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Patient Modesty: Volume 19
Continuing on with issues of patient bodily modesty and the inequality of patients to obtain the gender selection they desire for their healthcare providers. ..Maurice.
GRAPHIC: (6-16-2009) I switched graphics on this Volume since I found this picture through Google Image to be a more direct representation the topics being discussed than the one I initially posted. This image is from
"The Best of Gay New York" site and is licensed under
Creative Commons.NOTICE: AS OF TODAY JULY 8, 2009 "PATIENT MODESTY: VOLUME 19" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON
VOLUME 20
127 Comments:
We have a problem in this country...our doctors take matters too far.
Treating us all as that potential law suit. (and I agree with the money making comment)
I have dodged the DRE for years.
My wife is English and we visit her parents every few years.
I know these exams are not even offered in other developed countries until patients hit 50 years of age and now many countries have replaced the DRE with a blood test. The DRE only happens if the blood test shows a problem.
In this country, these things are pushed at us when we're very low risk (under 50) and this puts us off for life. The annual embarrassment builds up
I don't think people ever get "used" to these sorts of exams. It's always bad.
My wife has always refused annual gyn physicals. They are not carried out in the UK or elsewhere...so why should she start having them because our doctors say they're important?
How important can they be when they don't happen elsewhere?
My wife has no health problems at all and refuses to assume she needs checking every year. It has been harder for her to avoid in this country and made birth control a real challenge! (partly explains the trips to the UK to stock up)
Our daughter was a home birth (in the UK) with a female midwife in attendance. My wife was shocked to find our doctors insisted on lots of internal exams during the pregnancy....once again, not done elsewhere. The decision was made to relocate to London for 7 months until our child was born...so she could use more relaxed medical care.
We put patients through bad experience every year (and during pregnancy or to get birth control)when the rest of the worlds doctors don't behave that way or don't even think these things are necessary AT ALL.(let alone EVERY year!!)
My wife also found a research article (from UK)setting out all the risks of smears and that this cancer isn't a serious concern...other cancers and diseases are a MUCH bigger threat.
This brochure was produced by a women's health action group.
How can you work with a system that misleads us and has no respect for our privacy...pushing these things too early, too often or for no good reason at all.
Many of us end up having nothing checked.
Patients should only be put through these very embarrassing exams and tests if there is a VERY good reason. If they're not carried out in the UK, Australia or Europe...there is NO good reason to insist on them here!
When writing representatives about medical reform, perhaps we should emphasize recruitment of male medical staff given the current state of male unemployment and that men avoid medical care for modesty reasons. (OK, there's no research on the latter, but don't mention it to the pols. We just want to get the conversation started.)
--rsl
rsl. I had a meeting scheduled with my state rep. to discuss this very issue but it was postphoned when the state legislature went into special session. My point is exact what you are stating but approaching it from a different apect. (1) 80% of the job loss in this recession has been male (since it hit manufacturing)(2)We are paying a premium to bring nurses in from other countries (3)there is a looming catastrophic shortage of nurses (4)the provider shortage is driving up health care costs (signing bonus's etc) (5)Bringing in more male nurses will not only employee men on states employment roles but reduce over all costs and possibly have a residual benefit of encouraging men to be more proactive in their health care. I think the issue is going to be best served by getting states to encourage this through public service ads, encouraging school carreer centers, and encouraging state universities to get involved. I truely believe this is an economic issue for hospitals, it is cheaper for them to adopt an gender nuetral position than accomodate. So, I believe in addition to attacking it at the facility level both economically and PR wise, we need to get the state governments to see the dollars and cents of bringing more males into the system.
On a related note I sent a facility I recently visited a request for comment on the "female focus" of the facility including staff all female, the magazines in the waiting room (all female magazines), and a very telling item their web site. The webb site home page has a icon for "the Spirit of Women" which when you open it states like we believe women make 80% of the health decisions for the family so we have provided tools for them.......on the list of drop downs on the side they have listed Adults, women, children as catagories...notice any group missing???
I am getting fire up about contacting these people. The easy way is to use their web sites, they almost all have contact us tabs. The interesting thing is, in the past when I didn't get a reply from the web site...I followed it up with a letter and sent it to the patient advocate, PR, and hospital administrator and mentioned the no reply to the web site....you want to see someone scramble to cover their behind...let the folks who should have responded you just let the guy paying the bills know they weren't doing their job......try it, not sure how much it will actually accomplish in each case...but it tends to stir the pot a little...and it makes you feel better, not where we need to be as far as organized...but better than nothing till it happens...alan
Excellent work, Alan. These are the kinds of things we need to be doing rather than just talking about it on this blog. I would also suggest that we scour newspapers for ads from clinics that list women's health and children's health but don't list men's health.
Call them. Write them. But be careful. Most of the probably care about men's health but just haven't seen the light. Don't be aggressive. Be polite. It's a marketing ploy for them, not a personal issue. They think that women make all the health decisions for men and thus market to women. Let them know that this isn't the case for a significant number of men.
Keep up the good work, Alan, and let us know more about the results of your work.
Pg 80 of 'Professional Nursing: Concepts, Issues, and Challenges' states: "When patients enter a hospital, the traditional power relations are reversed and they find themselves vulnerable and dependent rather than strong and in control. At societal level(not every male patient will see his situation in this way)one way of redressing the balance is to metaphorically (or perhaps even practically) sexualize the encounter. This gives men power over women who have power over them. He may be frightened, anxious,and vulnerable"..."unable to walk pee or feed himself"..."and turn the nurse who has power over him into someone he can dominate,if not in reality, then in his fantasy."
If patient modesty is not high on the "ethical agenda" why do nursing manuals themselves point out how much men are being humiliated by female nurses? So much so that they would go to such legnths to block out or attempt to fantasize the experience. Also note how many times power and control are used in just one paragraph. It reads as almost a confession.
So, since the ethical question is certainly there from the very beginning, why do the nurses/techs "act" so surprised when we bring it up?
Perhaps they loose their "power and control".
alan:
If the med profession panders to women because they believe that they make 80% of in decisions, yet they they are not currently taking women seriously when they advocate for men....do you think the only way to break that cycle is to step aside and let only men advocate for themselves? Clearly women are not getting their attention.
I've often read or heard nurses talk about transference in reference to angry, hostile, or non cooperative patients. Transference is the "unconscious redirection of feelings for one person to another." The patient's frustration and powerlessness perhaps brings him/her emotionally back to a past experience, and those old feelings of anger get transferred to the nurse. I'm sure it happens.
What you never hear talked about is the reverse transference. That is, historically, nursing has not been a profession of status. Nurse have been under the direction, mostly of male doctors. Even today, the medical power structure in most hospitals is mostly male. One often reads nurses complaining of the male power structure and how they have to fight to overcome it. One wonders how often nurses transfer their frustration with the male power structures they so often have to fight toward the male (and sometimes female) patients they work with. People who feel powerless seek out power wherever it's available.Anyone under them can receive the brunt of their frustration and anger. The powerless patient may try to dominate the doctor or nurse. But that's not so easy because of the situation, the context. So they might take out their frustration on their family, or the cna or anyone they perceive with less power then they have. The same is true with nurses. They may not be able to tell a male doctor what they think of him, but unconsciously they may take that frustration out on a patient, especially a male patient.
Now, lest anyone think I'm being anti nurse, what I'm talking about is discussed in some medical texts. Earlier I quoted a British nursing text about the sociology of nursing. One of the chapters was titled "Nursing and Power." It's a valid subject, open to discussion and opinion. And every human being can be guilty of transference, patient, doctor, nurse. I just don't see this reverse transference talked about or even admitted. But I'm sure it exists.
swf, the patient must really be the one to speak up. If a wife speaks for her husband I don't think it is taken as legitimate or seriously by the healthcare team or facility. I think it is no doubt perceived as a "jealous wife". Sad to say but I think it is probably viewed that way. Now, if a husband were to speak up for his wife and demand "no cross gender" intimate care, would it be viewed as "a jealous husband?" Probably. Anyone?
Consider for a moment the indecent
exposure law, a class one misdemeanor but a class 6 felony
if to a person under 15 years of age. In my mind those who put
themselves in an intimate medical
examination when they're presence
is unnecessary are just as guilty
as if they've just exposed themselves.
After all one kind of behavior
compliments the other dosen't it,maybe you don't want to be exposed,see my point. Take for example, all the perverted female
clerks that made a point to be present during male military medical exams. They are just as guilty in my mind as some pervert out flashing children. Whats the difference? They had no business
being there and they knew it.
The physicians who conducted these exams are guilty as well. The
last time I've looked at the core
statements of a medical facility
it mentions nothing about gender
but everything about patients. Why
are male patients treated differently in regards to privacy.
PT
swf, no I don't, I think the opposite. I think a female advocating for the males in their life or otherwise sends a powerful message. Even as we continue to make progress, there still seems to be a certain amount of "war between the sexes". Perhaps there always will be to one degree or another. We tend to identify more with those who are like us, even though we may not want to. Even though we may try to be completely open, even though we may want to be completely unbiased...its really tough. That said, I think a female saying, this is unequitable about male patient treatment sends a really strong message. Its hard to see a female as self serving and biased. I think the resistance you run into probably comes from what I precieve as providers view of being in control being challenged. The fact that you are a female advocating for the males in her family makes it even harder for them to ignore....I personally think its great that you are willing to do so. When my daughters were younger and playing sports, I was struck by the inequality between the boys and girls teams. The girls had great teams, the boys were not as successful. At one point the girls were 13-1, the boys 1-15, yet they bumped the girls out of the gym for practice. When I didn't recieve a satisfactory answer I took my attorney to a school board meeting and had him explain title 13 to them and explain the ramifications if they didn't address it. The girls not only got their gym time back they got new uniforms instead of hand me downs. One of the board members said he had heard it from the mothers before...but just thought it just some women feeling sorry for themselves....and he was directing education????....I think its the same here....your voice perhaps rings louder than any males on the issue....alan
Does Hipaa go far enough to encompass privacy violations. In my mind this case screams for
justice and if you think this
is rare,think again!
www.honoluluadvertiser.com
Then search medical privacy violator at this site.
