Bioethics Discussion Blog: February 2009





Saturday, February 28, 2009

It’s Here, the Feminization of Medicine: Good or Bad?

Susan P. Phillips, MD, MSc, CCFP; Emily B. Austin, MSc writing a Commentary in the February 25, 2009 issue of the Journal of the American Medical Association titled “The Feminization of Medicine and Population Health” (not available online without subscription) describe the current physician gender relationships and generalist to specialist relationships in medical care specifically with regard into what area of medicine graduating female medical students go and how they perform in their medical work. After describing the details, the authors write in conclusion:

“Although physician density is not a determinant of health outcomes, a greater proportion of generalists to specialists among those same physicians is associated with increased longevity of the population. Because women across time and place tend to become primary care physicians, the feminization of medicine may well have beneficial health outcomes possibly attributable to the nature of the care they provide irrespective of women's lower volume output relative to that of men. Such an improvement in outcomes may occur because of the practice styles of women, who outnumber men in primary care, or because of the nature of generalism. Either way, as women increasingly enter medicine and become generalists, rather than being a liability by not working excessively long hours or abandoning parenting, the quality of the care they provide may result in improved population health.”

If the studies described in the article and assumptions are correct, it would appear that the feminization of medicine which is certainly currently becoming more and more a reality is to the benefit of society. What do you think? The authors, both women, would answer my thread title with the word “good”. ..Maurice.

Graphic: Photograph of Elizabeth Blackwell (from Wikipedia)(February 3, 1821 – May 31, 1910) who was the first woman doctor in the United States. She was the first woman to graduate from medical school (M.D.), a pioneer in educating women in medicine, and was prominent in the emerging women's rights movement.

Tuesday, February 24, 2009

Patient Modesty: Volume 10

Here we go..on to Volume 10 on the subject of patient physical modesty. To aid in the transition from Volume 9, I will copy below my selection of some of the most recent comments. ..Maurice.

At Tuesday, February 24, 2009 3:09:00 AM, Anonymous Anonymous said...

Alan, I accept your admonishment for my making an extreme argument on cost-sharing. I was of course just raising the issue of the cost of responding to gender-based modesty.

Here's where I was partially coming from. Since joining this blog, I've done a kind of informal survey. It wasn't scientific, but I was careful always to formulate two questions in the same way. The first was, "Do you have a preference whether doctors or nurses are male or female?" The second was, "Do you feel uncomfortable in terms of modesty depending on whether doctors or nurses are male or female?"

I asked my mother what she thought her close group of women friends (65-85 yrs old) would feel. She said they probably preferred doctors to be men and nurses women because that's what they have always been used to, but male nurses "are like mini-doctors" and more women in general is good. I asked my Dad and his tennis foursome (same age range) and they all agreed they preferred male doctors and had modesty issues with both female nurses and doctors. I mentioned to my university class (ethnic and gender mix 20-26 yrs old) that I'd be participating here and asked the same question. Overall, they said it didn't matter at all. A couple of the young men, however, indicated they were more comfortable with both women doctors and nurses. Randomly asking maybe a dozen friends (ethnic mix of 30-48 yr olds and among them only one other naturist), the consensus was no preference or modesty problem. One Danish friend said he sought out female doctors because "they usually had to be twice as good to get into med school." A friend from Chile commented that she suspected it probably varies among hispanics depending on whether they come from the city or countryside. An Egyptian-American friend admitted that he thought he might have issues when he and his wife some time ago switched to a female doctor, but he was very happy, and it helped with his mom who "can't cope with any male medical care."

All this made me think that maybe "modesty issues" with regard to the gender of medical staff is both age-driven and actually more problematic for men. The older women, even those with a preference for male doctors, don't seem to have a problem with increasing numbers of women in medicine. Young people of both genders seem largely gender-blind at the doctor's office. In-between, women seem used to the male medical contingent (worries about sex-crazed anesthesiologists aside) but welcome more women. Does it make sense, then, to think the hump of the modesty problem is with older men who are still dealing with conflicting images of women's social and professional roles? If so, this might help medical staff be more alert, and it might help with short- and long-term staff resource planning.

(PT, I think we are trying to understand here is patient feelings and perceptions so that health care personnel are clear what constitutes "unprofessional behavior" with regard to "modesty." As Dr M has pointed out over on the clothesfreeforum, medical staff in principle get an enormous amount of training about proper conduct.) (CSM)

At Tuesday, February 24, 2009 8:48:00 AM, Anonymous Anonymous said...

