...fear of being sued...and making money must be a BIG factor...
Surely though Dr's would be just as concerned about being sued by a patient harmed by this thoroughness...
Although, with the high rate of false positives from cancer screening and possible harm, mental and physical, you'd be seeing it by now...
The screening industry has an inherent conflict - release of complete information might put some patients off (and not all patients are a captive audience) and the worthiness of your program might be questioned... AND the dangers they face by NOT informing men and women of the downside - the possibility of harm & liability.
In fact, when the screening industry was challenged, one of their arguments was, "If we give women all this risk information, they won't present for testing"...
Well, that's called an informed decision....and because this testing is pushed at healthy people, it's vitally important that a Dr accepts the need for informed consent....

A lawyer friend has wondered why there have been few cases flowing from the high number of false positives - a patient facing a false positive has enormous anxiety, "Oh, I've got cancer"...they have the unpleasant follow-up treatment and either walk away incredibly relieved (unaware their Dr knew of the high chance of a false positive, but didn't inform them) or, they mistakenly believe they had a cancer scare - disaster was averted by screening - so they tell their friends, "go get tested"....and so the cycle of fear and ignorance keeps screening rates high...
I believe this has saved the screening industry from a HUGE number of claims...keeping patients ignorant...

The screening industry have to show a reduction in death rates to justify spending millions of dollars - so any reduction is automatically put down to screening. My GP believes some of the fall in cervical cancer rates must be due to the higher number of women who've had hysterectomies, yet this large group are totally ignored in their statistics...(in the States I think it's one in four women, which is very high)

Australia also, has lawyers ready to pounce, but we're probably still way behind the States, as far as that threat is concerned...

On the issue of patient modesty - I think patients are now more confident to speak up and not allow themselves to be processed...the "individual" takes over and demands a certain standard of treatment.
The attitude has changed because patients demanded more - the hospitals received complaints and the nature of the Dr/patient relationship changed - Dr's were no longer Gods and were more likely to be held accountable or challenged about insensitive or improper practices.
I think patients FORCED these changes...
Just the fact that the Police are more likely to be involved in cases of sexual misconduct these days...doctors going to prison, not just required to use a chaperone...
The use of chaperones in this country is haphazard, so we've had some shocking cases of abuse - the Butcher of Bega (mutilated his female patients) was permitted to abuse women for decades, even though the Medical Board received serious complaints - contrast that with the recent case of a dermatologist sent to prison for the digital rape of several patients - it still took too long, but action happened faster probably because some of the women went to the Police, bypassing the Medical Board.
The patients effected change...criminals, not bad doctors - Police, not the Medical Board - this empowers other patients to follow their example...and makes suspect doctors think twice...it also, forces the Medical Board to act - to suspend or cancel a license when the Dr is on bail...or in prison.

The power dynamic between Dr & patient has shifted a little....for many patients anyway...
I think fewer people just trust their Dr to make their health decisions - the "Dr knows best" thing has gone into the past.

The point made about vested interests in labs etc is a good one - perhaps, those interests should not be allowed...

I don't know whether our rates of cancer are higher than your rates, whether US patients face more follow-up procedures for false positives than Australian patients - I know that would definitely be the case for cervical and breast cancer - ANNUAL cervical screening means 95% of women will face colposcopy/biopsies in their lifetime. (with only a very small number having any malignancy) Most US women wouldn't know that (is my guess) but the screening industry would certainly know...
Mammograms in the States are started early as well - there is lots of research to say mammograms are not recommended for younger breast tissue - these women are FAR more likely to have biopsies etc for false positives. In this country, we start at 50 (and this is a controversial Test at any age) - in the States, I think it's 40....
There is new research that suggests you're MORE likely to get breast cancer with regular mammograms - they suspect the bruising of the breast tissue.
Also, the discovery of ductal carcinoma in situ - a slow moving cancer that usually doesn't bother a woman - once biopsied, it can become aggressive and once diagnosed, the breast is usually removed...
It's been said that 40% of older women have some DCIS....
I've told my Dr when I turn 50, NO MAMMOGRAMS for me! She can like it or lump it - it's MY decision.

In this country, PSA Testing for men has been criticized (also the UK) - because it's a simple blood test, most men will agree to it however, it's an unreliable test and the follow-up diagnostic testing can be very risky - biopsy of the prostate - and the risk of incontinence and impotence is a concern.

We have problems in this country too - we need more honest disclosure about the need and value of cancer screening and the risks, we need to stop the practice of doctors receiving financial incentives to recruit women into cancer screening - it IMO, encourages bullying behaviour and deters the release of complete information.
The brochure sent to women about mammograms is woefully inadequate.
I'm about to write to my local Member and contact the media about this brochure....of course, any Dr who questions the need and value of this testing faces a furious screening industry - it's success in large measure relies on people just trotting along compliantly - more and more Doctors are brave enough to speak out - people like Professor Michael Baum, Dr Angela Raffles and Margaret McCartney...much of the blunt criticism seems to come from the UK.
I know when cancer screening expert, Dr Raffles, released her statistics, a HUGE shudder went through the screening industry - 1000 women need to be tested for 35 years to save ONE woman from cervical cancer....
I know quite a few women who were angered and felt misled - many have now declined screening.
Many women were led to believe the risk of this cancer was high, it was an epidemic - not so...
Saying screening has resulted in say, a 50% reduction in deaths doesn't tell you anything - if 2 people get this cancer, and screening means 1 will get cancer and thousands face follow-up and potential harm from false positives - does that give you a better idea of risk and the value of screening to the individual?
I think so...so then you look at your risk factors and decide whether you want to be screened...this doesn't happen at the moment IMO, because patients don't have the information.

An American pathologist released some amazing figures recently - 1% of women will get cervical cancer - one third will have received one or more false negatives, so screening may delay treatment by falsely reassuring women. Of the remaining 0.66% there are very high risk women who won't have screening - then you factor in your risk profile - so the benefit for most women will be lower than 0.66%...

Surely it comes down to how much risk you're prepared to carry in your life and only the patient should make that call. A decision not to participate should be respected and accepted, yet these patients are labeled refusers or defaulters.
I've noticed there is not much critical review of these Tests in American Medical Journals. (some but not as much as the UK and Aust)

Sorry this is sooo long - one last point - in my grandparents day, they responded to symptoms, you didn't have screening pushed onto you/recommended/required...
I think there is an automatic assumption that we're better off with screening - catch it early...
I really question this thinking - the practice has alienated many patients...harmed many with worry and unnecessary follow-up tests and often, screening gives you no more time, you just know you have cancer for a longer period of time...
I think there must be a better way to catch high risk patients (if they want to be caught) and perhaps, this money is better spent elsewhere...
Personally, I think the blind assumption that you're better of having screening tests is a dangerous one.

The practice of refusing the Pill until women agree to pelvic and other invasive exams is disgraceful... this practice may partly explain the high rate of teenage and unplanned pregnancies - these exams have nothing to do with the safe use of birth control and screening is supposed to be "offered" to patients - informed consent is necessary...

Surely access to reliable birth control is a basic human right.
I did a little research and see there is some rumbling in the US...some questioning of this practice - hopefully this will force change.

The current system in the States that calls for these thorough annual exams probably results from questionable, but "established" practices that are now Law and beyond question, patients being unable for various reasons to force change (scare tactics, kept ignorant or misled), profits and Doctors fearing litigation.
A toxic mix to be sure....

 
At Friday, March 13, 2009 3:25:00 PM, Anonymous Jackie said...

I had one final thought - maybe insurance companies play a part in the States.
My private health insurer can't dictate to me - I see the Dr of my choice and agree to certain tests and exams and not others...
I hear Americans say things like..."my insurance company has given me a list of Doctors"...
Do they also, dictate certain Tests or exams?
Most health care is covered or partly covered by Medicare in this country, but many have private health insurance that covers stays in private hospitals and ensures choice of Doctor. You can also, pay for extra cover for physio and the like....

 
At Friday, March 13, 2009 3:42:00 PM, Blogger Maurice Bernstein, M.D. said...

As doctors and medical institutions, in these hard times, are allowing negotiation with the patient of their bills for service, perhaps, in the same way, patients can negotiate for receiving care by a patient-selected gender provider. Now those who believe that gender selection is a personal "right" and need not be negotiated, that raises an entirely different question. When can a right be denied? It can be denied if there is harm to others, beyond the person with the right, if the right is exercised. Such a right such as smoking can be and has been restricted on the basis of physical harm to others ("second hand smoke" documented effects). Motorcyclists having a personal right to not wearing helmets or automobile passengers not wearing seatbelts, once considered a individual personal right is now widely prohibited on the basis of "harm to others". What harm? Financial harm: the high monetary costs to society to treat and maintain those individuals who were acting on their right but were severly disabled by an accident.

So..what about insisting that selection of a specific gender healthcare provider is a right. Could one see that this could entail some financial harm and system disruption by attempting for a doctor or institution to meet that right?