PT
I think many of us don't fit the stereotypes.
Society is usually slow to catch up - things slowly change, but it takes years before things become accepted (to some degree anyway)
I see that in so many things...women who didn't want to change their surnames when they married were initially labelled feminists and petty and the man was down trodden and weak....today, it barely gets a mention.
Having kids outside marriage was once a shameful thing....now it barely gets a mention. Many of our friends co-habited and had kids before they actually married.
No one would dare call their kids illegitimate.
Women were once ridiculed if they asked for a female doctor, "don't be silly"....and sadly, a lot of it came from OTHER WOMEN.
I see quite a few male health clinics here in Sydney. I was told they were initially opened to cater to the needs of gay men.
Many assume younger men don't need intimate care at all (and that's true for some men whose first experience may arrive much later in life with a vasectomy or urological problems)...however, STD's mean many young men now need regular intimate care. A scientist friend tells me there are many new contraceptive options opening up for men in the next 5 year...so there'll be another reason for visits.
Anal cancer is also becoming a problem for receiving gay men...apparently, caused by HPV, which also causes cervical cancer. A gay colleague told me some gay men are now having anal smears to check for this cancer.
The changes in society (later marriage, more sexual partners, one night stands, casual sex) means intimate exams are increasingly necessary for men.
Prior to the 60's, the norm was early marriage (rather than risk an unplanned pregnancy)...
Now these clinics have noticed a wider market...and expanded to take in heart health, stress tests and treatment, psychological services, depression, sports medicine, urological health, sexual dysfunction etc...
It appears there was always a need or perhaps, the change in men over the years means these services are now wanted and used...
It also seems men have just put up with modesty issues. (as women used to do)
I certainly see changes in men these days...more likely to talk about their fears and failings...issues of modesty and dignity.
In many ways, we're all fighting against the system to some degree - rarely do we conform in every way.
It may be harder, but standing up for yourself leads to healthy self-esteem.
I don't see male doctors.
I feel more comfortable with female and it's as simple as that...
Anyone who thinks I need to explain myself, falls into the category of people who thought I needed to explain all the other choices I've made in my life... they don't really bother me...in the end, we're all happier when we're being true to ourselves.
The first step for men...refusing to accept a situation that does not meet YOUR needs.
As women asked and stood firm, more and more women found the strength to do the same thing....things start to change...become more acceptable...
Now...in any sensitive area...like BreastScreen...the receptionist usually volunteers that ALL their staff are female.
Boy, have things changed in 30 years!
I think that'll happen for men as well, but be prepared for a fight and start today - refuse unacceptable treatment.
I'd start a group for like minded men - it's harder to ignore a large number of people.
Letters and meetings with senior hospital and clinic staff asking for change. Become a thorn in their side...make complaints when it's warranted...it all helps and raises awareness.
Chloe
MER I also think that nurses (and others) use the transference to declare it to be the loss of control from the ailment or injury when the truth is an issue of modesty..but it is easier to say.."no, it is just loss of control or just being a big baby".
I commend you on your taking a stance for the girls, alan.
I also think that having ladies speak up in our defence is a very good thing... despite what some may think.. I suspect that they are given a great deal of credence.
leemac
Here is the complete link to PT's referenced article:
link
..Maurice.
swf,
Women advocating for the modesty of male family members get the same short shrift that individual males get. However, a groundswell of women would get more results than a group of men, a fact of Western society today.
BTW, I find your empathy for the plight of males almost frightening...but very refreshing. Did you grow up in Atlantis?
alan,
I made an A-B-C suggestion. You created an alphabet. Great work!
--rsl
"Frankly, I do believe that patient modesty is not high on the ethical agenda."
I think that's because they can't get into legal trouble by simply not caring about modesty or the misery their patients go through. They also know that their patients will have no choice but to return to them the next time they are sick or injured, regardless of how horribly they're treated (mentally at least). Drugs like VERSED really help too.
The privacy violater mentioned by PT has an even stiffer sentence than the year in jail and 5 years probation...this conviction will bar her from manyjobs in the future...and it is not likely anyone will ever place her where any sensitive information is kept.
It is a shame that she chose to set herself up to ruin her life, but I agree with the judge that a strong message needed to be sent to those in her position. It will probably take several such repercussions to get the attention of others...
leemac
swf-chloe
excellent posts, it is great to see this. I personally find it encouraging and empowering to know that you as females see this side of the issue. I think sometimes we break this down by gender and don't realize we are really on the same side of the issue. I appreciate your comments and thoughts. I googled the reasons men do not use medical care after I read the truely disturbing post by Dr. Orrange on daily strength regarding the same topic. I think interaction pointed out how little providers really look at this issue. It is as Chloe said, up to us to take a stand and to try to organize. I would once again urge anyone who wants to join in a group effort toward that to send your e-mail address to Jimmy at medical.privacy@yahoo.com....alan
swf & MER both made good points about the issue of power. As I and others have said before, I believe that the issues of power and control are a significant factor in this discussion.
What I keep coming back to is this: The so called "power" health care providers think they have is only perceived - it isn't real. The only power they really have is that which patients choose to cede to them in the form of informed consent to treat, which can be written or verbal, depending on the situation. They must have the permission of the patient. Providers have no legal right to force any care or treatment on a patient without their consent.
What this means is that the real power is always in the hands of the patient, and we as patients need to understand that. Providers of course, don't want you to know this - which is why they cajole, browbeat, coerce, hide things in fine print, and otherwise attempt to limit or inhibit the patients' rights.
As Chloe said in her most recent post, and many of us have said in the past, patients simply need to stand up for their rights and refuse that which is unacceptable to them.
Alan,
I too applaud your efforts and second MER's comments. We need to bring this issue into the open, hopefully in as positive a manner as possible, and force them to address it. That said, I also think it needs to be done at the individual level by communicating our preferences and expectations to our PCP and other providers we deal with directly.
Case in point, I recently had an opportunity to do just this. Several months ago my PCP moved out of the area, so I eventually had to choose a new one. After reviewing those available through my HMO, I selected one and scheduled a "meet the new Doc" appointment, which was last week. My purpose was to see if our concepts of the provider/patient relationship were compatible, and I let them know that when I made the appointment (they always ask the purpose). When I met the new Doc, I politely explained what I expected - his role is to provide detailed information, recommendations and alternatives with respect to any health care issues, and mine is to use that information in conjunction with my personal values and philosophy of life to make the decisions that I feel are best for me, and that I accept full responsibility for my decisions. I asked him if he had any problem with that, because if he did I would make arrangements to select another PCP and save us both a lot of hassle down the road. He told me he had no problem with it, so we'll see how it works out.
It was actually a pleasant meeting. He asked if I had any specific concerns, and I explained that I had strong preferences and some specific concerns regarding certain aspects of my health care. We discussed them briefly, and he seemed receptive and positive.
I asked if rather than tie up his time going into too much detail right then, it would be OK if I sent him an email going into more detail, and would it also be possible to have that included in my EMR. He agreed on both counts. So if everything goes as planned, I will now have my preferences in writing as part of my EMR.
I realize it's only a baby step, but we have to start somewhere......
In trying to keep with an attempt to make my blog graphics pertinent to the topics under discussion in the least ambiguous way, today I replaced my original graphic for this Volume 19 with the image you currently see. I look at the current graphic as pertinent..but that is only my subjective opinion. As a bit of a side diversion here, I would be interested to read how my visitors interpret the graphic and whether you agree or disagree with it as being appropriate to what is being discussed. ..Maurice.
Doctor:
I find your graphic interesting, quite appropriate, and provocative. As I see it, a provider is examining a naked man. It's difficult to determine the gender of the provider because of the mask. But it's clear that the patient is male and is nude. Very interesting graphic.
MER, I thought it was interesting, particularly since it is not obvious the gender of the examiner though I would suspect it was male since I thought the hands looked like that of a man and the graphic came from a gay website. However, I think that uncertainty about the examiner's gender adds to the pertinence to the topic. Anyone else with a comment? ..Maurice.
Golly, I have one more thought on the question. Since the examiner is "all bundled up" and the gender is uncertain, that kind of makes the scenario as a patient facing an examiner of unknown gender with the anxiety of that concern which has previously been expressed here or that this is perfect example of a "gender neutral" medical care provider. (Or is that a misinterpretation of the connotation?) ..Maurice.
With the gender of the provider being so ambiguous because he/she is so "bundled up", it not only makes it fit the "gender neutral" ... it really distances the provider from the patient and leaves one feeling a total lack of control by the patient(vulnerability). This photo really takes away any feeling of the human aspect of a provider.