CSM, I didn't mean to admonish you personally. I do agree with you on many of your observations. While I think the younger generation as a whole are less modest, I know from conversations in my office and among friends the modesty issue is still there. It also has some regional influence. Being from the midwest I would suggest we are more conservative and would have a different view than Calif. I don't have conflicting images of female physicians or nurses, for any procedure other than those requiring exposure I have no preference. It isn't that they are Doctors that I have concern with at all. I have two daughters and want them to be what ever they want...we have an office that has been together for over 10 years and have become very open over those years....the topic came up one day that a new Dr. (female) gyn had come to town, the vast majority of women from late 20's-50's all talked about trying her out and were glad to have the choice of a woman not only for themselves,,,,but for their daughters. I also know at a family get together they were teasing a nephew about his physical...he went to his family Dr. (male) only to find out he was on an emergency and the female NP did the physical...all of the nephews (16-25) winched and said they would have rescheduled when he talked about the hernia and that is a pretty small group...but I think it is preobably indicative of the area I live in...the interesting thing,,,very few studies seem to exist in this area...not so sure there is a norm...but I have to agree with your observation that it varies by age, gender, ethnic make up, region, religion...all sorts of things play into my question is why not err on the side of modesty, and allow those to opt out if they so choose...the cost has to be wieghed against the old "dying of embaressment" issue...the fact that the government ran a campeign "real men wear gowns" would make you think there is some recognition of the issue at the upper levels.....and CSM sorry if I came off to critical...didn't mean it that way.....alan (responding to Tues Feb 24)

At Tuesday, February 24, 2009 2:13:00 PM, Blogger MER said...


Perhaps your informal survey does indicate some trends. It's hard to say. But let me toss this out.

First of all, I don't think we can assume the word "modesty" means the same thing for everyone.

So asking people whether the feel unfortable in terms of "modesty" depending upon the gender of the provider -- may or may not produce a valid answer. If the questions were to be more specific relative to observation during a shower, shaving or an exam of the genitles, prostate exam -- then maybe you'd get specific responses to specific situations.

Secondly, perhaps one reason for the difference in attitude between older men and younger men -- if there is, indeed, a difference:

Most younger men have had little experience with intimate exams and procedures (excepting perhaps physicals)or long-term hospitalization. Thus, many of them are dealing mostly on theory, i.e. how do you "think" you would feel. There's a big difference between "thinking" about how you would feel and actually facing the reality of it. It's only when men get older, in their 50's and 60's, when then start having prostate and other problems that might need intimate exams and procedures. There are exceptions to this, but they are the exceptions.

Thirdly, that fact that this gender issue is so far under the radar in both medicine and the general public, shows how uncomfortable we all are with it.

Go to various radiology websites and look under various intimate kinds of procedures and exams. See what they say about embarrassment and/or the gender of the technician.

You'll find nothing. The silence is deafening. It's as if the problem doesn't exist.

This is true for other medical websites that deal with all kinds of intimate procedures. They'll explain the procedure in detail. In some cases they'll say there's no or little discomfort (meaning physical), that't it's "fast and easy" (from their point if view), etc.

Then, talk with patients about these procedures and see what they have to day and listen to their experiences.

When subjects like this are hidden away, it doesn't mean they don't exist or they're not a problem It more likely indicates they are problems that people don't want to face.

So -- I appreciate your survey. But what I'd like to see are exit surveys -- surveys done with patients as they leave the hospital asking them specific quesitons, some like the one's your asking, and other more realistic ones. Questions not about how they "think" they feel about things, but questions about how they actual "felt" about how things were done and whether they would have asked for same gender care if it had been offered and/or was available.

At Tuesday, February 24, 2009 4:39:00 PM, Anonymous Anonymous said...

My reply is if gender is not an issue for most why are female gyns busier than male gyns and why are male medical students refused more often than female students the opportunity to practise on real patients more so than ever before?
See these two articles: and
Clearly these show that there is a growing preference for same sex care for intimate issues.

At Tuesday, February 24, 2009 5:28:00 PM, Anonymous Anonymous said...