Of course, I am making this possible analogy not to stir already high strung feelings in some of my visitors but I am bringing this up to broaden the discussion going on here, even as a philosophical discussion, into an area not previously considered. This is the stimulating part of disussion when a discussion is widened rather than burrowing further down into one immutable concept. Afterall this is a discussion blog of an applied discipline of philosophy (bioethics). Any takers to my discussion challenge? ..Maurice.

 
At Friday, March 13, 2009 5:31:00 PM, Blogger MER said...

In 2008, the Alaska State Legislature passed Senate Bill 8 which gave mentally ill patients in institutions the right to request same gender intimate care. Note, the right to "request." All the institutions had to do was demonstrate that they make a "good faith effort" to grant that request.

I was suprised to see in the written and oral testimony that there were objections to this bill by mental health sites, e.g. the Alaska Psychiatric Institute. The bill not only gives these patients a right to request same gender care, but it also says that, if that request can't be granted, the institution must make note of that in the charts. One of the main arguments wsa that many of these patients have been sexually abused, and forcing a certain gender upon them for intimate care may cause trauma to return.

Note -- the testimony mentioned that laws like this one exist in other states.

As I read and listened to the testimony, some from lawyers, I was also surprised to see how the arguments and case law, provided, seemed to apply to the rights of all patients, not just the mentally ill. For example, the mentally ill are not the only people to have been sexually abused. And the elderly can be as vulnerable as any mentally ill patient. And if we start looking at the concept of vulnerability, that can apply to everybody.

During the testimony, a few legislators asked why this law shouldn't apply to everyone, not just the mentally ill. They were told that this wasn't a problem in the general system -- that people were accommodated. No evidence provided to demonstrate that statement. I think those backing the bill didn't want it to be watered down, generalized so much that it wouldn't be passed. Also, the mentally ill are expecially vulnerable and needed special protection, since many of them are involuntarily committed. But the basic rights discussed seemed to run right across the board to all patients.

My point -- Many in the health care system will oppose any offical policy or law that forces them to make even a simple "good faith effort" to provide same gender care for those who request it. They will say they're doing it already and there's no need for a policy or law.

They will also be opposed to being forced to record their failure to provide this care when it is requested. That would begin a paper trail, some data that can be studied to make a case that a certain percentage of men and women prefer same gender intimate care. That data could then be used in a BFOQ case to balance gender hiring to accommodate these patients.

So, doctor, whether it's a "right" or whether it's a "reasonable accommodation," it seems that the system will be against embedding it in policy or law. Personally, I hate to see this kind of relationship between patients and their caregivers, legislated. But unless the system makes more of an effort from within to change their attitudes and policies, I'm afraid that this is where it's going.

 
At Friday, March 13, 2009 6:32:00 PM, Anonymous Anonymous said...

First off I do not argue the cost for medical care is to high in the US, I do not argue profit drives some procedures. But, I would also argue the US not only has some of the worlds best health care when in need, but also many of the medical break throughs in the world came from the US. I work with folks from Canada, we joke, when you come to the US for your heart surgery bring cheap drugs...

As far as screening, you are right follow the money. My insurance company who is more profit driven than providers, pays 100% of many screenings including annual paps, PSA's, dermotologists, etc.. Why would they do so, becasue they think early detection is cheaper than treating something that shows later. No one likes profits more than a publically traded company. They would not pay 100% of a procedure and not charge your experience for it if they didn't feel it was cost effective, and running the numbers is the insurance industries job....they aren't in the health industry, they are in the numbers game, playing the odds....what is the cost of 99 tests vs 1 who dies after a battle of cancer...what is the cost monetarily and to the person and family, which poses the greatest risk, the test or no having the test.

On a related note, to your point Dr. Bernstein. If you say the cost is to much to allow gender choice by patients, what is the cost to society for those who do not seek or put off health care becasue of modesty concerns. While I do not know the exact number, the percentage of the total amount spent on a person for medical care in the last two weeks of life is huge. The cost of treating someone in advanced stages of disease and illness drawfs what it would cost to prevent them. The smart money would be on doing everything we can to encourage proactive care...not discouraging it.

There is no doubt the patient provider relationship is in tranistion, as if the whole focus on medical care...as patients become more mobil and willing to challenge health care and providers, and are willing to travel for what they want and need...the provider as an ultimate authority is changing to a patient as a customer, and while the medical industry would is trying and would prefer to go gender nuetral, the pursuit of profits will give opportunity for patients to effect change by requesting accomodation or going elsewhere...alan

 
At Friday, March 13, 2009 9:24:00 PM, Anonymous Anonymous said...

I have noted three major themes of the latest posts here. 1)sexual abuse or misconduct 2) possible excessive and needless exams and test 3) modesty in the context of shyness-
The first one is a matter best handled by prosecussion...and adds a tremendous cost to health care. The second is one that I think the medical community debates continually in order to assure that their patient's health is safeguarded (at least in most instances) and too much or too little monitoring also adds a great burden to health care costs. When a patient is too shy to seek advice from a doctor out of modesty concerns until they are far sicker than they need to be....also really costly...
The third cost is the object of your challenge I think...Because there is evidence that in many places male caregivers ,other than doctors, is growing...so providing same gender caregivers is is more easily accomodated by health care institutions than in the past. This means that they are not going to have to hire on excesive staff.
So my question is "How would this raise medcail costs?"
leemac

 
At Friday, March 13, 2009 11:24:00 PM, Anonymous Anonymous said...

To further elaborate on my previous comment....I do not think that smaller instutions, facilities or practices should be held to a quota of gender parity....it is probably economically impossible in many rural or poorer areas...and I do not want to deprive folks of medical care they need...BUT in those cases I think that it should be possible in most cases to accomodate a patient with a little change in procedure...(Does the nurse really neeed to be present? If not then keep her out...) Can the patient help with whatever needs to be done (bathing particularly)?...It may still boil down to having to have opposite gender present....but can it be done to minimise exposure, touching, etc.
and in any event...How much can placing a modesty cloth over the privates add to the cost?
leemac

 
At Saturday, March 14, 2009 12:10:00 AM, Anonymous Anonymous said...

Patients reject doctors for reasons other than shyness/embarrassment etc or fear of abuse - I have a few lesbian friends and they all absolutely refuse to see male doctors - not really shyness or fear of abuse, more uncomfortable dynamics...
If a system didn't accommodate them, they'd refuse treatment and find a hospital etc that respected their wishes.
Questioning a patient as to their preference is unacceptable - many patients may not want to talk about their sexuality, past abuse...or whatever....no one should be asked to explain their need for same sex Dr or opposite sex Dr...
TK

 
At Saturday, March 14, 2009 7:47:00 AM, Blogger Maurice Bernstein, M.D. said...

To make my view clear relative to my last posting, I don't think that provider gender selection by a patient is a matter of personal liberty or a legal right. I think the gender selection request is based on personal emotional choice. Like many such choices in our lives, some can be fulfilled and some cannot. ..Maurice.

 
At Saturday, March 14, 2009 8:44:00 AM, Anonymous Anonymous said...

Dr Berstein, I am trying to reconcile your commentary on personal liberty or legal right of a patient to make choices (whether based on emotions or other criteria) for themselves at least understand it. When does a patient have a right? What choices do they have? Is the only alternative to reject treatment period? Would this rejection (ie failure to get a timely test or exam) be more or less costly than trying to accomodate a preference? There are already times when it is considered to be "in the states interest" when a person is not allowed to make choices for their health care...this holds in case of serious injury or illness presented in the ER. it also holds if an extremely contagious disease is involved (ie..the new strains of tuberculosis and enforced isolation).( I just do not see how overriding my personal feelings is beneficial to anyone or how they are going to add cost)Would having these folk simply behave decently in also doing the little things that would also grant some dignity to the patient be too great a cost or burden?
If I am told that my only choice would be whether or not I got treatment..not on who would be involved, I would really have to think about trying some other mode or trying to find somewhere where I would have more say.
While it is true we often can not get what we want, most of our decisions are emotion based in most aspects of our life...that includes seeking to be well or extend life.
I think the cost factor is not to be taken lightly..especially in these times. I also do not see why I can not ask for a caregiver of the same gender...and at least recieve accomodation to mitigate my embarassment if one is not available. I do think I have a right to choose my caregiver based on any criteria that is important to me...I may not voice my reasons...this is partly because of an inconsistent argument...Part a is you need to be completely honest and open with your physician...but if doing so may give him/her reason to not honor your wishes...you are simply going to keep your mouth shut...and most likely start on a road of an adversarial relationship and the end of trust.
If I were your patient and I voiced my feelings and concerns and you told me I had no right and no choice, it would be the last time you ever saw me.. if the meeting ended on the same note..I would pay my bill at the front desk and leave..I would go off of your radar and might not even tell you that I already knew I would never come back...if it were to be in a hospital I would look for the first chance to escape..and take it.
leemac

 
At Saturday, March 14, 2009 11:45:00 AM, Anonymous Anonymous said...