I am at loss as to the words to express...how much this photo made me cringe...
leemac
I just read some interesting documents about Title V11, the civil rights act of 1964 which was to help women get into jobs that they were previously banned from. Nice concept, except I think its surpassed its intended use and got us to where we are with our delima in the health care system today. Men having no choice in intimate personal gender care. Along with it I found some interesting reading on "Same Sex Privacy & the Limits of Antidiscrimination Law". Its mainly about BFOQ's and how the courts recognize weather same sex care is discrimination or not. In this article it pretty much states Customer Prefrence is not a consideration for the Hospital Administration to hire or ban staff on the basis of. If thats the case its only going to get worse. It seems like what started out to be something of a good thing for women...ended up totally discriminating against men. The other word that escapes this article is "CHOICE". Is this America?
http://www.yalelawjournal.org/pdf/112-5/kapczynskiFINAL.pdf
LJS
Regarding the graphic. We need to be honest. Some patients are more comfortable with an anonymous, gender neutral stance as show here. That's why the gloves and masks, to a significant degree, from what I've read. Distancing is an important concept. But what gets lost, I think, is that not all patients feel comfortable with this model -- and I think medicine often sees distancing, masks and covering as the answer to the modesty and embarrassment issue. Sometimes it may be an answer. But not always. As leemac has pointed out, sometimes this depersonalization makes patients quite uncomfortable. This is what I mean when I talked about doctors and nurses using strategies to deal with modesty and sexuality. The individual and context is so important. A strategy like this may work with some patients but not with all. The danger is in seeing this strategy as "the" answer to the problem -- assuming the doctor or nurse is even aware consciously that this is a problem.
I think that the mask really got to me...it came across more like a robber to me...
I have no doubt if I were in this situation I would have an extremely strong feeling..called the flight thing.....I doubt if I would even hear half of anything that was said...most uncomfortable. And this is only if the provider were male...if I could not determine gender or if it was female...this situation would not exist at all...as I would be long gone.
leemac
Respectfully:
At this point, I don't understand how we can still even argue the fact that nurses "may not be consciously aware that this is a problem". They are taught that this is a problem. They are given tools to help them do want they want to do dispite a patients humiliation and hesitation. Pretending to be surprised that this is an issue is like a phlebotomist being surprised that they have to draw blood.
MER trying to manage to have a trusting relationship and yet maintain a distance is a balancing act..I do not expect my provider to be my best friend (or even a friend) for however it sounds I do have to trust and respect him though. There would have to be some sort of relationship before I had to stand naked before a provider who was so covered up...and then there would have to be a darn good reason for the getup.
I looked at the picture again...and do not see gloves...which seems strange...I don't mind gloves, but I sure do not like the mask.
with the patient nude and the doctor all covered up..it becomes a striking difference......and does not evoke any sense of security for me......I hope I never wake up from some emergency to such a sight...I think I would freak out...and it would not be just over whatever happened to me either.
leemac
In order to understand the graphic better, I tried to see in what context it was originally presented on the gay site. As you can read on going to the site, it appears it is used in conjunction with advertising a show ("A FREE COCKTAIL,
a show
and naked men!
What more can a girl ask for?!
Tonight is BOYS NIGHT OUT at the theatre with CATCH 22.
FULL FRONTAL nudity is included,
for free at this performance")
I don't know whether this photograph is from the "show" or from some other photo source.
In any event, a doctor could be grossly dressed like this particularly if the patient had active tuberculosis for example, though the doctor should have been wearing gloves and the mask being worn is not approved for use with a communicable disease and is used only to keep the doctor's spit in his or her mouth and away from the patient. The doctor could be performing a total dermatologic survey.
The reason for my speculations is that when looking at a picture, learning the context may help the viewer understand and accept the scene. However, unless it was supposed to represent the context noted above snd the doctor's dress and patient's nudity was fully explained before hand to the patient and accepted by the patient, I would heartily agree with the views already expressed by my visitors. I wouldn't want to be that patient! ..Maurice.
Reconsidering after hearing more about the context of that graphic, I think we're just viewing a Madison Avenue stereotype. As Dr. Bernstein said, this doesn't really represent a common situation. It's an advertising campaign, a studio shot. This highlights a problem with medicine. We don't really get the "candid" shots of medical care. We can't. Privacy. Even what claims to be photojournalism or documentaries -- those are mostly set ups. Are reality TV shows really reality? After all the set ups and editing, how much "reality" really results? The intent of the graphic seems to have more to do with fetishism than with reality.
Secondly, I think it's amazing what human beings can train themselves to be unconscious of. Routines and defense mechanisms can do wonders to wipe away what we don't want to hear or see. I'm not saying doctors and nurses don't know about these things. I'm suggesting that after a while they just don't see them anymore -- unless it's pointed out. And then they actually seem surprised, at least at first. But you're right. They intuitively know about this issue.
Third, regarding that BFOP law article. Note this quote:
"The first category of cost is in evidence in the labor and delivery room cases, where men are acceptable as doctors but not as nurses. It may be that asking women (and men) to accept men as nurses causes distress, but that
distress itself simply cannot count for much when we are considering when and how to challenge discriminatory gender norms in the workplace. Where
the cost in question is a fact of changing norms about gendered employment themselves, we ought no more accept it as applied to male nurses than female flight attendants."
First, note that they are saying that gender for intimate care in medicine isn't the same as gender in more mundane areas like flight attendants. It's more personal and cost factors should not necessarily prevent patient choice.
Second, notice that the assumed position is that a male nurse working with women is problematic. But no where in the article does it say anything about female nurses working intimately with men. Still, the same principles would apply for men. Few men have ever challenged this in court.
Finally, most of the cases quoted are from prison situations. Patients are not prisoners. They have more rights than prisoners. Some of the reasoning in this article is too prison-specific.
SWF I like your candor, I agree, how could a person, and they are people long before they are providers...not know how uncomfortable at least some people will be in these situations...I think its it probably more a case of not acknowledging they recognize it more than not actually knowing it is there. If they acknowledge it they may not be able to do anything about it, and it may threaten their viablity if they have to accomodate it.
SWF and anyone else who feel so lead we are trying once again to light a spark of activism. If you would be willing to go to Dr. Shermans site the first section is an effort to make a decision on where to go to establish the basis for a united effort
Dr. Bernstein would you be willing to post a link to Dr. Shermans site I think your wish to stay nuetral as a moderator vs activist makes a lot of sense...but if you would be willing to be a conduit for those who come here and want to go further it would be very helpful....alan
Alan, I think I posted Dr.Sherman's "Medical Privacy" blog previously, though here is the link.
I have a few blog links noted in the right sided column of the blog page. I'll put a link to his blog there too.
I also think that those of you who are working to form an activist group should get your own blog or website. Getting a new blog is free on Google's Blogger.com. ..Maurice.
Lack of choices,inequality and
disparity all equal discrimination
for male patients. Ever notice how
many womens hospitals there are
in america. They are even called
womens hospitals when services are
provided for both genders. Ever
heard of a hospital for men?
What might be the core values
for such an institution, "if you
have a penis,we want to see it"
would be my guess. With females
constituting 91% of nurses they are
not the only reigning majority.
Consider the registration personel or patient representatives
as they are called. I call them clerks and they represent over 95%
female. If you are a female patient entering the emergency room
with say a gyn problem you will fly under the radar unnoticed.
For a male patient with an injury to the penis news travels
fast among these clerks. Is it
appropriate for these patient representatives to share sensitive
information among each other regarding er patients?
PT
MER
I think you are on to something..it does look like a Madison Avenue advertising sterotype...a couple of points though...this is also how many of us view and/or have experienced this same thing in real life...also..this seems to be the stereotype many providers think is ok (as Dr Bernstein has said many times..it is a lot because they have never thought about it) but even more it is the stereotype of what the general public sees as the way it is.
The context in which this photo is used on the website Dr Bernstein found it is obviously to sell tickets to thosewho wish to see the frontal nudity... and it seems to be an accepted stereotype that this always happens to males in the Doctor's office and is just the way it is....and it is used as an advertisement to those in a voyeuristic manner.(especially the touching part of the photo of a nude male)...
To me, once again, it more resembles a scene from the TV show the Twilight zone..and the doctor takes on aspects of some alien...and not necessarily in the context of all that is going on is to the good of the "patient".
PT.. a better set of core values for a Men's Hospital would be "If you have a problem we want to help" ...
SWF you make some interesting observations..and at least are forthright about stating them..thanks
leemac
MER
I believe you are right about the idea that after awhile they don't see the issue anymore. Perhaps the difference in my point of view is that they choose not to see the issue anymore. I also believe that their surprise has more to do with the fact that someone actually questioned them and perhaps even said no.
Small difference perhaps, and I wish that I could view them as more innocent as you do. It certainly would help my heart if I extended them some grace. However I can't see it as yet.
Anyway, motive is not my place to judge and probably doesn't matter in the end result of fighting for gender friendly facilities.
Mer
I agree on the core values you
mentioned,however,in the real world
core values mean nothing. I assure you if you asked every nurse or physician in every hospital of
this country if they could recite
one phrase or one statement of that
facilities core values,they would be dumbfounded.
PT
PT, you've got that right!
PT wrote: " I assure you if you asked every nurse or physician in every hospital of
this country if they could recite
one phrase or one statement of that
facilities core values,they would be dumbfounded."