An interesting thing is that many of the facilities make no effort to address it on the front end, however will address it or accomodate when asked, I recently had some back and forth with a facility that was very supportive of acknowledging and offering to accomodate AFTER I asked, they indicated it was a valid concern and not the 1st time the issue had been brought up. I think it indicates more of an awareness than we might think, but they are not going to intiate the effort becasue of the "burden" it would put on them. We have discussed numerous reasons the fact that they take act as if it is about them (I have done this...) etc. CSM I intend to visit the site and appreciate hearing all sorts of perspectives......the one we seem to be missing is the professionals...I would assume some have visited...but whether they don't want to be confronted about it or the tone of confrontation....we don't get much from them...that would truely add to this....alan

At Tuesday, February 24, 2009 7:12:00 PM, Anonymous Anonymous said...

Dear CSM

In reference to Dr M's comments
that medical staff get in principle
an enormous amout of training about
proper conduct holds very little
Consider the analogy, most know
the dangers of running red lights
yet even the most seasoned drivers
do it.


At Tuesday, February 24, 2009 8:11:00 PM, Blogger Maurice Bernstein, M.D. said...

LH, two excellent links. Thank you.

New York Times article

Student British Medical Journal article

I hope all my visitors take a look at both. They certainly add to the discussion on this thread. ..Maurice.

At Tuesday, February 24, 2009 8:31:00 PM, Anonymous Anonymous said...

Back in 2007, there was a link posted on this blog which indicated the "gold standard" in gender sensitive care. The page is still online:

Let me quote some of it here.

"A Gender Sensitive Exam is an
examination that involves touching and/or inserting an instrument into a body cavity by a technologist or radiologist of the opposite sex...

No matter what exam you are scheduled for, everyone has the choice to request a same sex
technologist to perform the exam. If the same sex technologist is not available in a timely manner,
you have the following options:"

The hospital is in Toronto
but the text adds that "technologists... are registered under provincial Canadian and American governing

Hope this helps show what can be done.


At Tuesday, February 24, 2009 8:52:00 PM, Anonymous Anonymous said...

Dr. Bernstein:

The New York Times article on
the rights of the male OB-GYN
physician misses the point as
to why such discrimination is
allowed. It's not that women
feel more comfortable with women
doctors. That would be like
claiming a legal position
exists in that white people
feel more comfortable associating
with white people.

The legal position is that the
BFOQ provisions of the 1964
Anti-Discrimination Act allow for
discrimination in hiring when the
patient makes a request for
privacy LINKED TO MODESTY. These
female patients are actually voicing that position when they talk about their comfort level.
That's totally within their rights. The issue immediately

I once asked a constitutional
law professor how this position
can be maintained. He said it
is only maintained for the
same reason the "whites only"
position was the rule throughout
institutions in the south at one

At Tuesday, February 24, 2009 9:27:00 PM, Anonymous Anonymous said...

"The Hand That Rocks The Cradle don’t help to dispel the idea that some male doctors have something other than a mere clinical interest in the female genitalia."
So they are saying that it never is the case? So what do we make of all the sexual misconduct cases?

Graphic: From, an illustration from a book "The People's Common Sense Medical Advisor or, in Plain English, Medicine Simplified" by R.V. Pierce, M.D.
"Carefully Revised by the Author, assisted by his full Staff of Associate Specialists in Medicine and Surgery, the Faculty of the Invalids' Hotel and Surgical Institute." January 1895.

To me, it is interesting that the illustration seemingly showed no concern for depiction of a enlarged, pathologically filled man's scrotum and yet demonstrated modisty by not allowing the reader to see what would have been a normal penis under the leaf.

The text within the illustration was present as the description of the illustration in the original book. I added color to the original illustration for emphasis using ArtRage.

NOTICE: This Volume 10 is now closed for further comments. Continue the discussion on "Patient Modesty: Volume 11". ..Maurice.

Monday, February 23, 2009

Medical Care System in the United States: Looking at the Road Ahead

What is happening to the medical care system in the United States? And what is going to happen to it in the road ahead? This topic is currently being discussed on a bioethics listserv to which I subscribe. An ethicist wrote there a very succinct description of what is happening and perhaps what to expect. With the permission of the ethicist, I am reproducing it here. I do look forward for President Obama to come up with plans for a better healthcare system for all patients including their healthcare providers. However, personally, I think it will take more than just to put all medical records on computers. And, you know, as the ethicist implies, there should be “widespread ground-level discussions between individual patients and their (vanishing) primary care physicians about the concrete ends of medicine as applied to them. “ What is it that can be done for the patient but also what should be done within the limitations of any system? What do you think? ..Maurice.