to complete my thought of the last post...If as my doctor you tell me and are honest about it...that you simply can not accomodate me with same gender (as in can not...not will not)...but you will work with me to mitigate the situation my response will be a lot more favorable...I am capable of understanding that you may not be able to carry the expense of a larger staff...If you can not accomodate me be honest..and be honest about if it is a case of can not or will not. Granted in a case of will not our relationship and association will probably be terminated..but I will appreciate your being honest...and will be able to tell others that your are a trust worthy doctor.
If we are unable to be able to find an acceptable compromise on the mitigation of my feelings about exposure...we will probably also part company...without hard feelings on my part... If you lie to me or are arrogant.. I am gone...and most definately will let others know you are not trust worthy.. I may not have the right to tell you who you have to have on staff ( I guess I really don't), but I have the right to choose the who from and how I receive medical care from...in most instances.
If doctors (and I have many statements elsewhere about the doctor being frustrated at a patient delaying being checked out over modesty issues) want you to come in ...what is so hard in trying to find some sort of accomodation...even if it means that the doctor can't have his nursein the exam room..and tell her to stay out period. The patients request is not a desire to run the doctors practice , it is just the patient trying to cope..
If we can come to a mutually acceptable way of doing what you want in a way I can accept....I'm gonna thinik you are the greatest thing since sliced bread...and am really going to take every order/request you make seriously
leemac

 
At Saturday, March 14, 2009 11:56:00 AM, Anonymous Anonymous said...

Now we're getting down to brass tacks -- the space between "refusal to respond" and "obligation to respond" to patient gender preference in their health provider. "Routine care" = full patient choice of facilities willing/able to respond. "Specialized care" = informed best effort of health facility to respond and patient right to refuse. "Emergency care" = medical response trumps gender preference. Meantime, in terms of modesty in all cases and for both genders, facility obligation to routinely collect, make accessible, and check for stated patient gender/modesty requests, and to assure minimum genital modesty through standardized clothing items, draping procedures, etc. (CSM)

 
At Saturday, March 14, 2009 12:48:00 PM, Blogger MER said...

When I heard about the gender choice bill in Alaska, I wrote to have the testimony files sent to me. In a letter to the Alaska legislature, the Disability Law Center in Anchorage wrote:

"Federal courts have clearly enunciated that encompassed within the right to privacy is the right to shield one's unclothed body from view. As the Ninth Circuit Court of Appeals held over forty years ago, "We cannot conceive of a more basic subject of privacy than the naked body. The desire to shield one's unclothed figure from view of strangers, and particularly strangers of the opposite sex, is impelled by elementary self-respect and personal dignity." (Story v. York, 324 F.2d 450 (9th Cir. 1963.

They go on to say that "The courts have held that this right is not destroyed simply because one is institutionalized." So...all of us outside of these forced institutional situations have this right, and it doesn't disappear when we're institutitonalized.

"A person's interest in not being viewed unclothed by members of the opposite sex survives incarceration." (Robino v. Iranon, 145 F.3d 1109, 1111 (9th Cir. 1998).

They quote Lee v. Downs, 641 F.2d 1117, 1119 (4th Cir. 1981):

"Most people, however, have a special sense of privacy in their genitals, and involuntary exposure of them in the presence of people of the other sex may be especially demeaning and humiliating. When not reasonably mecessary, that sort of degradation is not to be visited upon those confined to our prisons."

Note the "When not reasonably necessary..." That's where the debate can come in. This is where it can get complicated within a medical situation. But I would suggest that having viewers in an operating or exam room who are not absolutely necessary for the operation or exam, (without the patient's specific, informed permission), is a clear violation of the patient's privacy.

I think you'll find this interesting from Local 567 American Federation of State, County & Municipal Employees v. Michigan Council 25, American Federation of State, Country & Municipal Employees, 635 F. Supp. 1010, 1013-14 (E.D. Mich. 1986 footnote omitted.)

"Obviously most people would find it a greater intrusion of their dignity and privacy to have their naked bodies viewed (or any number of personal services performed) by a member of the opposite sex. Although there will be a certain reliquishment of privacy by necessity when anyone is admitted to a hospital or mental health facility, this is not to say that a patient has forfeited all rights to privacy."

Interesting. That leaves the question open to discussion, doesn't it? But it does seem clear that patient feelings, requests, values are part of the equation and need to be addressed.

In Jennings v. New York State Office of Mental Health, 786 F. Supp. At 384, the federal district court of Michigan wrote that the failure to recognize the privacy rights of institutionalized mentally ill patients "is contrary to the concept of normalization which recognizes that mentally handicapped persons have a right to lives as close to possible to that which is typical for the general population."

Look what they're saying. They're saying that it's a given that the "general population" have these privacy rights, that is the "normal" condition. Therefore, the mentally handicapped should have these rights, too.

Let's be clear, within reason (which is debatable) we all do have these privacy rights, the courts seem to be saying

I wanted to quote all this with the sources so we could get some facts on the table regarding privacy rights. This is from a legal letter supporting these privacy rights. I found no letter in the testimony refuting these rights with specific case law.

I would really like to have a lawyer on this blog respond to this. As I've said, I'm not a lawyer. But I can read. These cases seem to clearly imply that the courts are just extending what are considered normal rights that the general population has to prisoners and mentally ill patients.

It seems assumed that regular patients have these rights, within, of course, certain constraints. That's where the debate lies. What does it mean that there "will be a certain relinquishment of privacy by necessity when anyone is admitted to a hospital...?" And what does it mean that, even though that's the case, when the court writes, "this is not to say that a patient has forfeited all rights to privacy."

You write, doctor: "I don't think that provider gender selection by a patient is a matter of personal liberty or a legal right. I think the gender selection request is based on personal emotional choice. Like many such choices in our lives, some can be fulfilled and some cannot."

I think, as these quotes from the courts demonstrate, it's more complicated than that.

 
At Saturday, March 14, 2009 5:15:00 PM, Anonymous TT said...

leemac,

Patients have the absolute legal to refuse care by any provider for any reason they choose. At that point the health care facility has the option to honor their request, discharge them if their condition permits, or transfer them to another facility if it doesn't.

TT

 
At Saturday, March 14, 2009 9:32:00 PM, Anonymous Anonymous said...

I believe in either 2007 or 2008
the medical board in a particular
state disiplined an equal number
of male and female physicians for
having sex with their patients.
Furthermore, one of the female
physicians that was disiplined
additionally provided her patient
with an unnecessary number of
prescriptions for very strong pain killers. Sadly, her patient committed suicide.
Prior to his death she carried
on this sexual relationship with
him while as his personal physician. Interestingly, considering the statistics that male physicians far outnumber female physicians in that particular state,there were an equal number of reprimands.
In regards to the bill introduced
in Alaska referencing same sex
provider,female nurses on the
allnurses site were against it.
Apparently, they feel there exists
more then an adequate number of
female nurses for female patients.
Their gist is they don't want male patients to have a choice
and as expected one can only wonder why!
The good news is that my hatrid
for the female medical community
runs deeper than the hypocrisy
they try so hard to foster.


PT

 
At Sunday, March 15, 2009 2:05:00 PM, Anonymous Anonymous said...

There's nothing wrong with womwn health care workers. Men should concentrate on getting well and not be concerned with wjether the people helping them have a penis or not.

Piƒƒonitöl™

 
At Sunday, March 15, 2009 5:15:00 PM, Blogger Maurice Bernstein, M.D. said...

Leemac wrote the following at 11:19am today. ..Maurice.



It has been suggested that the patients may have a need for control and modesty becomes becomes the visible manifestation of this...There may be times that a patient has so little or no control over the situation...that it is the only thing they have left in self-determination..
I also wish to say that while I would always prefer same gender care and I do know I could get a male who was totally oblivious to my modesty because he has no issues there.
TT having a say in your care does not extend to the ER if you are there because of serious injury or illness...a doc finally convince me that , even though a patient may think they are totally with it...they may not be and it is the provider who must do his/her best for the patient until such time as teh provider is convinced of teh ability of the patient to make decisions and I was a real hard sell on this point and it is not a matter of arrogance on the part of the provider,,it is a legal, ethical , moral obligation....No matter how we feel...the position of the provider has to be considered as well (Hey, if we give them no consideration..we can't expect them show us any either...just the Golden rule)
PT
No one is disputing that the medical community (being made up of human beings) also has their share of cretans and perverts..but it is not fair to tar all of them with the brush of the guilty being overly antagonistic towards them is diverting the attention (and eliminating posible allies) from the modesty issue..I note that the medical boards do still revoke the license of offenders and the law prosecutes a whole host of crimes.. but then recently my city has had several teachers (both sexes), school bus drivers, car salesmen, firemen, policemen, and folks from many ethnicities, economic situations, and walks of life arrested on molestation, prostitution, .. we can not condemn the whole human race though...that would be like me condemning all brown eyed people because the guy who shot my Dad had brown eyes..I am not going to condemn based on an eye color..
leemac

 
At Sunday, March 15, 2009 5:55:00 PM, Anonymous Anonymous said...