I agree with you. That's why we, as patients, need to go into the hospital culture armed with the knowledge of these specific core values attached to each specific hospital. If confronted with modesty problems, we then need to do ask them if what they are doing fits in with the core values of the institution. See if they know the core values. If they don't remind them. Keep in mind that it's easy to put words like "respect" and "dignity" into philosophical statements. Rarely do we try to define those words in the contexts of what we're talking about. We often just assume that everybody knows what they mean. It's not as easy as that. I've found articles out of UK trying to define these terms in medical contexts. I haven't found them in the US.
Just because doctors and/or nurses may not know know these core values, doesn't mean they don't exist, or that patients should not know them. We all have ideals. We all often don't meet our ideals. The fact that doctors and nurses are busy is a reason but not an excuse.
But remember, none of us likes being reminded that we don't live up to our ideals. So when we confront them with this, don't always expect a pleasant experience. At best, if they're decent people, you'll embarrass them. At worst, you make them angry.
Patients need to go into these encounters with their eyes wide open, knowing the potential responses and being prepared to meet them.
The Arizona republic featured an
article last week regarding a
womens only health club. Men were
not allowed in this club so as to protect womens modesty. There was
no exercise or weight lifting
equipment, just jazzercise.
Some of the women were muslim who
would wear all their clothing during exercises as well as obese
women who wanted to work out in
privacy. What angered me was not
the disallowance of men,but rather
the concept itself.
I have my own private gym in my
home and visiting a workout club
is something I would never consider. The article actually used
the phrase,to protect their modesty. I should have clipped the
article from the newspaper and
forwarded it to some of the local
hospitals.
I'm sure many of the female nurses would have found this helpful,not that they would ever
appreciate the double-standards
against male patients,but rather
visit this facility to lose weight
as the majority of female nurses
are grossly obese. After all shouldn't they project an image of
good health to their patients.
PT
Until about 3 years ago I was a total stranger to the inside of a hospital. Since I had a hip replacement, my whole body seems to be falling apart.
I have been having problems (a gross understatement) with my bowels for about the last 2 years. I was referred to a specialist recently.
When I saw him this week, after my initial conversation with me he said he needed to undertake some initial examinations of me. He aid he would need a nurse in the room for this, I objected and said I did not want a female nurse in the room, he duly obliged very magnanimously.
He then asked how I would cope with the colonoscopy he was recommending given my reservations about female nurses. I made it clear I was VERY uncomfortable with any women being present for such an event.
He was able to request an all male team for me.
I am SO GRATEFUL I spoke up and did not just "lamb to the slaughter" go along with the "norm".
My advice for what it is worth....
Speak up, say what you want, be specific, dont give in...
They will help you if you make it clear how important to you it is....
Modesty is a good thing and should be respected. Every effort should be made to accomodate the patient. That said, modesty isn't practiced as it once was in the English-speaking countries. It has been portrayed as a now useless vestige of Victorian days. Also, I get the impression that some medical practitioners view the patient's desire for modesty as impractical.
Alice writes; "...modesty isn't practiced as it once was in the English-speaking countries. It has been portrayed as a now useless vestige of Victorian days."
I would agree that this is how the media often portrays modesty, especially male modesty. But I reject that as to the reality of how many people really feel about this. As I've pointed out, we see ourselves in our society as having transcended the prudery of the Victorian Age. This is a myth. But the media feeds us this image and we accept it. It's just a different kind of prudery we have adopted. Because there's so much pornography in our culture, we often think we're free of sexual inhibitions. We're not. Pornography is fantasy, not reality.
I would also say that there is a double vision of modesty in medicine. From the provider's point of view -- how the patient should view his or her modesty. From the provider's point of view -- how they, the provider, as a patient in reality views their personal modesty concerns. I don't believe that the general population of providers is no different regarding medical modesty as are the general population in general. I don't think medical professionals have transcended this concern any more that non medical people have.
Let me give you an example of media fantasy from an episode of Law and Order: Special Victims Unit. A man is accused of rape. He claims the woman consented. It's a he said she said situation. Both agree to an examination by a medical examiner.
Of course, the medical examiner is a woman. The female alleged victim is modestly gowned. When they show the male being examined, he walks out of a room completely naked and stands in front of the medical examiner. He appears to be not phased by this whole process -- he's not embarrassed. He seems not to care. This is how the media portrays male "modesty." If a male is shown to be truly modest in the media, he is shown to be a fool or buffoon. By the way, the episode ends with a question as to what really happened between the man and the woman.
You also write: "Also, I get the impression that some medical practitioners view the patient's desire for modesty as impractical."
I applaud your use of the word "impractical." I haven't seen that word used in the context of what we're talking about in this blog. I find it an excellent description of what's happening so much of the time. Another good word is "inefficient," with the definition of efficiency translating into money.
MER,
You posted:
"I applaud your use of the word "impractical." I haven't seen that word used in the context of what we're talking about in this blog. I find it an excellent description of what's happening so much of the time. Another good word is "inefficient," with the definition of efficiency translating into money."
Agreed. As long as we're looking at "idjectives", you could also add "inconvenient" to the list.....
gve,
Good luck getting your all male
team for the colonoscopy, I've
been lied to,twice.
If you don't get it in writing ahead of time,
they'll just tell you there was a sudden staff shortage, etc.
It happen to me. I cancelled the appointment when informed and rescheduled. I then came back
a second time expecting everything would be as promised. They didn't say a thing about it, just wheeled
me into the room with female staff waiting as if we hadn't been over this before. I was very angry but
said nothing as I needed the test done then after a week's delay from the first incident.
So expect they'll play dumb all the way. I still hate myself for going through with it. I'm sure
those techs were laughing at me behind my back all through the procedure. I'd love to have had a hidden camera recording their comments when I was under.
Part of the problem was my colo-rectal surgeon who viewed my request with a quick dismissal and told me to take it up with the facility he was sending me to.
I found this blog after that
incident(couple of years ago)
and the first thing I did was
find another colo-rectal doctor.
I should have told him why but
then I'd be blacklisted should
my new doctor ever need to
discuss my situation with the
old physician. This has happened
between doctors a couple of times.
I'm viewed as a problem patient.
It's the risk you run when you
challenge anything a doctor says.
I've never met a doctor who treated
me as an equal when involved with
my care. They know it all and it's
their way or no way.
- Avram
Not only is patient's request for modesty viewed as "impractical" it is viewed as "inefficient" (for them) and "not doable" (as I have been told - "women do it because that is who works in that area".
They have a million excuses don't they?
AWESOME gve!!! I think you've made many readers of this blog proud. There is no better way you could have done it.
Britain seems to be ahead of the U.S. in respecting their patients, although they still have a LONG way to go as well. At least you were able to talk them into a all-male medical team, that still seems to be unheard of here in America.
LG
Congrats gve. Not only have you relieved some anxiety in your own life, you've probably paved the way for others who have not been as brave as you. Hopefully your doctor considers this an eye opener.
Do any of you read the comics regularly? You may have noticed the Blonde strip from around June 15 or 16. Dagwood is a doctor's office sitting on the exam table in his boxers and t-shirt. A nurse comes in. "When is the doctor going to come? I'm freezing," he says. The nurse replies: "Well, put some clothes on." Dagwood says: "But you told me to strip down to my shorts." The nurse replies: "For heaven's sake. When are you going to stop letting women boss you around?"
Though probably quite innocently written and fitting quite well into Dagwood's character -- I thought the comic quite telling.
The patient bill of rights was created in 1998 for the purpose
of helping patients feel more
confident in the U.S. healthcare
system. In 2005,there were about
7500 hospitals nationwide. Each
hospital has its own core values
which seem to be partly derived
from the patient bill of rights.
One key aspect of the patient bill of rights states that you
have the right to considerate
respectful care. I have looked
at the core values of many facilities and the single core
value that seems to stand out
states that "treat everyone in our
diverse community with respect and dignity."
If the facilities core values
do not cover this aspect then the
patient bill of rights does. The
website for the american hospital
association is www.aha.org
Take a few moments and visit the
websites of the local hospitals in
your area. On those sites you will
find the core values for those institutions.
PT
Found this discussion by an Australian GP covering the modesty/nudity issue and intimate exams. He also did an informal survey of some other practitioners. Others will review this and come no doubt to different conclusions but a few points I found interesting:
- I note the lack of comment or criticsm on the behaviour of others which I found interesting including the Doctors own prostate exam.
- Inconsitent treatement between male and female patients. And the doctor in question being unaware of this, until pointed out.
-The belief of one specialist that if you don't have any personal items in the room, that somehow that means your behaviour in looking at patients as they undress is acceptable.
-No discussion of the value in offering patients practitioners of the same gender. Or even recognise that this might be an issue.
- No discussion that some consistent standard, especially the non GP group might be in order.
My initial "take" any way.
This is the link:
http://www.australiandoctor.com.au/news/98/0c05ab98.asp
Chris
Interesting site, Chris...
I note that one doctor commented that they had all had hospital training Where privacy was only paid lip service.... and it seems that they are trying on one level...but I did note that males concerns seemed limited to one doctors experience where he did not care..and I suppose that is supposed to represent all other males feelings as to their own nudity/exams.....at least by his reckoning.
leemac
Great article, Chris. It at least shows that these doctors have become aware of this issue. A few observations:
-- You're right. No mention of whether same gender care would influence patient comfort levels. Apparently, doctors still need enlightenment in this area.
-- Note how "incestuous" this research is. He only interviews other doctors and colleagues. No patient interviews. On one hand, some doctors say that the patient is a "partner" in the process and their concerns should be respected. Yet the research stays within the medical profession. The interest isn't really to determine how patients feel about this and what they would prefer -- the research is to determine how doctors handle situations like this. It show show insulated the medical culture can become.