Truth is, as professional organizations such as [American College of Physicians] have observed, the morale of primary care docs and the supply of same is low. There is an entire boomer generation of MDs that are counting their shekels in anticipation of exiting the system were they to take an economic hit with the introduction of more "reform." The current generation of trainees, weaned on the requirements of limited work-hours, are encouraged to understand their vocation as shift-work. The didactic model of trainees actually seeing and dealing with the consequences of their therapeutic intervention has, accordingly, been gutted. The "mistakes" avoided by the absence of adequate sleep are just being kicked down the road, giving rise to a generation of attendings who never learned from said "mistakes," not being around to see them, and not being required to own them, thus creating a generation of attendings who commit mistakes without any awareness or responsibility for same.

The old model of a primary care physician who sees their patients in the clinic and in the hospital is increasingly rare with the segregation of duties into "hospitalist" and "clinic doc" is on life-support. The idea that "extenders" will solve this problem is folly: Extenders will simply shift the delegation of duties to individuals with less training, less experience, less oversight and less responsibility than MDs.

"Preventive medicine," for all its virtues, won't fix this problem, just kick it down the road. [For example, in the field of nephrology], the vast uptick in the number of prevalent dialysis patients can be attributed to the success of preventive medicine: Since the vast majority of patients with chronic kidney disease (CKD)(but not end-stage disease) die from cardiovascular complications before they reach end-stage, interventions which permit people with CKD to survive their (previously fatal) MI or CVA permits more people to live long enough for their kidneys to fail. Such are the wages of success.

Anyone enamored of the virtues of socialized medicine should closely examine the economics of end-stage renal disease,ESRD being the only disease category with a fully-funded entitlement under Medicare, cost the government $22.7 billion in 2006. In context, 0.6% of Medicare beneficiaries consumes 6% of the entire Medicare budget. (Private payers account for another $12 billion annually). These are sick patients, progressively older (wages of success again), with a panoply of medical problems which require a competent and attentive internist to manage (correct drug-dosing in this population alone is worthy of a graduate course). By all means, this entitlement has meant that hundreds of thousands of our fellow citizens are above ground rather than below, but not cheaply.

The ESRD model reveals a truth about the economics of health care: "Health" is a bottomless well, economically speaking. Draconian top-down line-drawing will have unintended but often forseeable consequences, and the affected players will unsentimentally shift their positions accordingly. With so many moving parts, top-down interventions will inevitably give rise to examples of what Bastiat called "What is seen, and what is not seen."

As the failure of the Oregon plan showed, those who lose in a system of scarce resource allocation are often quite sympathetic. Coarsening the capacity for sympathy for the unfortunate to achieve system-wide economic sustainability has its own consequences. What is conspicuously missing from all this is any widespread ground-level discussions between individual patients and their (vanishing) primary care physicians about the concrete ends of medicine as applied to them. Getting all weepy about the way it used to be is just sentimental self-indulgence....the old model is under hospice care. But until that conversation is had in some broad, effective way, my grandchildren will be paying the monthlies on the third mortgage we're now taking out on our health care system.

Graphic: The Road Ahead photograph from Mythsnlegends

Sunday, February 15, 2009

Commonwealth of Kentucky v. Ina Cochran in the Supreme Court of Kentucky: Is A Pregnant Woman Criminally Responsible for Her Fetus During Pregnancy?

Case No. 2008-SC-000095, Commonwealth of Kentucky v. Ina Cochran in the Supreme Court of Kentucky: Is A Pregnant Woman Criminally Responsible for Her Fetus During Pregnancy?

Here is the legal and ethical issue as presented by National Advocates for Pregnant Women 15 W. 36th Street, Suite 901 New York, NY 10018 as the organization has been trying to get ethicists to join an amicus curiae brief in support of the defense for a case to be heard by the Supreme Court of the State of Kentucky very shortly.

“Ms. Cochran gave birth to her daughter Cheyenne on December 29, 2005. Both she and her daughter, who was born otherwise healthy, tested positive for cocaine. Ms. Cochran was charged with endangerment of a child, and her attorney filed for a motion to dismiss, citing Commonwealth v. Welch, a case where the Supreme Court of Kentucky held that child endangerment statutes do not apply to the context of a woman's relationship to the fetus she carries. Cochran's motion to dismiss was granted, but the State appealed.