I take a no prisoners approach as
all men are discriminated against,
therefore we are the ones who have
been brushed as guilty despite the
fact that we are paying for this
service.
Remember, I have not once been
treated professionally as a patient
by female providers. That is why
I avoid them and thats why I don't trust them.
Had everyone on this thread walked in my shoes and experienced
what I've experienced all of you
would have a newfound appreciation
for what I've been saying here.

PT

 
At Sunday, March 15, 2009 6:18:00 PM, Blogger MER said...

Am I the only one who's closely reading those court cases? Read them carefully.

Although we don't have solid data as to how many men or women prefer same gender intimate care, the courts seem to assume that most people DO care about this. Look at these two cases:

The first is from Local 567 American Federation of State, County & Municipal Employees v. Michigan Council 25, American Federation of State, Country & Municipal Employees, 635 F. Supp. 1010, 1013-14 (E.D. Mich. 1986 footnote omitted.)

"Obviously most people would find it a greater intrusion of their dignity and privacy to have their naked bodies viewed (or any number of personal services performed) by a member of the opposite sex. Although there will be a certain reliquishment of privacy by necessity when anyone is admitted to a hospital or mental health facility, this is not to say that a patient has forfeited all rights to privacy."

This is from 1986. Note the use of the word "obviously." The court assumes that "most people" would be bothered by a member of the opposite gender taking care of them intimately. The court also assumes that this is obvious.

The second cases is from Lee v. Downs, 641 F.2d 1117, 1119 (4th Cir. 1981):

"Most people, however, have a special sense of privacy in their genitals, and involuntary exposure of them in the presence of people of the other sex may be especially demeaning and humiliating. When not reasonably mecessary, that sort of degradation is not to be visited upon those confined to our prisons."

This from 1981. Although the court says that this involuntary exposure only "may be" demeaning and humiliating -- it still says that "Most people" have this special sense of privacy connected with their genitals. I think it's significant that the court uses words, like "demeaning," "humiliating," and "degradation."

Now, I do concede that the court does talk about what's reasonable and some constraints. We can debate that. But I think patients have a role in this debate. This isn't something that the Medical system or the profession alone should decide

Three points I get from this. The court seems to say that it is just common sense, obvious, that most people have modesty in this area. Secondly, the court belives that these rights need to be protected, within reason. Third, the court seems to say that, rather than "assume" gender neutrality, places like hospitals should "assume" the opposite, since this is "obviously" how "most people" feel about this.

Thus, it appears to me that, based upon these legal opinions, the burdon of proof doesn't lay with those of us who support the right to same gender care, but rather with those who assume it shouldn't be granted or is not needed because it isn't an issue.

 
At Sunday, March 15, 2009 9:37:00 PM, Anonymous Anonymous said...

Thank you MER

Only a matter of time before the
legal system takes a very close look at this issue. It's no secret
that female prison guards commit
more sexual crimes than male prison
guards. Department of justice statistics.
Requesting and expecting same
gender care is really about trust.Are we really saying that modesty or so called modesty is truly not the issue but rather trust is the factor. That in essence we request the same gender
care because we feel that our
privacy cannot be respected or
trusted by opposite gender providers.
Consider this analogy when you are a patient in a hospital. Two
million patients a year recieve
nosocomial infections while
hospitalized. In 1995,there were
88,000 deaths from nosocomial
infections. One-third are preventable. This cost comes in
at 4.5 to 11 billions dollars a
year. Nosocomial infections are
hospital-acquired infections.
The primary cause is lack of
hand washing. Consider your child
hospitalized for surgery and while
recovering in the hospital acquires
RSV simply because the nurse did not wash her hands. Your child then
dies. Happens more than you think.
Recently, at the local hospital
big advertisements were put up by
the cafeteria. Hand washing is important. Did your nurse wash her
hands. This all on the heels of the
new announcement from medicare that
should a patient acquire an infection while in the hospital, we
will not pay for it.
The point I'm making here is trust or the lack of. If you cannot
expect the nurse to wash her hands
do you really believe they can be trusted with something less important, like respect for your
privacy.


PT

 
At Sunday, March 15, 2009 11:54:00 PM, Anonymous TT said...

leemac,

This is slightly off topic - it applies more to informed consent, but does have implications here, so let me respond.

You posted:
"TT having a say in your care does not extend to the ER if you are there because of serious injury or illness...a doc finally convince me that , even though a patient may think they are totally with it...they may not be and it is the provider who must do his/her best for the patient until such time as teh provider is convinced of teh ability of the patient to make decisions and I was a real hard sell on this point and it is not a matter of arrogance on the part of the provider,,it is a legal, ethical , moral obligation....No matter how we feel...the position of the provider has to be considered as well (Hey, if we give them no consideration..we can't expect them show us any either...just the Golden rule)".

Actually this is not completely true - what you refer to is the principle that if a patient arrives unconscious or otherwise incapable of making an informed consent, an implied consent to treat immediately life threatening conditions according to the accepted standard of care is assumed. This implied consent ends when the condition is stabilized, the patient becomes competent to participate in decisions or when their personal representative is able to act in their place.

The legal standard is that competency of a patient to make decisions regarding their medical care is assumed until proven otherwise, not the other way around. A competent patient has the absolute legal right to refuse any treatment or procedure, even if such refusal may be life threatening (and there are a number of court decisions that have affirmed this). I'm not saying it's a smart thing to refuse care in these circumstances, but the patient does have the legal right to do so. Further, such refusal, in and of itself, can not be used to determine competency to make medical decisions.

Now if the patient is unconscious, or too sick or injured to give informed consent, then what you said applies. On the other hand, if the patient is AOX3, they'd better take the time to get an informed consent, and be real careful in deciding to over-ride the patient's wishes. Ultimately, from a legal standpoint, competency can only be determined by a court of law, so if a provider chooses to over-ride a patient's wishes, they'd better be able to back it up in court if it comes to that.

Further, forcing a procedure or treatment on a competent patient that has refused it is a criminal act (assault and/or battery depending on the laws of the specific state). While most DA's would likely not pursue this in most instances, in many jurisdictions the patient, if they really wanted to push it, could choose to to make a "citizen's arrest". This usually requires a law enforcement officer to take the alleged perpetrator into custody based on the sworn arrest complaint of the alleged victim. Put's whole different spin on things, eh?

Now the likelihood of it ever going this far is extremely slim, but why take the chance? If you've got a conscious and alert patient refusing care for any reason, do the informed consent procedure, complete with worst case doom & gloom scenario, with witnesses, and document it seven ways from Sunday. Then if they still refuse, the options are what I indicated earlier - attempt to accommodate their wishes, discharge if their condition permits or transfer to another facility if it doesn't.

TT

 
At Monday, March 16, 2009 3:57:00 AM, Anonymous Anonymous said...

Maurice you suggest that routine exams are more common in the US because of a fear of a missed diagnosis could lead to litigation. But how can a doctor be sued for not doing a particular routine exam? My understanding is that you can sue for missing a diagnosis after performing an exam but not for not performing it. I'm only talking about screening obviously and not if the patient presents with particular symptoms.
I also live in Australia and I have never had a pelvic exam (I've even had two children by c section) and only have to have a pap smear every two years and without stirrups. I did not realize how American women are treated by the system. I agree that the dread of the annual exams must be the reason why teenage pregnancies are higher in the US than other developed countries. I would also like to add that due to the increasing numbers of Muslim immigrants to Australia, modesty concerns are an issue that health care providers are more conscious of.
Sue

 
At Monday, March 16, 2009 8:47:00 AM, Blogger Maurice Bernstein, M.D. said...

TT, much of what you say is correct, however I just want to clarify some points. First of all, the issue with regard to consent to medical treatment is called "capacity" and this is not an evaluation made by the courts but is made by the attending physician. The patient's capacity is the ability to demonstrate that the patient understands the clinical situation and the options and can make a decision along with being able to explain the basis for the decision. It doesn't matter what the decision is but that the patient can provide an explanation that would make sense to the average person. *Competency" is set by the court and deals with a more general ability to handle ones own affairs. Important to emphasize is that a person may not have the capacity to make a number of other decisions but they still may have the capacity to make their specific medical decision. Patients who arrive "alert, oriented and cooperative" may or may not have the capacity to make their specific medical decision. You are correct, except in a life-threatening emergency where no surrogate is available to make the decision for the patient, all examination and procedures must be made with the patient's informed consent otherwise it could be considered legal battery to do otherwise. All physicians should be able to judge capacity and it need not take a long time nor require the presence of a psychiatrist.

Sue, failure to perform a test which is considered to be a standard of medical practice can be just as significant as to misinterpret or not followup after a test is performed. ..Maurice.

 
At Monday, March 16, 2009 9:00:00 AM, Blogger Maurice Bernstein, M.D. said...

I received the following from a legal consultant who had read MER's initial posting of the case law on March 14th. ..Maurice.