-- Note the "surprise" that emerges in this article -- as if, wow, this is an issue. This is something "new" to this doctor, a whole new subject. This shows what Dr. Bernstein has been telling us. Most doctors are ignorant about patient modesty from a patient's point of view.
-- Doctors have these "strategies" they use, but they are untested strategies. Rather than successful practice, these strategies are mere habit. To find out what works and what doesn't would require significant research that would involve a variety of patients with a variety of attitudes. This hasn't been done. The doctors interviewed are making assumptions about what works from how patients react to them within this unequal power dynamic. They assume their experiences represent the truth. The context of their experience is not one where people can openly communicate on equal terms.
This is an article worth reading, and perhaps responding to, as you an do at the bottom of the link.
Yet another string on allnurses.com. The subject is "Do I have to take off my clothes?" So many nurses are disgusted at the possibility of taking their clothes off to practice and many say "I would NEVER take my clothes off for anybody but my MD or husband..." Could they possibly be more hypocritical?
http://allnurses.com/general-nursing-student/do-i-have-166223.html
My first impression from the picture was that the patient could’ve had some type of communicable disease or a dermatologic exam but I questioned why the provider wasn’t wearing gloves. In any event, as long as the patient agreed to this type of exam, I don’t see an issue with it. On Dr.Shermans site I posted a link for a Muslim modesty gown designed for women and he pointed out that in the doctor/patient relationship it is important to have that face to face to see their responses and pick up on what their thinking. I think the same can be true for the patient that can’t see the providers face. Jimmy
Dr. Bernstein:
I don't see my lengthy Friday evening posting which responded to gve over his possible
false hope for same-gender during his pending colonoscopy.
Was it too strong for you?
(Avram)
Avram and others: Don't panic :-)
I am on a weeks vacation and so there may be some delay in moderating the comments but starting today, I will try to keep the postings published on the day they were submitted. Please be patient for the next few days.
I am glad to see that some patients are making known their wishes directly to their healthcare providers. Nobody ever said that physicians have the ability to know what their patient thinks. We can only guess until we are told. ..Maurice.
Dr. Bernstein:
Hope you're having a nice vacation. Sorry for being pushy... but now that my posting has been published it appears a dozen
entries back-dated and chances that your readers know it has been post-posted are greatly diminished. Might I point out that this posting has been added for Saturday morning, June 20th. It was a message for "gve" in particular. Thanks.
- Avram
I don't know who originally mentioned this book -- My Angels Are Come by Art Stump -- but I just read it and everyone on this blog needs to read it.
It covers much of what we're talking about, from the personal experience of a man who went through prostate cancer treatment. What's important, I think, is that he is extremely observant and quite even-handed in his assessment of the hospital culture. He is able to separate the kind, caring nurses and techs who work with him from the cold, calculating administrative, financial, management of the hospital. As the title of the book suggests, he considers his nurses and techs to be angels.
A horrible experience happened to him, an invasion of privacy and dignity that is almost beyond belief. Excuse me if I use the word obtuse (meaning insensitive and stupid) to describe the people who did this to him. With his reaction, what you see is how traumatic these events can be -- I would call it post-traumatic-stress. His mind, body and spirit completely shut down while the event was happening, a survival strategy our we use to get through things like this. It reminded me of how women describe the shutting down, the out-of-body type experience they have while being raped. This man was emotional raped.
But he fought back. He complained. He wrote a letter. He didn't get a satisfactory letter from the hospital administration -- just a cliche-ridden, lip-service response. But then, he got the final word by writing his book.
I plan to post some quotes from it, but I strongly recommend that Dr. Bernstein create a special thread for responses to this book.
Frankly, I would not grant a license to any doctor or nurse or tech or cna or, especially, hospital CEO, who has not read this book. I exaggerate, of course. But that's how important this book is for the topic we're discussing.
Frankly, we're swimming in circles on this blog. Responding specifically to a book like this might help move things in a more productive direction.
There are three types of nurses
based on employment status that
you might encounter,staff, agency
and traveler. An agency nurse
might be assigned for one day to
weeks wheras a traveler usually
has a 3-month assignment.
Agency and traveler nurses are
paid by their agencies and show
no allegiance to the hospital
and as such usually have their own
agenda.They can usually be identified by their id badge which
instead of a name they are given
a number.
They often don't have the experience they claim to have and
these agencies are all too eager
to fill the ranks. In fact, an
article in the AJN (american journal of nursing) found that
from 2001 to 2005, of all
nurses that were reprimanded
for serious infractions 40% were
repeat offenders. The majority
of these were agency and traveling
nurses.
PT
MER:
I'm confused. Would a 'productive direction' to you be a letter, survey, web site, or all of the above?
And, are we all willing to work collectively, or is everyone going it alone?
I would say all of the above. And I'd be willing to work with a group collectively. I've posted some text we could send to hospitals asking that use it on their website. And I'd be willing to do some more writing and compile a bibliography of articles and books. And I don't think we're really spinning our wheels here. We're adding new information. It's a worthwhile venture as it is.
I must say that the book "My Angels Are Come" both encouraged me and made me extremely angry. Stump is quite fair but doesn't pull any punches when it comes to the violation of patient privacy rights that happen every day in hospitals.
Realistically, to solve this problem will require our own
website. It will require awareness
and education as well as legal help. We will need to reach out
to substantial numbers of people
and institutions. We will need to
enlist and encourage males to enter
nursing programs.
I have ideas on securing attorneys in every state willing to
help pro bono. I see this as a doable project taking perhaps 7 to
10 years. This project would take
on momentum considering that the
problem is driven by discrimination. We cannot change
the attitudes of those that promote
this problem,but rather change the
dynamics of the industry itself.
PT
MER:
Thanx for clarifying. Perhaps it was just me feeling as if I couldn't quite get the "read" on you. Your words are powerful and moving, but I always sensed an independant spirit.
It seems strange to me that Dr. Sherman's site is dedicated to patient activism, but I don't see any of these excellent suggestions posted there.
--rsl
Perhaps this may be a premature question, but I also wanted to ask:
It has pointed out a few times that we would need a credible organization behind us to give us the clout we would need for momentum. Now, although I have a few positive experiences, I haven't as yet found any facilities/organizations who would exactly champion the effort. Do we feel we need these type of "endorsements" before we attempt our own web site?
You guys all complain too much. So what if a woman sees your wee-wee. Do you think it makes their day to see you naked? I always say "look away".
Piffonitol
sswf ????what's up with you????
mike
To Piffonitol
In my case obviously it did
make their day as they came to
my military induction physical,
I didn't invite them!
Lets reverse the roles for
a moment, so what if men see their
wee-wee as you so eloquently
described it. Does it make our
day?
PT
piff.. How well do the nurses accomodate you when you tell them to look away???
leemac
Leave swf alone. I like his/her suggestions and passion.
"sswf ????what's up with you????"
Geez....what did I do
Piffonitol..the female will think and feel whatever she will viewing someones privates...that is not the issue though...if the female was bothered by such sights she would make a career change..it is the feelings of those who are "viewed" which are expressed here.. it is their embarrassment... the provider can change their occupation... something a patient can not... except to not recieve treatment at all. If it bothers you (the comments here) why are you coming to read and comment here?
leemac
I am back from vacation and will return to be more engaged in moderating this thread. All visitors, please remember to avoid personal criticisms of writers themselves. Instead, critique the concepts. On the other hand, visitors should be constructive in the concepts they present and not simply post comments that are designed only to distract valid discussion. ..Maurice.
This happened apparently at an
arkansas prison where a prisoner
had smeared his feces on himself
while the prison nurse gave lap
dances to the guards. The prisoner
nearly died.Go to www.cbsnews.com/
stories/2009/06/23/national/rr
Now this might make modesty issues more fair with patients,
however,I must say I haven't seen
many nurses that I'd want a lap
dance from.
PT
Piffonitol..don't think it is possible or practical to approach this issue by 'telling the female nurse to look away'.. How does one look away when they are doing a procedure such as a urinary catherization, a surgical prep, an ultrasound or any other procedure where the provider must "LOOK" in order to do the task?
Brillant.. piffonitol.
leemac,
Beware of mythological creatures known to hide out for the purpose of causing trouble....
troll: someone who posts controversial, inflammatory, irrelevant, or off-topic messages in an online community, such as an online discussion forum or chat room, with the primary intent of provoking other users into an emotional response or to generally disrupt normal on-topic discussion
They somehow get their kicks from provoking response - best solution is to completely ignore them, if you get my drift.......
ATTENTION TO MY VISITORS: I do want to read your opinions about the functioning of these Patient Modesty threads. I want the discussions here to continue to be civil but also constructive and of value. In this regard, I urge you to communicate with me but NOT by POSTING about the moderation and functioning of these threads. Please write me e-mail ( DoktorMo@aol.com). I will write you back by e-mail and I will NEVER disclose your e-mail address to anyone without your specific permission. I want to be aware of your concerns but let me know by e-mail.
The other matter I wanted your opinion is whether we should narrow the commentary on these Patient Modesty threads with a named sub-threads for example dealing with plans for group activism (or would that be necessary here in view of Dr. Sherman's blog) and, for example, MER's suggestion for review of the views within a specific book (though, to have a meaningful discussion, a number of visitors should have had access and read that book)?