The appellate court held, that despite binding state supreme court precedent and Kentucky law that requires issues of drug use and pregnancy to be dealt with solely in the public health sphere, that in light of feticide laws and unborn victims of violence laws meant to punish a third party's acts against a pregnant woman, the state's child endangerment statute can now apply to the pregnant woman herself.

Not only does that appellate court decision effectively overrule Welch, based on highly faulty reasoning, it also undermines Kentucky's Maternal Health Act of 1992, which states ‘the General Assembly finds it is necessary to treat the problem of alcohol and drug use during pregnancy solely as a public health problem by seeking expanded access to prenatal care and to alcohol and substance abuse education and treatment programs.’

The Maternal Health Act's enlightened approach, which is in line with the position statements of practically all medical and public health organizations promoting treatment over incarceration in order to improve maternal and fetal health, is under attack by the Cochran appellate decision. Furthermore, by blurring the line between third party acts and a pregnant woman's experiences during her pregnancy, this case focuses squarely on whether the state can view a pregnant woman in relationship to the life she carries as no different from a stranger, or a batterer, a drunk driver, or a man who brutally kills a pregnant woman."

The question is whether a woman who uses cocaine during pregnancy and gives birth to a child is guilty of criminal behavior such as endangerment and should be prosecuted as such. If so, what is the difference in this situation between a pregnant woman smoking cigarettes, drinking alcohol, risking the fetus life by riding a motorcycle or not wearing a seatbelt while driving, permitting implantation of 8 embryos created through in vitro fertilization knowing the risks involved to some of the fetuses she will be carrying . If it is true that “the state can view a pregnant woman in relationship to the life she carries as no different from a stranger, or a batterer, a drunk driver, or a man who brutally kills a pregnant woman” doesn’t that essentially reverse the Roe vs Wade decision that an abortion at the request of the woman is legal? What do you think? Where does one draw the line? ..Maurice.

Graphic: Original photograph from Wikipedia subsequently digitally modified by me using Picasa 3 and ArtRage.

Friday, February 13, 2009

Physician’s Stress Without an Outlet? : Physicians, This Thread is an Outlet

Physicians, of both genders, face stress in their daily and hourly work but also in their off-work, at home life. The work demands may affect the responsibilities in the physician’s home life. Stress may make itself known in various ways from bodily symptoms to personality changes to impaired functioning within the professional activities. As examples the stress comes from simply the hours of work, the complexity of the responsibilities including running an office, the demands for service, and the uncertainties or results of the clinical outcomes and the consequences. Stress can also arise, at some point, from a discouragement about attaining the financial, professional or even specifically the humanistic goals which were set at the beginning of the career in medicine. Stress can arise from seemingly irresolvable conflicts between the work and the home life.

Stress buildup toward symptoms, including anxiety and depression, can be controlled though various approaches including specific professional stress counseling. The self- prescribed use of drugs or the use of alcohol may yield to dangerous and unprofessional consequences. Other methods such as physical activities and exercises, hobbies and simply ventilation of concerns in communication with interested and supportive listeners can diminish stress. Though outlets for stress are available, some physicians may look at their stress burden as having no resolution except retirement.

For an interesting interview on the problem of physician stress and remediation, go to this link of the September 2006 issue of Physician’s News Digest where Barry Bub, M.D., Director, Advanced Physician Awareness Training and author of
“Communication Skills that Heal: A Practical Approach to a New Professionalism in Medicine” answers questions from the News Digest.

It is for communication as one outlet for physician stress that I have created this thread. Though other resources on the internet may be available, I offer physicians (and nurses) the opportunity to write and thus ventilate about their professional stresses here. By reading their stories, we all can learn more about and perhaps understand better the life of a healthcare provider. I have provided the same opportunity for patients to ventilate on “I Hate Doctors” and “Patient Modesty” and the hysterectomy threads as examples.

To those professionals writing to this thread, you may remain anonymous (though identify your specialty) but use some pseudonym including initials to aid in the reading continuity. Please don’t name names in your stories. We would like to read your experiences and how you are coping with the stress. ..Maurice.

Graphic: Street photograph I took today and modified it with the help of Picasa 3.

Wednesday, February 11, 2009

Medical Humor: A Joke or a Poke?