MER’s interpretation seems reasonable, provided that one accepts (does MER?) that the courts recognize that in the hospital a patient loses a great deal of usual privacy, and part of that recognition is surely that persons of the opposite sex often have to perform intimate acts for patients and patients often have to be “seen” by such persons—with the protection lying in the “distance” or “depersonalization” that attaches to someone acting in a professional role.

I’m not sure that any of this has a great deal of relevance vis a vis one’s freedom to choose, on a wide range of grounds, including gender, one’s physician.


 
At Monday, March 16, 2009 9:02:00 AM, Anonymous Anonymous said...

TT I am not always clear...your great post is , ofcourse, correct.
The doctor who I talked to did make a good case....He wanted to know if I would really be willing to die because I would not endure a few moments of physical/emotional unpleasantness. The example he used was refusal of a catheter when I had a possible injury that pressure in the bladder can somehow trigger cardiac arrest..Did I hold my life to be of such little value?
I am not familiar with the term AOX3 is it like a DNR/DNI?
PT..with all of the health issues you have had, I am sure that disrespect of your person must make it much harder for you.
leemac

 
At Monday, March 16, 2009 9:11:00 AM, Blogger Maurice Bernstein, M.D. said...

Leemac, AOX3 means "alert, oriented to person, place and time". Alertness and such orientation does not necessarily indicate that the person can make a medical decision. Such capacity must be demonstrated. ..Maurice.

 
At Monday, March 16, 2009 9:32:00 AM, Anonymous Anonymous said...

As to the issue of unneeded testing and screening, I think one has to understand the medical community hardly seems unanomous on anything. One thing to consider when determining if these test are needed is the financial issues. Sorry to say follow the money to the answer is often correct. Our insurance company pays 100% for screening procedures with no deductible. The pay for PAP's, annual physicals, DRE/PSA, etc. While insurance companies are not in the health care business, they are in the numbers business. They make or loose money by determinng the odds of occurances. They evidently have determined it is cheaper to pay for testing than to pay for treatment after the fact. Evidently the odds of finding issues early outwiegh the costs for testing and finding nothing...so, financially driven, I think one may say so but not nesecarily in the way we assumed. If it makes sense for the insurance companies...it might make sense for us. I hate my yearly visit to the urologist for prostate screening...I dread it, but I figure if my insurance company is paying for it...an ounce of prevention...I would assume the same with PAP's, unpleasant yes, odds they will find something, small, benefit if they find something early...perhaps life saving...alan

 
At Monday, March 16, 2009 10:15:00 AM, Blogger MER said...

Doctor:

Thank you for having that legal authority respond to my post. Would you ask him or her the source for the statement that the courts "recognize that in the hospital a patient loses a great deal of usual privacy..." I'd like to see where that comes from. I want to see "a great deal" written in some case law.

Also, the lawyer writes: "persons of the opposite sex often have to perform intimate acts for patients and patients often have to be “seen” by such persons—with the protection lying in the “distance” or “depersonalization” that attaches to someone acting in a professional role."

Ask the lawyer to respond to this:

First -- where does the double standard for men fit in here. When the lawyer talks about the "patient" it makes a difference often whether that patient is man or a women as far as what accommodations for privacy that can be made.

Second, would the lawyer supply me with some csee law that mentions the "depersonalization" and "distance" as a factor.

I've quoted specific cases as well as my opinioin. The lawyer has just quoted his/her opinion. Granted, that lawyer's legal opinion is worth more than mine, but I'd like him/her to back up that opinion with some case law.

I think there could be a case for gender discrimination if one gender has to give up much more privacy than another because of the imbalance of male and female caregivers. As long as both genders must give up the same amount of privacy -- but then I don't think most women would put up with what most men tend to tolerate.

 
At Monday, March 16, 2009 12:40:00 PM, Anonymous Anonymous said...

Dr. Bernstein..Thankyou for the clarification and differentiation of capacity and competency. I have been erroneously using the two interchangeably.
Thank your legal consultant as well...I get the feeling that the only way to cohesively merge all of the points made by MER and your consultant is that phrase "within reason"..

This seems to leave us in a position where our negotiating skills are going to be the deciding factor a lot of the time...as to how the modesty issue is treated.
leemac

 
At Monday, March 16, 2009 3:05:00 PM, Anonymous TT said...

Dr. Bernstein,

Dr. Paul Appelbaum states in his Nov 2001 article in NEJM titled 'Assessment of Patients’ Competence to Consent to Treatment', "The terms “competence” and “capacity” are used interchangeably since the
oft-cited distinctions between them — competence is said to refer to legal judgments, and capacity to clinical ones — are not consistently reflected in either legal or medical
usage."

In the numerous published articles I have read related to this subject, including guidelines for determining patients' competence or capacity to make medical decisions, they are used interchangeably, and in fact one guideline stated unequivocally that a determination of a patient's capacity is a determination of their competence, since it has the effect of depriving them of their legal right of self determination they would otherwise have.....

leemac,

Sorry about that - will try to avoid uncommon acronyms in the future.....

TT

 
At Monday, March 16, 2009 3:31:00 PM, Blogger Maurice Bernstein, M.D. said...

TT, it is true that in the past competence and capacity have been used interchangeably but since the present ethical understanding of capacity is that patient capacity to make his or her decision is clinical situation specific this would not be the same as competence which, determined by the court, covers a wide range of personal and family or work responsibilities for which the patient would be responsible. Competence is determined by a judge. A person who is deemed incompetent needs a surrogate for legal managment of personal affairs. Capacity to make medical decisions is determined by a physician. A patient who has no capacity for one medical situation may well have capacity to make a decision in another medical situation.

Finally, as chair of my hospital's ethics committee I can say that our committee evaluates evidence of capacity for the patient to decide based on the physician's examination and we don't have to go to a court of law for such a determination. Unfortunately, realistically, our cases are "no-brainers" since the vast majority of the patients are from the critical care unit and are unconscious at the time and, of course, at that moment cannot speak for themselves except through a surrogate who can make the decision for the patient based on past communication. ..Maurice.

 
At Monday, March 16, 2009 3:49:00 PM, Anonymous gve said...

take a look at the end paragraph regarding Urodynamics......

Double standards never shone so brightly.....


http://www.wellsphere.com/chiari-malformation-article/medical-tests/499302

 
At Monday, March 16, 2009 3:59:00 PM, Anonymous Anonymous said...

She had a male urologist and a female tech. Getting a female urologist wouldn't be as easy as getting a male one in the same way getting a male nurse isn't as easy as getting a female one. Hopefully more females go into urology in years to come and more males go into nursing in years to come as well. It will help to balance the disparity in both.

 
At Monday, March 16, 2009 4:35:00 PM, Anonymous TT said...

Dr. Bernstein,

I understand, and appreciate your clarification. The way I understand it from the court decisions, medical guidelines and other articles that I have researched (mostly to do with informed consent), from a legal perspective, competence is not an all or nothing thing. A person may be competent to manage personal affairs in some areas but not competent in others that was the reasoning in my previous posts. It's also my understanding that if the patient or family disagrees they can take it to court for adjudication. Thankfully that happens rarely, as both the health care system and the courts would bog down if it was routine.

As a matter of policy, does your ethics committee make the final determination as to capacity in all cases? If not, why not? I guess my problem is with the attending physician making a sole determination when they have a conflict of interest (ego - re:their recommended treatment or procedure; financial or other gain from doing the procedure, etc.) in the outcome - I seriously doubt their ability to make a determination impartially and without prejudice. It would be far better if such a determination was made by a disinterested 3rd party - such as the ethics committee.

Just my $0.02.......

Again, my apologies for going off on a tangent from the topic of this thread - my last post on this issue, I promise! I would appreciate it, however, if you would answer the couple of questions I posed....

Thanks!

TT

 
At Monday, March 16, 2009 5:33:00 PM, Blogger Maurice Bernstein, M.D. said...

TT, you are correct that competence as set by the court need not be in all categories of functioning and responsibility. Yes, an ethics committee would judge the physician for conflict of interest or secondary gain in the same way the committee would judge the legal surrogate or any surrogate who says they were speaking for the patient.

The patient is deemed to have capacity by the physician unless the physician finds evidence to the contrary. If the patient has failed capacity evaluation or is comatose, the physician still must obtain informed consent from a surrogate. Sometimes, like with the homeless there may be no surrogate available. In that case, the ethics committee must look into the physician's decision with regard to the best interest of the patient as well as. if necessary, evaluate the patient's capacity ourselves and then either agree or disagree with the physician's decision. In the this case, there must also be at least one community member on the consult committee. ..Maurice.

 
At Tuesday, March 17, 2009 8:18:00 AM, Blogger Maurice Bernstein, M.D. said...

Two messages:

1) To Anonymous who wrote today suggesting to go to a medical student website to read about how women patients are viewed by the students, resend your comment and please make sure you include the FULL URL address. You previously sent only a partial address.

2) To those who want to read more about how patient capacity to make medical decisions is arrived at, I had written a thread on that topic in March 2005. Here is the link to that thread. ..Maurice.