As you can tell, out of my 700 topics on this blog, these Patient Modesty threads have been the most written to and now approaching 4 years old has a special life of its own. If this life is worthy of keeping healthy and productive (which I think it is), I do need your help and suggestions. ..Maurice.
For those interested, I have opened a thread on My Angels Are Come by Art Stump at MER's suggestion.
I have invited the author to comment and he has posted.
Joel, thanks for the link to your blog. With the sub-topics to patient modesty available on your blog, probably sub-topic threads here might be unnecessary. ..Maurice.
When I said "Look away" I meant "Look all you want, I don't care. Look away".
Piffonitol
PT
What are your ideas on enlisting males to join nursing?
Thanks for asking! With our lagging
economy many are looking for a career change, a better paying job
and more challenges. The U.S. is
looking to fill these jobs with
nurses from the phillipines and
Canada. Did I mention that the state of Georgia is passing a law
banning phillipino nurses.
Apparently,they haven't recieved the level of training deemed
necessary. My first idea is to
solicit the top 100 student loan
companies. Let these companies reach out to males in high schools
with such advertisements as
" Nurses can earn $100,000 as year
and its not a job for sissies."
Secondly, to write every nursing
program in the country and pose
the question, what are you doing to encourage males to enter nursing
programs?
Thirdly, to write the company
that prints the book scholarships
2009 and encourage monies for
young men to enter nursing programs.
Fourth, you always see bullitin
boards with a female nurse and the
comment,finish your bsn in three
years. Lets start advertising men
on these boards.
These represent only a few ideas
of the many that I have,however,
bear in mind that it needs to be
an agressive program which would take a number of people to prepare
drafts.
PT
PT,
Your points and suggestions on recruiting more men into the nursing profession are good ones. I believe it's pertinent to the discussion here, because if the male/female ratio improves, it significantly mitigates one of the reasons providers use to avoid accommodating same gender care requests by men.
Things are improving - we recently attended my niece's college graduation, and of the 53 BSN graduates, 9 were male, and of the 22 MSN's 4 were male.
Don't know if I've mentioned it before, but both my wife and sister are RN's (and no my niece didn't become a nurse like her mother - she wanted to be an engineer/scientist like her favorite uncle...). We've discussed these issues, and believe it or not, most nurses want to see more males in the profession and are happy to see the numbers increasing.
There is an issue with demographics - male nurses statistically do tend to gravitate towards the more intense fields of practice such as ER and ICU, as opposed to your basic med-surg. As the percentage of males in the nursing profession increases, I suspect that will level out somewhat.
I agree with the comment that male nurses tend to gravitate to fields such as the ER & ICU. They also tend to move-upward into supervisory positions thus away from direct patient care.
The numbers illustrated at the recent graduation are still very skewed, but...improving.
Soooo...if I were a female and wanted to a CNA, could I change things from the inside? Would I be part of the problem and not the solution?
That depends if you are female,are you?
PT
"So.....if I were a female"
yes
Dr B,
This question has come up on my blog. You're in a better position to answer as you work in a teaching hospital.
What percentage of patients agree to allow students or others to be present at their exams? Of this group, what percentage would you guess do this reluctantly or perhaps would refuse if they thought they could?
Joel, the two hospitals in which I participate, one (Los Angeles County-University of Southern California Medical Center) is a county hospital and generally none of the patients are private physician patients. The other teaching hospital (University Hospital) has primarily a population served by private physicians. In both hospitals, there is virtually no rejection of student physical examination. I think I mentioned this before on these threads, students come to me to request another patient when they find their assigned patient sleeping and wish not to disturb the patient. If a patient is awake and does reject the student it is explained by the patient for reasons not apparently related to modesty but to "wanting to be left alone", repeated previous student examinations or a common excuse "I'm packing my clothes to get discharged". Again, whether these responses are truly not related to physical modesty, I can't be 100 percent sure. But these are my observations. Again, virtually all patients when asked by the student who examined them for permission to have a review of a specific physical finding by a group of 5 other students usually agree. However, before the student goes to ask, we all make an evaluation of whether the ill or tired patient would tolerate further poking and examination. These observations are the same in both hospitals. By the way, all patients are informed that their decisions are voluntary. ..Maurice.
"By the way, all patients are informed that their decisions are voluntary"
But do you think that many patients believe they will have problems if they refuse, like poor service or bad bedside manner? Do they realize that their care will not change at all if they decide to refuse?
"Soooo...if I were a female and wanted to a CNA, could I change things from the inside? Would I be part of the problem and not the solution?"
Would you give every male patient a clear choice for intimate care and find a male nurse to take over for you if he chooses a male? Would you refuse to do unethical intimate care and share your opinion with others?
I somehow doubt that a CNA would have any influence with how things are done where you work. You know what control freaks the RN's and others are. Unethical methods mean nothing to most of them, and NOBODY can tell them what to do. Just a suggestion or refusal might get you fired. But if you at least tried I would have a lot of respect for you.
LG
Hexanchus:
"Don't know if I've mentioned it before, but both my wife and sister are RN's (and no my niece didn't become a nurse like her mother - she wanted to be an engineer/scientist like her favorite uncle...). We've discussed these issues, and believe it or not, most nurses want to see more males in the profession and are happy to see the numbers increasing."
When you discuss these issues with them, do they say whether it is difficult/possible to accomodate those with same gender care issues? Is it easy for them to identify the "body language" of those who are reluctant to expose themselves to opposite genders? Do they feel that they have enough options to provide the requested care mentioned above?
I would be interested to see it from their point of view as to how important these issues are.
Thanx!
I thought the visitors to this thread might be interested in a posting today from the "I Hate Doctors: Chapter 2" thread. ..Maurice.
Hello Maurice and Fellow 'Posters',
I have just graduated as a Master of Nursing/Nurse Practitioner and will be writing my state board exam in 11 days. My wife is an MD-a radiologist. She is a lovely, sweet, kind person and my best friend. However, I have been a nurse for 25 years, and have to say that I simply hate physicians who embody the archetype of same. I suspect this has to do with having had a patient's chart thrown (and hitting) my head in my first year of nursing because an orderly was late in transferring a patient to the OR. Or maybe it was when I called the responsible internist to report that one of his patients clearly had a pulmonary embolism and needed transfer to the ICU immediately (this was in my 3rd year), and he told me that I was stupid and incompetent. I circumvented his authority and she was transferred to ICU for a week's stay and returned to my floor still on a heparin drip (no worries, she survived). Or, it could have been the snap of the surgeon's fingers as he yelled 'come on girls, get with it' as we ran to scribble down his orders. In more recent years, perhaps it was the arrogance of an inexperienced and masogynist MD who I had to work with in Africa who caused my early return home. Funny enough, the MDs on our African team had telephones, internet, and a vehicle - we 'women' (RNs) had none of these and had to ask them to drive us to buy clean drinking water, never mind food, or to contact our elderly parents at home via phone.
I'm in a very awkward position - I am overcome with disgust when I think of the medical profession as a whole, yet my wife is a physician. And further, I continue to ask myself why, oh why, I have put myself through such hell as to become a Nurse Practitioner? One reason that I can think of is that this is my way of slamming that patient's chart hard, right back into the noggin of the physician who physically assaulted me - along with the long line of equally arrogant physicians with whom I had to work. Maybe it is that I need to prove my worth to my sweet and loving wife. But most of all, I think it is because I know that I am an intelligent, knowledgeable, expert RN who makes large differences in patient's lives.
Regardless of the reason, I know that I need to do some serious work in tempering my attitude. But I also must say: MOVE OVER, you MDS - we NPs have arrived!!!
HIVRN
I have almost as much respect for (male) Nps as I do doctors. I guess they think their extra few years of school make them gods.
To be honest, I would much prefer to have "HIVRN" (NP) as a caregiver than his wife (doctor).
I am not quite sure what to make of HIVRN...While I am sure (having witnessed a couple of extreme outbursts by physicians in a hospital)that there are abusive prima donas among providers(including nurses and techs) and it is most unpleasant for anyone working around them, I would hope that getting even does not spill over into how patients are going to be treated. By this , I mean I sure hope HIVRN and all other nurse practioners genuinely want to provide quality health care delivered with respect and compassion. How are they going to respond to males who have a modesty issue? I do not want to become a "living clipboard" so someone can get even with some MD.
I sincerely hope that any nurse practitioner would not treat their patients as just a means of revenge or to flatter an ego.
Recognising that such things as male modesty has all to often been ignored (largely because of ignorance of feelings...particulary males who tend to avoid situations that are embarrassing or won't speak up about how they feel)
HIVRN... I congratulate you on your accomplishment.. I hope you will, because of your experiences, have insight and compassion to go along with your diagnostic/treatment abilities.
leemac
HIVRN and Anonymous do bring up an interesting point. What I'm about to describe happens in all professions and organizations but when it occurs in hospitals the patient can be at the receiving end. I'm talking about the psychological concept of transferrence. Nurses, particularly, take the brunt of much abuse, not only from some doctors and other nurses, but also from some patients. Medical professionals talk about patient transference, how patients transfer their feelings toward the caregiver -- but they don't often talk about how they may transfer their hostile feelings toward the patients. So often nurses feel so disempowered, that I wonder if sometimes that frustration doesn't show itself in interactions with patients.
I think this ties into the modesty issue in general, and in particular into the male modesty issue. Female nurses are still often in positions where they have to deal with men in power, doctors, admins, CEO's, etc. They have no power over these men. Those who feel powerless often take power wherever they can find it. I wonder how this effects relationships between female nurses and male patients. The same could be said for male nurses and female patients.