When I was pregnant with my first child ( I am married too BTW) I said to my PCP that I was a bit nervous about giving birth. To which he replied" you should have thought of that before you opened your legs"

The above example of doctor to patient “humor” was written recently by a visitor to my thread “I Hate Doctors: Chapter 2

I wrote there I have actually several threads covering "humor" in medicine but none specifically on what the professional considers ‘benign humor’ as expressed to the patient or others but actually is deprecatory and belittling of the patient as a person and a fellow human being. .. I put the word "humor" in so-called scare quotes to emphasize my view that, unfortunately, humor may not really be humorous to the patient or others.

An article in MedScape from the Student British Medical Journal discusses the examples of un-humanistic joking with patients titled “Just Having a Laugh”. Patient beneficent views state that humor “creates a psychological barrier that prevents the carer from getting too attached to the patient, and another reason might be that it forges a bond between those privy to the joke" or that "humour reinforces a sense of togetherness” or “is a protective mechanism against the horror and suffering before them.” Yet a patient maleficent view would hold that this humor is “an outlet for feelings of anger, frustration, or disgust towards certain patients (such as obese patients or those with conditions that are perceived to be self inflicted.)”

I think that humor in medicine is constructive or destructive depending on how it is applied. Should a patient already in distress and seemingly lacking the extent of power given to the physician be subjected to personal humiliation? On the other hand, could carefully applied and empathetic humor be binding to a relationship, constructive and therapeutic? This thread is for my visitors to give examples, in their own experience, of good jokes received and what they feel were bad, deprecatory jokes. But please no identifying names of the jokers, good or bad. ..Maurice.

Graphic: From

Sunday, February 08, 2009

Suffering, the Unconscious and the Application of Dignity: What is the Science, What are the Ethics?

Here is an extract of a current news item from Associated Press which raises important scientific and ethical issues: Can a patient who is seemingly unconscious in a permanent vegetative state suffer? To whom is dignity applied if a patient is kept alive against their wishes, the patient or others?

ROME— Pope Benedict XVI on Saturday [February 7 2009] affirmed the need to protect life even while suffering, making a last-minute intervention as Italy grapples with a fiercely debated right-to-die case.
Eluana Englaro, 38, has been in a vegetative state for 17 years after a car crash. On Friday, after a decade-long court battle, her nutrition began to be reduced in preparation for removing her feeding tubes, which her father has said was her wish.
Benedict didn't refer by name to Englaro in his message Saturday for the annual World Day of the Sick. But the pope said he wanted to reaffirm with vigor "the absolute and supreme dignity of every human being" even when "weak and shrouded in the mystery of suffering."

This case, is now involving the political system of Italy with the Premier and his party attempting, against the opinion of the Italian President and the decision of the Italian courts to create a law to prevent the doctors from removing the feeding tubes. Shades of Terri Schiavo in the United States!

The issue can also involve the question of “what does the word ‘suffering’ really mean?" And in the case of a patient in persistent vegetative state with a family, who is actually suffering, the patient or the family or both? And if tube feedings are continued in the patient so that the patient can continue to be alive for whom is the “dignity” of further feeding being attended to, the patient or really the family?

With regard to the definition and use of the word ‘suffering’ and its associated or independent word ‘pain’, there is a very good description in Wikipedia starting with “Suffering, or pain is an individual's basic affective experience of unpleasantness and aversion associated with harm or threat of harm. Suffering may be qualified as physical, or mental. It may come in all degrees of intensity, from mild to intolerable. Factors of duration and frequency of occurrence usually compound that of intensity. In addition to such factors, people's attitudes toward suffering may take into account how much it is, in their opinion, avoidable or unavoidable, useful or useless, deserved or undeserved. All sentient beings suffer during their lives, in diverse manners, and often dramatically.”

There already has been research into suggestions of the nature of the awareness which might be present in a patient who is in a permanent vegetative state. A brief article which describes and references some of the research can be found in the September 2008 issue of the American Journal of Bioethics/AJOB Neuroscience “Suffering and the Unconscious—The Harder Problem” by James D. Duffy (page 29). There is evidence that these patients may be aware in a momentary sense of a “pain” or some sensation, however they may not actually correlate it with memories such that the stimulus actually produces “suffering”. Much more research with the current modern tools of neuroscience is necessary.

All persons, whether alive or dead deserve dignity. All patients whether conscious or unconscious deserve dignity. But the question is how is the dignity expressed. In the case of Eluana Englaro or as in the case of Terri Schiavo is the dignity expressed by continuing a life prolonging treatment that went against the patient's previous known wishes or is it actually to preserve the dignity of a family, if present or a Pope, President, Premier or the assumed dignity of society? What is your answer? ..Maurice.