 
At Tuesday, March 17, 2009 8:47:00 AM, Anonymous Anonymous said...

Dr. B.,

Thank you for catching the previous insufficient link address I had sent.

To everyone who thinks that the gyn exam is simply clinical, here is a link to a student doctor website, where both medical doctors and students are discussing their thoughts about women, and also their appalling thoughts while when giving these types of exams.

Required Reading:
http://forums.studentdoctor.net/showthread.php?s=18c975e84e4aa1bd887c7c9d0857af04&t=604811

 
At Tuesday, March 17, 2009 10:19:00 AM, Blogger Maurice Bernstein, M.D. said...

I will continue to caution all those who are going to read what is written on the "student doctor" website to maintain the same caution with which I would advise visitors going to the allnurses website or any other forum website where there is no positive personal identification of any of the posters and where everyone can write in an anonymous fashion. By the way, that includes also this bioethics website!

The visitors have no proof which of the posters are medical students or graduates or what and no basis to make a judgment as to what was the motivation of what the poster had written. It is fully unwise to read all the stuff written there and start making assumptions about what medical students or physicians think about women, about pelvic exams or about sexuality in medicine. In no way are the comments on that website the basis for any sociologic study or conclusion about attitudes of medical students.

With that preface, I can tell you some real facts about medical students since I have been working with them for all those many years. At my school, the students are exposed to male genital and female pelvic exams by teacher-subjects and they would be given strong feedback by them if the students didn't follow professional guidelines for these exams. The students are shy and apprehensive about this leap into observing and performing intimate exams and remain so well beyond their first encounter. Yes, tension may be relived by joking but they are aware that even joking amongst themselves, while perhaps temporarily therapeutic for their tension is really a demeaning behavior towards the patient who will be putting their trust in the doctor. If that attitude persists into later practice, this can lead to dangerous casual attitude towards patients and unprofessional and perhaps illegal behavior toward the patient. There is already too many unknows in the practice of medicine and we don't need doctors displaying either amongst themselves or to patients such an attitude. ..Maurice.

 
At Tuesday, March 17, 2009 12:55:00 PM, Blogger MER said...

I must respond to that "student doctor" website." I started reading it, but couldn't go on it was so disgusting. I agree with the cautions Dr. Bernstein recommended about sites like that. But I think the medical profession needs to go further.

In the "old days," professionals in different fields ranted and raved and told off colored jokes in the privacy of the break room or halls. Now some of them do it online for all to read. And as the doctor said, we don't even know for sure who they are, whether they are indeed students, in this case.

That's why Dr. Bernstein's and Dr. Sherman's site are so important. They're properly moderated by known professionals who can be trusted. Sites like allnurses and the student doctor one, should only allow actual medical professionals on so those reading it know who's talking. Now, I don't know how this can be done, technically. Maybe it can't.

But the damage done by sites like the student doctor one when they allow conversations like this one to happen in public -- that damage to doctor-patient trust is extremedly severe. Same with some of the discussions on allnurses.

The profession needs to somehow get hold of this problem and regulate it. Having said that, realistically I don't know how it can be done. But all this perhaps belongs on another thread.

 
At Tuesday, March 17, 2009 3:21:00 PM, Anonymous Anonymous said...

I have to agree, I don't believe most of those posts are bogus, one would assume it would take a certain amount of intellegence to get into med school....not much shown there. I think allnurse has a little more credibility, the majority of conversations on allnurse are clinical in nature, not something trolls would find interesting...and it does seem the moderator trys to keep it reasonable. An interesting note is how they shut down conversations that get heated over the modesty issue. I think this is a major point of contention between patients and providers...the reluctance of providers to enter into conversations or debate on the topic........alan

 
At Tuesday, March 17, 2009 5:05:00 PM, Anonymous Anonymous said...

PIFFONITOL On Sun. March 15 @ 2:05
pm you said

" Theres nothing wrong with womwn
health care workers. Men should
concentrate on getting well and not
be concerned wjether the people helping have a penis or not."


Perhaps you should make a similar
statement to a black man who wanted
to ride a bus in the 50's. Perhaps
he might say something to the effect that "it dosen't matter what
color your skin is when all you
want to do is get from point A to
point B.
I don't think I need to explain
what black people went through in
the 50's or 60's,however,it's
similar to what men go through now
in healthcare,discrimination. An institution that obviously you are oblivious to.
That's a bus I do not want to
ride on. True, some men like to
ride on that bus,so do some women.
Don't lump me together with those
and don't make any assumptions until you've walked long and hard
in my shoes.


PT

 
At Tuesday, March 17, 2009 5:09:00 PM, Anonymous Anonymous said...

With all due respect if you allow
a link to a student website, then
you must read what is said about
male patients on allnurses.com
The thread under general discussion: things you'd like to
say to a patient.
Please go to page 100 and 101 by
simply clicking on last page and going back to page 100 and 101.
Very disturbing!!!

PT

 
At Tuesday, March 17, 2009 6:57:00 PM, Anonymous Anonymous said...

I "mistyped" I meant to say I don't believe most of the posts were students. I did find the posts on allnurse distrubing. Perhaps that is another issue, providers claiming the high road which allows them a pass on modesty, but then giving themselves a pass to be "normal" and talk about patients....maybe part of the problem is patients just don't buy the it means nothing to the provider.....perhaps we see it from our side and perhaps we see and hear enough to make us doubt....alan

 
At Tuesday, March 17, 2009 7:19:00 PM, Blogger Maurice Bernstein, M.D. said...

To LH and others, please don't carry over the content from the medical student forum or other forums which contain material written by unknown individuals for unknown motivations. Their disgusting comments on those websites to me do not in anyway represent information with which to make generalizations or to be part of a discussion of bioethics. Sure we could search trashcans for gems of wisdom, use and value but digging through them usually will end up only with filthy hands and minds and simply no rewards. In a way, my bioethics blog can be or maybe is already a potential trashcan but that isn't what I intend it to become. So, if you see that I don't allow some comments to be published, especially those written to and within a different atmosphere be tolerant of my particular view of the way of creating a discussion site. ..Maurice.

p.s.-If you find a site that you feel makes your point simply present us with the URL and those who are interested can go and investigate but keep the texts there and don't bring them back here.

 
At Tuesday, March 17, 2009 9:05:00 PM, Anonymous Anonymous said...

PT
You all make such a fuss about who's got what in their pants. Say you have an accident that makes you temporarily lose your vision and you were being treated in the hospital. If the nurse helping you doesn't make a sound how would you even know what sex organ the nurse that's helping you has between their legs? All that should matter to you is whether they did a good job or not.

The last couple of generations have completely lost touch with what is important. Male, female, what's the difference? Most likely neither gender is going to feel sexually attracted to you. If you guys spent the same amount of time in physical therapy after a surgery as you do whining and complaining about the gender of your caregivers you could be fully recuperated in a matter of hours.

I don't need to walk long and hard in anyone elses shoes. I've walked enough in my own shoes to know that the gender of your caregiver makes absolutely no difference. PT and others here are starting to sound like the whiners on the voy boards.

Why don't you just accept the fact that things aren't going to change? No matter how much you whine it's not going to change the fact that 92% of nurses are women. Why not just lay back and enjoy the site of the pretty nurses?

Piƒƒonitöl™

 
At Tuesday, March 17, 2009 10:22:00 PM, Anonymous Anonymous said...

Who said they were pretty, not from
what I've seen. The vast majority
are obese and angry.
Unfortunately,most don't do a
good job. Read the handwashing
statistics. As far as a temporary
loss of vision perhaps you should
get your glasses checked.
Things are changing and yes for
you thats a hard pill to swallow.


PT

 
At Wednesday, March 18, 2009 10:01:00 AM, Anonymous Anonymous said...

Whether the nurses are pretty or not has nothing to do with this thread. That type of dialouge is more fitting for the voy blogs rather than one that is seriously addressing a valid issue. Pf just because you have an opinion or feeling about a issue doesn't mean those with a different view are wrong or silly. That is perhaps one of the things that really enrages people, that some people and some providers think just because they think it should be a certain way, everyone else is wrong and should adopt their position. I see you post numerous times on the voy blogs...hopefully we won't let this blog get drug down to that level. I fear we will put Dr. Bernstein in the unwanted postion of censoring the posts if we head that direction....and yes 92% of nurses are female, but the percent of males in nursing school is climbing, and at one time only about 10-15% of doctors were female, fortunately they didn't just accept it, niether did Rosa Parks or any other people who changed society...alan

 
At Wednesday, March 18, 2009 3:38:00 PM, Blogger Joel Sherman said...