The personal relationship dynamics between medical professionals happening in hospitals is something that ultimately affects how patients are treated. There seems to be a significant amount of stress within the hospital culture among these various professional relationships. Probably not more than in other professions.
I'd be interested in Dr. B's response to this.
MER, I can't give you an "in the trenches" full view of the interactions between the nursing staff and physicians because my life-long experience has been as internal medicine doctor, office practice, admitting my patients occasionally and making rounds on my patients without being within the hospital wards for long enough periods to observe fully. Doctors such as surgeons and other specialists, including hospitalists spend more time in the hospital and have more potential for interaction and observation.
What I can tell you, as chair of my hospital's ethics committee, is that the majority of the requests for consultation come from the nursing staff and deal with physician issues in the context of patient care. I can't recall getting a consult request from a nurse primarily because of unprofessional behavior of a doctor towards a nurse. Though I suspect some of concerns regarding the physican's patient management is provoked by the ignoring of nurses views and certain demands upon the nurse as examples. Despite their upset with the doctor, I don't see them taking it out on the patient, in fact, my observations particularly in the critical care unit is that the nurses are always speaking for the patient--truly patient advocates. But, again, I don't observe their routine interactions with the patient. This is all I can tell you. ..Maurice.
To LG
Well said to the wanna be cna
as they wouldn't change anything if
they could. Everyone knows from
state nursing board statistics that
cna's physically and sexually abuse
patients more then anyone. That being said what makes me believe
that they would be concerned about
my concerns regarding gender care.
My future certainly dosen't look too good as a nursing home patient as I'd probably get beat up by someone simply for requesting
opposite gender care.
PT
For some reason, I got a bunch of visitors today from a October 8 2007 posting on a blog “Addicted to MedBlogs” to which I had written a response to the issue at that time. What was the issue that I think might be pertinent to the present patient modesty thread? The moderator had found that Sitemeter had reported the following search words from one of the visitors:
“If a patient doesn’t pull his pants down, what does the doctor do”
My response was:
“If the patient doesn't pull his pants down and it is necessary to examine properly and thoroughly the patient behind the pants, the issue is one of miscommunication between the doctor and patient. The doctor hasn't first fully explained the necessity in terms the patient can understand (so as to get "informed consent"). The patient hasn't first communicated with the doctor about the patient's own issues regarding modesty and if those who are interested want to come to my bioethics discussion thread on patient modesty will find many examples of the various issues within the hundreds of comments.
"What does the doctor do?" Take a little of the precious time and talk to the patient. ..Maurice.
The totally innocent response by Dr B is I think telling.
Until Doctors stop calling us patients and instead start referring to us as CUSTOMERS, NOTHING will change
LG
Thank you for your words. The question came from an arguement my husband and I had. I NO LONGER wanted to be part of the CNA program and I felt I would do more harm than good. He WANTED me to because he believed I could have tried to make a difference.
Sadly, I still believe I am right.
PT
I'm not a perv after all, but your comments did help to show him that I was right and he was wrong.
I would reject the analogy between doctor-patient and market store manager-customer. There is a little more in the issue of trust and responsibility involved in the relationship between doctor and patient. Yes, over the years there has been more in the way of autonomy given to patients decisions but it is still the doctor who makes the diagnosis and it is the doctor who offers the treatment options. It is the doctor to whom society has given the privilege to examine, to operate and to dispense certain drugs to the patient.
Yes, when speaking about the basis for the utilization and cost of healthcare, the patient is the consumer but in the doctor-patient relationship, this consumer is not simply a customer. ..Maurice.
If I go to a garage and have a problem with my car, it is the mechanic who diagnosis the problem and offers resolution options. He does not patronise me by calling me his "patient", he deals with me as I am, namely his customer.
Any difference between this and doctor/customer relations is primarily in the head of the doctor.
The sooner customers start to speak up and get the physician to accept the dynamics of the relationship is not one of intelligencia addressing retards, the better.
Whilst I take Doctor B's comments that there is a difference between a Doctor relationship and say a store manager and their customer, there are a couple of points I would ad.
Firstly I can think of other professions where the knowledge of the professional is much superior to the customer, yet it is still a customer relationship. (EG Pilots that Doctor B has previously mentioned).
Secondly, the term patient is also about relative power implicit in that term. Its something like "be patient and compliant whilst we do what we do to you what we think is best". I have written about this before, but in my experience I have found considerable resentment when a patient actually wants to participate fully in the decsion making.For example, when I do some research on various papers that outline different approaches to surgery and question the doctor as to the proposed approach. Frankly I think that doctors are going to have to recognise that there "patients" will increasingly actually want to be involved in a true partnership around medical options.So perhaps a little bit of "customer service" and the relationsip that that term implies, would be good for all parties.
Chris
But gve, a car, a refrigerator, a toilet, a TV set..they are all OBJECTS and, of course, they are not patients and yes, their owners are customers. A person going to the doctor is a SUBJECT and therefore is called a patient. And yes, one of the important big points we try to make in teaching medical students is that their patients are not objects. As I have noted on other threads, identifying a patient as "the gall bladder case in room 212" is non-humanistic and unfairly treats a patient as an object. This distinction between an object vs a subject is a concept both medical students and the public should be made aware when thinking out relationships in medical practice.
Gve, perhaps all the concerns expressed on these modesty threads stem from physicians and patients failing to recognize the difference. If the patient considers themselves an object they are less likely to step forward and express to the doctor their own feelings and personal desires. If the doctor simply looks at the patient as an object, they will not listen to nor care for the patient's expression of their feelings or personal desires.
I say, don't fret over the word "patient", disregard the word "customer" but remember when dealing with a physician you are a subject and no object. Got it? ..Maurice.
Back in the day patients were called patients. Thanks to all these medical shows I suppose and
perhaps a little consumer activism
the word patient then gravitated
towards client. I never liked that
word client, it makes me feel like
I'm visiting an attorney and am
about to get screwed,which is what
attorneys like to do to you.
I'd always prefer to be called a
patient rather than a customer in
that patients are to enter into a
mutual agreement to solve your medical problem, a partnership if you will.
That customer notation to me is
simply to drop your money for a
product and send you on your merry
way. Patients these days are little more medical savy more so than they were 30 or 40 years ago.
Their expectations are more and
tend to dictate the direction they
want their care to go. We see that more often as in end of life
directives and other avenues. Our
care these days it seems are
dictated more by the interests of insurance companies as well.
PT
Dr B, you are no doubt correct in stating a patient is a subject (or suppose to be) rather than an object. However, from my experience I was treated like a piece of meat and an object.
Sorry. Your definition is how it is suppose to be but not how it IS.
JW
Dare I suggest, Doctor B., that a patient is both a subject and an object. The doctor's skill and talent rests is knowing how to humanistically balance the two concepts. The patient's skill and talent rests in knowing when to surrender control and voluntarily become an object to be worked on.
I say "dare I," because I cannot step into a doctor's shoes. But on earlier posts I wrote about the sociologist E. Goffman's theories about game playing and how it relates to intimate medical exams. Most of the writing has been done in terms of female exams.
Act 1 -- (Scene 1) You enter the doctor's office. You meet the receptionist. You're a person, a subject, and treated a such. Small talk happens. Laughter, perhaps.
(Scene 2) You're led down the hall to the exam room. You're still a person. There may be some chatting with the nurse as your vitals are taken, but your transformation to object begins. The nurse gives you a gown and asks you to undress. She leaves the room
(Scene 3) You're naked under the gown. The doctor enters. Some chatting, friendly, hows the family, etc. You're asked to get on the exam table and we go into the next act.
Act 2 -- How this happens depends on individual doctors. Some are able to maintain the subject/object split with a balance toward the subject. Others do not, and, although you're not told directly, your role as patient has been assigned. You're supposed to be a object. the little play begins. If this is the first time for you, it's strange because a little drama is taking place around you and you don't know your lines. You've not even read the script. During Act 2, certain kinds talk are usually not accepted. No chatting about family and friends. Depending upon the procedure or exam, the doctor may need to really focus on what he/she is doing and may need to concentrate. If you start chatting or bring up certain subjects, you may break the wall established by this game and cause people to be embarrassed. As I said, some doctors can handle this better than others to make the patient still feel as much subject as object.
Act 3 (Scene 1) The exam is over. You're asked to get dressed as the doctor leaves the room. You get dressed. Soon the doctor returns, and the consult takes place either in the exam room, or even better, in the doctor's office.
(Scene 2) You're in the doctor's office. You and the doctor are both dressed. You're a person, a subject again, and the conversation is about the results of your exam, and maybe some small talk about friends and family.
When you go to strange hospitals and deal with strangers, often personal relationships don't develop right away. Often the "person," subject stage is either skipped or pretended to happen. The patient is thrust right into the object stage.
Anyway, just a theory that's been written about by sociologists. Any thoughts.
I think that the distinction between " subject and object" is OK as far as it goes, but I did a quick google on "subject" and came up with the following:
subject /sub•ject/ (sub-jekt´) to cause to undergo or submit to; to render subservient.
________________________________________
subject /sub•ject/ (sub´jekt)
1. a person or animal subjected to treatment, observation, or experiment.
2. a body for dissection.
Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.
________________________________________
subject
an animal subjected to treatment, observation or experiment.
________________________________________
subject contrast
the difference in relative densities within the subject as distinct from the differences between the subject and the surroundings.
Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc. All rights reserved
________________________________________
subject
Clinical research A person being studied. See Human subject Medtalk → Vox populi Person.
McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.
Now I know the above aren't necessarily the absolute definition, but it seems to be in using "subject" in a medical situation we are still in real danger of putting the patient in clearly a "subservient" position.
Chris
hhmmm Considering how customers get treated so much of the time... and considering that the doctor/patient relationship is one that is like no other... I think I far and away prefer to term patient.
If I ever hear a practitioner refer to patients as customers... I will know that no relationship exists... and that I would do as well to go to a five and dime (guess they are dollar stores now) for medical advice and treatment.
leemac
Chris, of course the patient as a person is the subject. And yes, the patient as a subject is subjected to the examination--not the physician. But the patient is not an object, simply a vitally inert body (like a table) to be manipulated. A table doesn't respond to the actions of the carpenter, a patient is expected to respond unless deceased.
In clinical research, subject vs object differential is also an important difference to keep in mind. It can be easy for the researcher to look at the human subjects of the experiment as objects (data points) of the study and yet these volunteers are not simply statistics to be manipulated to form a statistically significant outcome. They are subjects and always need to be considered by the researchers as such. And don't believe it isn't easy to look at and treat thousands of subjects in a big study as objects. One has to stop and be aware that each one of those thousands of volunteers are individual persona with their own history,values and goals..subjects. ..Maurice.
MER, in a way the examination or procedure process you describe is realistic but most often there is enough interaction between the human doctor and the human patient to maintain the status of the patient as a subject.
I can tell you where there is a great potential for the patient to appear to the physician and others as an object. That occurs in the operating room when the patient is fully draped and only the operative site and surgical wound is visible to those at the table. There can be, in such a situation, a loss of awareness by the staff that the body on the table is a subject and it is only by communication with the anesthesiologist (who sees that the body on the table is a person and is constantly observing that the body is alive and functioning) that the surgeon can stay aware he or she is not operating on an object.
Any surgeons in the audience to comment on this point? ..Maurice.
"I wonder how this effects relationships between female nurses and male patients. The same could be said for male nurses and female patients."
I think this happens much more often with women nurses/male patients not only for the obvious fact that 92% of nurses are women but also because male nurses seem to be kept on such a short leash. Male nurses know that one simple mistake or misunderstanding with a female patient and their career could be over. Female nurses on the other hand know that they can get away with just about anything.
LG
Dr. B said "in the doctor-patient relationship, this consumer is not simply a customer." I'm sure to many doctors this is true, and I have a lot of respect for doctors that really care about their patients' mental health along with their physical health.
But so often the patient makes it clear to the doctor that he/she isn't the least bit comfortable with opposite gender support staff performing or observing intimate exams or procedures and the doctor doesn't seem to care at all and just ignores what they say. They seem to think it's not worth their precious time to arrange for same-gender care and it's not important enough to care about. Doctors often give the impression that the patient is already lucky enough that he or she (the doctor) took time out of their busy schedule to see them and what happens with the support staff after they leave is out of their control and none of their concern. Apparently in situations like that the nurses are in charge and the doctors have no say in the matter.
That doesn't sound like a very healthy doctor-patient relationship to me.
Anon
To the "wanna be cna",
I'm grateful you want to be able to help the modesty issue from the inside, it's nice to know that someone on the inside actually cares. Even though you may not be able to change much the fact that you understand the issue could help at least a few people under your personal care have a better experience. Even if you don't have the power to switch patients with a male nurse if requested, there are still many things you can do to make it a better experience for a few shy male patients. Simple things like turning your head while he pees in a bucket or while he washes his own private parts can make a big difference to many patients. It would to me.
It would be a shame to see someone that actually cares about male modesty drop out of nursing school. Sorry, but I have to agree with your husband, special people like you don't come along very often. Your nursing supervisors may not like your campassion and understanding but I guarentee that a lot of your patients would.
I repeat, you may not be able to change any SOPs from the inside but you can make it a better experience for patients under your direct care. You may also be able to influence other CNAs you work with and help them to understand the issue. I hope you do.
DG
Another site that was mentioned here earlier seems to be improving and I like what I see. You should check it out again. It's still pretty small but seems to be expanding.
http://patientmodesty.org/index.aspx
I'm a bit suspicious of that new site on patient modesty. They still haven't constructed the page "About us," so we don't know who's behind this. Those of you on this blog, consider: What gives this blog credibility is that we know who's behind it and we know his credentials. Until I know who's behind that new site I won't take it too seriously.
First, I agree with those who say that it is the nurses/techs that patients have to deal with before and after the doctor comes through to see you.. and the doctors do not have the time/desire to run their offices in many cases....they delegate and if you do not like what the nurse/tech says, you have to take it up with him/her or the office manager most of the time.
Second, to the lady who was considering becoming a cna.. the change must come from both within and without.. it just depends on how diplomatic and tenacious you are as to the response you would get from bosses and co-workers.. I encourage you to go for it...but be prepared as it may not be an easy thing for you.
Again, I am not buying groceries nor am I getting my car fixed..when I go to a health practioner.. but I know if they call me a customer.. that I will be treated just like a number or a sack of beans... my innards are not some engine or transmission nor am I some produce to be thumped and picked over for my "ripeness".... if I do not qualify for patient status...I am gone.. a patient is a living human being.. the semantics of subject and object don't quite convey that concept very well.. I am a living human being with an enlarged prostate.. not a prostate that grew legs... or was towed in by the tow truck.. and my prostate is not a watermellon ya thump to see if you want to buy it.. the same thing goes for all of the rest of me..Including my feelings .. such as modesty issues.. or what I consider to be dignity in my treatments ... even to what I consider to be a dignified life.. and a dignified death.. you can toss my carcass in a ditch and kick the bank down over me after I die... I don't care, but while I am alive.. I am both and yet neither..subject/object..I am a patient.. a person.
leemac
MER, I almost thought it was one of my visitors who was behind that referred patient modesty website. Of course, I went there to look around before allowing the link to be published on my blog. It still looks to be in a developmental stage. It seems to be giving advice to male and female healthcare providers but doesn't represent, in my view, a truly activistic group endeavor (The WorldWide Association of Patients For HealthCare Provider Gender Selection: WWAPHPGS) which is what I have felt was necessary to carry out change. ..Maurice. p.s.- the title of the organization obviously can be changed. I just quickly thought one up! In fact, to get started on an organization, why not (for the final comments on this Volume 19) begin deciding on an appropriate title for that organization.
Any naming of an activistic group or is it first necessary to set the goal and approaches to meet that goal? ..Maurice.
Perhaps setting the goal and listing the approaches...a mission statement and list of ways to achieve the goal(s) will make coming up with a fitting name easier.
leemac
Dr. Bernstein,
On 5 July you stated "It is the doctor to whom society has given the privilege to examine, to operate and to dispense certain drugs to the patient."
I have to disagree. What society grants to doctors is a "license" to practice medicine. It falls into the category of "professional license" which includes, among others, doctors, nurses, attorneys, engineers and CPAs. It's issuance is based on the individual's ability to demonstrate a combination of required education and adequate knowledge of and practical competence in the specific discipline.
By contrast, a privilege is a special entitlement or immunity granted by a government or other authority to a restricted group, either by birth or on a conditional basis. In a broader sense, 'privilege' can refer to special powers or 'de facto' immunities held as a consequence of political power or wealth. One of the objectives of the French Revolution was the abolition of privilege - the removal of separate laws for different social classes (nobility, clergy and ordinary people), and instead subjecting everyone to the same common law.
The bottom line is that physicians are no different that any other licensed professional - they are a service provider. And while I agree that there are perceived semantic differences, the terms patient, client and customer are technically synonymous.
Further, except in very limited specific circumstances, the physician must have the consent/permission of the patient before they can provide treatment, and can only treat within the limits set by the patient.
SWF,
On 3 July you posted "When you discuss these issues with them, do they say whether it is difficult/possible to accommodate those with same gender care issues? Is it easy for them to identify the "body language" of those who are reluctant to expose themselves to opposite genders? Do they feel that they have enough options to provide the requested care mentioned above?"
Sorry for the delay in responding - was off TDY again....
Fair questions - the short answer to all three is "usually, yes". Now I need to qualify that with a little background - both my wife's and sister's areas of specialization are in woman's health. They both graduated from the same BSN program in the early 80's and were hired directly out of school into the high risk L&D unit of a local hospital. My sister's entire career has been in OB/GYN, and while my wife's has a little more variety, the majority of her experience is in areas related to woman's health.
That said, let's take the questions one at a time:
1. Can they usually accommodate? - yes, but it hasn't always been that way. The increase in the number of female physicians made a huge difference.
2. Is it easy to identify the body language of the patient when they are reluctant to expose themselves to opposite gender caregivers? - usually it is now, but wasn't always early on. It truly only comes with experience.
3. Do they feel they have enough options available to accommodate requests? - pretty much the same answer as question 1 - today yes, but it wasn't always that way.
Both think that there needs to be more gender diversity in nursing and are strongly in favor of significantly increasing the number of men in the nursing profession. Why? Because they've been around it long enough to have seen both sides, and feel that men deserve the same options as women.
N.O.T.A.G.A.I.N.
NATIONAL
ORGANIZATION
TEACHING
AGAINST
GENDER
ASSUMPTIONS
INVOLVING
NURSING
NOTICE: AS OF TODAY JULY 8, 2009 "PATIENT MODESTY: VOLUME 19" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 20.
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