Graphic: Classic art from The Lion and Cardinal web site.

Saturday, February 07, 2009

HIPAA: Medical Information Privacy but also Patient Access

In the United States, HIPAA is the Health Insurance Portability and Accountability Act which together with the Federal Privacy Regulations of April 2001 and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has established the law and standards which are aimed at protecting the privacy of an individual’s healthcare information and regulating access to it. HIPAA defines who has access to the information and establishes the patient’s rights. This thread will deal with patient’s rights with regard to their medical information, one of which includes the right (with minimal limitation) of the patient to access and read medical records which contain their personal medical information.

To get started on this topic, here is a recent e-mail I received from a visitor. By the way, in keeping with HIPAA regulations I am not identifying the writer or providing any other personal identifying information in order to protect patient privacy. I am assuming that the scenario itself is common and the few details presented are not specific enough to provide such personal identification for someone who is not already aware of the individual and the details.

I am trying to find out more information on the topic of transferring one patients records from one PCP to another PCP.

The original PCP had been my fiancees PCP since childhood. In the last two years my fiancee had developed several symptoms and the original PCP had run an EKG and an MRI two years ago and let it go at that. The symptoms still bothered him and continually grew worse. The originally PCP treated it more like drug seeking behavior and whining and never addressed the issues or pursued more testing. My fiancee has insurance through his employer and payment was not the concern. At much badgering from me my fiancee finally switched PCP's. Upon requesting the transfer of his medical records to the new PCP the old PCP only sent a letter and a copy of the most recent blood work and the EKG, no other history was included.

Is this considered with the parameters of medical history for a patient considering the extent of time he was with the original PCP?

The new PCP has found several very alarming conditions that have been untreated and undiagnosed because of the other PCP's lack of time with my fiancee. At this point she is looking for all the information she can get her hands on to develop a treatment plan that is aggressive.

I am extremely concerned because ethically I thought all of the patients case history was to be sent once the patient released it and the PCP was not allowed to pick and choose.

Please clarify if at all possible.

I wrote the patient back the following:

If a summary of a patient's medical condition is inadequate, to my knowledge, the patient has every right to access to a copy of the entire chart for transfer to another physician. In the U.S., patients can read their own chart except for psychoanalysis commentary. Check with a lawyer regarding transfer of records in your community.

Here are the details pertinent to this topic as obtained from the Los Angeles County Department of Health Services HIPAA Privacy and Security Comprehensive Self-Study Guide (content adapted from Health Care Compliance Strategies, Inc. revised November 2005.)

A. HIPAA empowers patients by guaranteeing them access to their medical records, giving them more control over how their protected health information is used and disclosed and providing a clear avenue of recourse if their medical privacy is compromised. The Privacy Standards protect medical records and other personal health information maintained by health care providers, hospitals, health plans and health insurers.

B. HIPAA and the Federal Privacy Regulations (April 2001) established the patient’s right to maintain the privacy of their health information. These rights give the patient a right to access their personal health information (PHI), amend their PHI, receive an accounting of disclosures of the PHI, request restrictions on the use of their PHI, file complaints and receive notice.

1. Right to Access: Patients have the right to access and inspect their health record and obtain a copy from their health care provider. Patients may access or copy their health records for as long as the information is retained. There are few exceptions to access related to psychotherapy notes and protections under state law.

(HIPAA requires that requests be granted within 30 days if the information is located on-site and within 60 days if the information is located off-site. However, California state law is more stringent and requires requests be granted with 15 days regardless of where the information is located.)

2. Right to Amend: Patients have the right to request an amendment to their medical record. The request must be put in writing and submitted to whoever maintains the medical record. The organization will then review the request and determine agreement or disagreement. The request for amendment becomes part of the permanent medical record.

3. Right to Account for Disclosures: Patients have the right to request a list of when and where their confidential information was released (within the last 6 years but not prior to April 16 2003), the date of disclosure, the name and address of the person or entity who received the information and a brief description of the reason for disclosure. Disclosure is permitted for treatment, payment or healthcare operations.

4. Right to Request Restrictions: Patients have the right to request their provider or hospital to restrict the use and disclosure (release) of their PHI. However, the provider or hospital is not required to comply with the request if the use and disclosure does not otherwise violate HIPAA Privacy Standards.

5. Right to File a Complaint: Patients have the right to file a complaint if they believe their privacy rights have been violated.