The comment was made above that 1 in 4 women are sexually assaulted during their lifetimes. I commented that the statistic comes from feminist literature where they defined what an assault or rape was in their own terms using very very broad criteria which often the 'victims' did not themselves agree with.
Here's the other side of the story, a masters thesis first noted by MER which reviews the literature and concludes that 1 in 6 males have been sexually abused. The author freely offers that it is very difficult to standardize terms and methodologies so these figures are coarse approximations, but it makes the point that women are not alone in being subjected to abuse and that it is a major problem for all. It does make me wonder though why so much is said and legislated about protecting women from abuse and relatively so little concerning men who are portrayed as abusers frequently but uncommonly as victims.

 
At Wednesday, March 18, 2009 4:22:00 PM, Anonymous Anonymous said...

Thanks Alan

I suspected that PF was one who
enjoys those kinds of things and of
course that is his business.
One of the great things about life is being able to make choices
and naturally I equate choices to
freedom.
I'm not one who forces my opinions on others, I'll offer
suggestions and free advice all
day long. The reasons for my posts
are disturbing and I wouldn't want
anyone to go through them.


PT

 
At Wednesday, March 18, 2009 4:29:00 PM, Anonymous Anonymous said...

Piffonitol


I've never been on the voy forums and wouldn't know where
to look. The only fetish I have
is wanting to be treated with
some respect!
Please be respectful of others
opinions, some of us have histories
of abuse as a patient in these regards.


PT

 
At Wednesday, March 18, 2009 5:17:00 PM, Blogger Maurice Bernstein, M.D. said...

This blog is for rational and civil discussion and should have nothing to do with the imagined personality or motivations of individual writers to this blog. Again, virtually everybody is writing here anonymously with no proof even of gender or age or background daily life or even for sure whether the same person is writing the same pseudonym initials. It is not fair nor is it even rational to make derogatory statements about some person one does not know and is just represented as text on a screen.

Now this anonymity doesn't preclude visitors, even anonymously, presenting concepts which are open to discussion as concepts. The concept is not anonymous and that is open to agreement, disagreement or modifications. Concepts are open to research and documentation. This is what I am looking for on this entire blog and not uncivil or ad hominem remarks. Please remember this as you submit your next postings and those beyond. ..Maurice.

 
At Thursday, March 19, 2009 10:43:00 AM, Anonymous Anonymous said...

I am considering having a more accurate test undertaken for prostate cancer. The PSA test is not at all reliable, the new test PCA3 is far more reliable.

The test involves having the prostate massaged before the sample is taken. When i asked for a male nurse for this procedure, i was telephoned back by the senior nurse at the test centre. She wanted to go into great detail of the skills and sensitivity of the female nurse who conducts the test. I stopped her dead and said i would not care if the female nurse had a million years experience and a male nurse alternative had only one day experience, there would be no contest as to who i would prefer. She tried to "educate" me as to why i should accept the female nurse. Needless to say she failed completely. What is so wrong with people that they cannot simply accept that men require the same level of dignity that women routinely expect and get for themselves.

 
At Thursday, March 19, 2009 2:14:00 PM, Blogger MER said...

Two questions that we've consistently discussed on this thread are:
1. What is the source of body shame?
2. Is it totally learned, all cultural, or is it partially inbred.

Here's an interesting link from the BBC -- an experiment conducted by a psychologists who claims shame of nakedness is all learned and can be unlearned. I'm always a bit skeptical of experiments like this -- the old Heisenberg's uncertainty principle -- how the experimenter influneces the experiment.

But I'm open to new research and willing to consider new findings. Read the article, and the comments after the article.

http://news.bbc.co.uk/1/hi/magazine/7915369.stm

 
At Thursday, March 19, 2009 8:07:00 PM, Blogger Maurice Bernstein, M.D. said...

I do not understand the details of the "study" involving a male and a female subject nor do I how the conclusion was drawn. I am not sure if the "study" was to establish the mental mechanism for the bodily modesty, for example whether it is shame or whether it is fear. Shame, that the subject finds their body unattractive or negative in some way and fear, presumably an unwanted sexual attraction or unwanted evidence of sexual interest. To me I gained nothing from the presentation in this regard except that somehow there was a change to acceptance in the subjects concern about their nudity. Whether this would continue is unclear. I thought the theory of the physiologic value of a essentially hairless human ("nude body") compared with animals who are clothed with their body hair with the suggestion that human nudity was not a useless and incidental development in the species.

I would like to know something of the dynamics of those who have been through their life textilists and then enter the naturism culture, how many quickly leave, how many stay and eventually leave and how many stay and continue to stay and participate in the culture. I would like to know how long a person's fear and shame, if present, clothed persists when exposed to nudism in a social environment and whether these are truly lost forever while in that environment but do they return when the individual returns back into a clothed social environment? In other words, if fear and shame are part of the dynamics of the initial concern can they be totally "unlearned"? And therefore the only reason a nudist would be uncomfortable naked (if that is so) in a clothed social environment is because of legal concerns, social disapproval or environmental physical issues such as temperature as examples.

Maybe CSM you can help us with these matters if you are still around. ..Maurice.

 
At Friday, March 20, 2009 5:12:00 PM, Anonymous Anonymous said...

Re: PCA3 prostate test.

Don't know why you are having
a nurse do this(?) My GP or
my Urologist, both males by
my choice, take care of the
necessary massage before the
urine sample is collected.
Go to a male doctor and tell
them you want no female chaperone
or no chaperone at all. My
doctors always work alone so
I didn't even have to ask.
Whatever you do, just don't give in.
I personally would never
allow anything like this to be
done by a female, unless I was
in the ER for a serious emergency.
Then, of couse, I'd be much
more focused on other concerns.
Good luck. Adam K.

 
At Friday, March 20, 2009 5:13:00 PM, Anonymous Anonymous said...

Re: PCA3 prostate test.

Don't know why you are having
a nurse do this(?) My GP or
my Urologist, both males by
my choice, take care of the
necessary massage before the
urine sample is collected.
Go to a male doctor and tell
them you want no female chaperone
or no chaperone at all. My
doctors always work alone so
I didn't even have to ask.
Whatever you do, just don't give in.
I personally would never
allow anything like this to be
done by a female, unless I was
in the ER for a serious emergency.
Then, of couse, I'd be much
more focused on other concerns.
Good luck. Adam K.

 
At Friday, March 20, 2009 7:34:00 PM, Anonymous Anonymous said...

I would call your doctor and see if he would be willing to do the massage instead of a nurse. If you explain the situation he might accomodate you. It doesn't hurt any to ask. If he isn't willing to do it I'd call around and see if another doctor will.

-cm

 
At Friday, March 20, 2009 9:43:00 PM, Anonymous Anonymous said...

Prostate massage? What next! Sounds
like a scam to me. If you've been
following prostate ca reports lately most of the tests cause more
harm than good. If you doubt this
I'll quote the source, AMA among
others.
Just one more thing for female
nurses to get their hand into,no
pun intended.


PT

 
At Friday, March 20, 2009 9:50:00 PM, Anonymous Anonymous said...

Mer i don't think we are ashamed of nakedness. I am sure most of us have partners whom we don't feel embarrassed about being naked in front of. What most of us here fear is being ridiculed by female nurses if we are male or if female being a source of sexual gratification for male doctors. We truly do not know what the health care provider is thinking when viewing us naked.
I've worked in hospitality. I am extremely polite and friendly towards my patrons. But some of them I despised because of their arrogance or whatever. The truth is they would have no idea how I felt towards them as I was a "professional". It's not hard to hide your true feelings.
LH.

 
At Friday, March 20, 2009 10:09:00 PM, Anonymous Anonymous said...

I just also want to add I don't think that discussions about naturalists are really relevant as everybody is expected to be naked. As I understand it you are given a day or two to lose your inhibitions at these nudist retreats and if you do not shed your clothes then you are asked to leave. Being naked in front of a fully clothed health provider is a totally different situation.
LH

 
At Saturday, March 21, 2009 2:05:00 PM, Blogger MER said...

One point I’ve tried to consistently make in my past posts is – how we feel about nakedness is contextual, depends upon the situation. The same person who may frequent nudist events may be embarrassed or even humiliated being naked in other contexts. The same is true for those who are extremely embarrassed being naked in front of a female nurse or doctor. In other contexts, in front of a male doctor or nurse, they may not be embarrassed.

I’ve been trying to study the change in attitudes toward nakedness in Western culture, especially the US, within the last 100 years or so. This is a complex subject and I don’t pretend to have “the” answer. But I do have a few suggestions. In the late 19th century, early 20th century, interest in Greek culture with the start of the Olympics, reminded us that these Greek athletes competed in the nude, and often trained in the nude. The Greek perfection of the unity of mind and body became visible in statues of the “perfect” athletic body. I think the early Olympics had some influence on attitude changes. This about the time we begin to see the growth of modern nudism and males swimming nude in public swimming pools.

About the 1890’s, when Boy’s Clubs, YMCA’s, (the scout movement, etc.) became popular, attitudes toward masculinity changed. The notion was that we were becoming weak as a culture, especially males, with the closing of the frontier. These male bonding institutions in connection with exercise and wilderness experiences helped shape our attitudes toward nudity. In UK, as the empire was declining, a similar attitude developed about the decline of masculinity and the traits associated with it. Early indoor swimming pools started being built. They had filtering systems that were sensitive. For that reason among others, males were required to swim naked. It started in the YMCA’s and Boy’s Clubs and later came into some of the college and high school systems. But, and this is a big BUT – it seems to me that there was always an understood, tacit agreement – no females were allowed. This would be strictly for men and men felt safe in these situations.

I don’t think naked military induction exams really became standard until WW1. That’s not to say it didn’t occur during the Crimean War, the American Civil War or the Franco-Prussian War. We’d have to research that. But before “modern” warfare, governments were more interested in bodies in any condition to man the front lines. Doctor’s examining naked bodies didn’t really begin seriously until after the French Revolution secularized the hospital system and doctors from all around the world headed to Paris to study and get access to real bodies. Read George Eliot’s “Middlemarch” to see how one of the main characters, a British doctor, brings back modern medicine to England from his Paris studies. There’s a revealing chapter in Tolstoy’s “Anna Karenina” where Kitty is ill and must go through a complete examination with one of the “new” thinking doctors who insists that he examine her entire naked body. Very revealing. It shows the arrogance of that doctor, how the modesty of the patient is completely ignored. If ever there’s a literary example of Foucault’s medical “gaze” it’s there in Tolstoy. Kitty was simply an object for this doctor to examine. My point in all this is that the modern medical examination of the complete naked body doesn’t start until the mid to late 19th century.

We occasionally see photos of naked soldiers from WW1 and WW2 being examined. This was standard. But I would argue that there was a strict, assumed, tacit agreement that there would be no women present. The question is often asked as to why these men felt comfortable swimming nude together, or being examined naked during military inductions. I would argue it was because of this understanding that this was a male ritual that excluded women.

Now – something begins to change after WW2 and comes into being in the 1960’s. It has many sources, but I argue that it’s closely connected to what we call the “sexual revolution” and the growing feminist movement. As more women enter male occupations, as this process gets embedded in legal doctrine, that is, giving rights to the same access for women as for men – we see things change. As more women want access to these indoor pools the policy about men swimming naked changes. As gay rights becomes an issue and as more gays come out of the closet, some men show more homophobic tendencies and become less comfortable being naked around other men. As sexual abuse, predation and crimes become more publicized, people become more wary with exposing their bodies in more and more situations.

How does this relate to what we’re talking about? Before we get to medicine – we see one example with the military induction during the Vietnam War. With more women becoming doctors and joining the military, we find many anecdotal examples of naked male inductees facing female doctors and nurses. In fact, there are a significant number of anecdotes of female clerks and other non medical personal having access to these naked men. Here’s where we see the old understood, tacit, agreement breaking down. In the past, it was understood that there would be no females present for these nude male rituals. Things now change. I would argue that during WW1 and WW2, as a general rule males in the military (unless seriously wounded – again, I’m not referring to extreme examples) were not subject to intimate examinations by female doctors or nurses. I grant the exception of the USSR and some other European countries. But remember, medicine wasn’t opened to women in the early USSR because the Soviets were concerned with gender equity. I suggested more women became doctors than men because being a doctor didn’t have the social status it did in other countries. It wasn’t considered the highest, most honorable calling for men.

Combine all this with the dominance of post modern philosophy – the concept of gender doesn’t exist, it’s only a cultural construct – and we see this attitude enter the medical system. Exempting emergency situations, it wasn’t that long ago that male orderlies or nurses or doctors handled intimate procedures with male patients. Even the “older” retired nurses today will tell you that. As more women entered medicine, it was just expected that gender didn’t matter and that they would have access to males just as the male doctors over the years had had access to females. Although attitudes are changing, this world view is still significantly embedded with the medical culture. These attitudes changes that now claim gender neutrality have come relatively quickly and without an open, honest discussion which includes patients at the table.

I don’t claim this is the whole story. I’ve probably missed some important elements and movements. I present this summary, my opinion, for discussion and criticism. I believe it’s relevant to what we’re discussing here.

 
At Saturday, March 21, 2009 3:25:00 PM, Blogger Maurice Bernstein, M.D. said...

MER, thank you very much for the work you put into preparing and writing your last post. This is exactly what I want as part of a discussion of patient modesty and is in contrast with postings which make accusations of this or that group particularly without specific documentation.

As you can tell, we have really rushed though Volume 11 with now over 100 posts in less than a month. I am preparing to start Volume 12 and I would like to put MER's piece up as the Narrative portion of the new thread. MER, if there is any changes or new input you want to add before I do this please write me the additions or changes to my e-mail address: DoktorMo@aol.com . I even recently took a picture showing the separate women's and men' rest room buildings at the Santa Monica California beach which I think will be an appropriate graphic for the topic. Again, thanks. ..Maurice.

p.s.- According to my Sitemeter readings, the patient modesty threads are often the most frequently accessed thread by those visitors coming to my blog. Unfortunately for all of us regulars, those folks are generally not commenting.

 
At Saturday, March 21, 2009 9:29:00 PM, Anonymous Anonymous said...

Thanks for your posting MER. Well thought out...
leemac

 
At Saturday, March 21, 2009 10:20:00 PM, Anonymous Anonymous said...

Thank you MER for that thoughtful post. You make a lot of good points and I believe your data to be accurate. One point that I noted a few posts back was the attitude that you sometimes run into with nurses when you make a gender request. Many do get offended and don’t even bother trying. It was my opinion that this is because they had to endure for most of their lives being examined by male doctors because that was all there was. In a way, this is their payback for all those years of not having access to a female provider. I don’t believe they do this on purpose, I just think it offends them because of what they had to endure. I have found it easier to talk to the younger nurses on this subject and they don’t give it a second thought, but the few times that I’ve mentioned being covered at all times and keeping my underclothes on for a more experienced nurse, they threw the SOP book at me. It’s interesting hearing the different opinions from different age/generation groups. I guess for me though, things are looking up. Jimmy

 
At Sunday, March 22, 2009 12:45:00 AM, Anonymous Anonymous said...

Not true! There always have been
female providers and THEY have
always had a choice. It is done
on purpose and that purpose is
for their own enjoyment!
It should not be a "run in" as you have a right to decide who participates in your healthcare and
I suggest that it is unprofessional
behavior on their part not to
immediately comply with your requests as a patient.


PT

 
At Sunday, March 22, 2009 6:06:00 AM, Anonymous Anonymous said...

I always thought the female gynecologists I saw were more rude than the male gynecologists I saw. The woman gynecologists were a little scary with short demeanors and condescending attitudes about questions I would ask. I wondered why a woman would want to look at vaginas every day, were they lesbians. So I continued to see male gynecologists whenever I needed to see one, which wasn't very often. I thought if a medical doctor was seeing so many women naked they certainly weren't getting excited about one or the other. I even thought it was a gross profession to look at vaginas all day every day.
A woman who signs an ob/gynecologist surgeons "female reproductive" organ consent form for "possible cancer" has, unknowingly, just allowed a gynecologist surgeon clearance to amputate all of her healthy reproductive sex organs for profit by deceit.
Who? would ever even think gynecologists were amputating the sex organs of tens of millions of women in America with no medical basis and no cancer by deceit for profit, who?. It seems impossible, but it occurs every minute every day in America. I realize now the entire medical community is aware of the epidemic de-sexing of the American woman by deceit for profit, but stands by and watches the heinous act to protect their status as medical doctors. If the de-sexing of the American woman by deceit for profit isn't o.k. with you sign the, HERS Foundation, petition to pass a law to stop the epidemic.
The discussion on this bioethics thread makes me sick. As an artist I have drawn many male and female nude models. While drawing the nude model I viewed the model with respect and studied the naked human form as a beautiful and interesting artistic form. I would think a person with the intelligence to become a medical doctor would be viewing the human form as a human being who needed medical "care", not "checking them out".
Every thought I have ever had regarding the care and compassion of a schooled medical professional has been negated. The medical profession, as it is today, is on it's way out of fashion with the public. The public is slowly educating themselves on matters of health and things they don't understand on the internet. The public in the near future will not allow for greed, hatred, lying, bullying, abuse and iatrogenic physical maiming by cunning perverts trained in medical deception.

 
At Sunday, March 22, 2009 9:33:00 AM, Blogger Maurice Bernstein, M.D. said...

Please, please let's keep these threads on patient modesty directed to that issue and not to the specific issue of allegedly unnecessary gynecologic surgery (discussed in detail on the "Use and Abuse of Hysterectomy" threads) or to the more general concerns of physician behavior (discussed in detail on the "I Hate Doctors" thread. Also, remember to idenfiy your postings with some consistent pseudonym or initials if you want to remain anonymous. ..Maurice.

 
At Sunday, March 22, 2009 10:33:00 AM, Blogger Maurice Bernstein, M.D. said...

NOTICE: "Patient Modesty: Volume 11" is NOW CLOSED TO FURTHER COMMENTS. Please go to "Patient Modesty: Volume 12" to continue the discussion. ..Maurice.

 

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