6. Right to Receive Notice: Patients have the right to receive a Notice of Privacy Practices handout, which describes how medical information may be used and disclosed and how to access and obtain a copy of their medical record. It also provides a summary of patient rights under HIPAA, describes how to file a complaint and gives relevant contact information.

OK, so those visitors to this blog who live within the United States know your rights. You may want to check with governmental resources within individual states regarding state changes as noted above with California. Those from outside of the United States should check with their local governmental agencies regarding the rules or laws applying to personal medical information. Keeping personal medical information private and restricted only to those who need to know is not only an ethical practice but is now the law in the United States.

Now, I would like to pose an ethical question to my visitors. The fact that the HIPAA law allows patients to have access to their medical record and to read it, do you think that this right is always in the best interest of the patient and also would this right, at times, be unpractical? Doctors notes and records can be difficult to read not only by handwriting (if handwritten) but also the meaning and significance of the words may be obscure to the patient unless reviewed along with the physician. This would require additional time spent with the patient for the doctor to provide this guidance to the patient. How should the doctor balance this time with the duty to the ill patients awaiting a visit in the waiting area? Should the doctor charge for this service to the patient? Beyond psychiatry notes restricted to be accessed by law, would there be other parts of the doctor's notes which should be off-limits to the patient? Think about it.. and let us know. ..Maurice.

Graphic: My ArtRage combination of graphics to form "Zippered Lips".

Friday, February 06, 2009

Patient Modesty: Volume 9

Continuing on from Patient Modesty: Volume 8, the current ongoing discussion was about the discomfort of some male patients to be examined or procedures carried out by female healthcare providers or their female assistants because of physical modesty issues. Described in the postings are examples where for one reason or another, the patients can’t request and receive the same gender providers with whom they would be more comfortable. It seems that providers and institutions fail to consider these patient’s rights of privacy. I changed the context of the discussion a bit with the following question:

I am interested in learning about the specificity of the privacy/physical modesty concerns related to the healthcare provider's gender. What I want to ask those who have concerns about their physical modesty and/or privacy, how do they feel with regard to sensitive historical privacy with regard to the provider's gender. Would it make any difference in the gender selection of a provider if intimate questions are being asked or may be asked of the patient. For example, regarding sexuality or sexual practices or other aspects of the sexual history, if these questions were asked in a professional manner and were a necessary component of the patient's medical history? (I don't mean in an office visit for a simple "cold", the provider asks whether the patient masturbates regularly!) Or, in terms of general privacy, would responding to questions about financial worries in a depressed patient or marital discord issues require gender selection? … So.. is there also gender selection concern in history taking?

Go to Volume 8 to read visitors’ responses to my question but now continue the discussions here since that Volume is now closed for further comments. ..Maurice.

Graphic: Cupidon by William-Adolphe Bouguereau (1825-1905} from Wikipedia


Tuesday, February 03, 2009

Preparation: Making Ethical/Moral Decisions in Advance

Preparation: Making Ethical/Moral Decisions in Advance

The issue for this thread is whether it is good practice and ethical as a method of preparation for society or individuals to make ethical and moral decisions in advance of an action or the acquiring of all the facts. For example, human cloning has been said to be an unethical procedure and yet there has been no human cloning and no experience as yet as to what the consequences to society might be if human cloning had occurred. There has been expressions of rejection of genetic engineering without many of the projects criticized actually having occurred. On another level, society and individuals for ages have made moral assumptions prematurely about other individuals without being aware of the specific facts but based simply on generalizations or stereotypes.

The examples of Nancy Cruzan and Terri Schiavo demonstrate how some individuals prematurely expressed their judgments of the moral or ethical issues. One group declared the issue was the right to life. Others argued that these victims had the ethical right to liberty. Yet, how many of those who made these ethical and moral expressions had, in advance, all the facts of these cases?

One can, on the other hand argue that preparation, with limited facts and limited experience, is an essential aspect of moral or ethical decision-making when the consequences are threatening to individuals or society. Consider, making these decisions, in advance, regarding triage practices in the case of an infectious disease pandemic where care of the sick was limited by healthcare providers or facilities or equipment. What lives are not worth saving in such a situation so that other lives can be benefited? All the facts are unknown and we can only make assumptions. Could a moralistic expression such as “the Axis of Evil” describing a number of countries be likewise supported by that preparation argument but regarding only the anticipated behavior?

Should we take the time and energy to stuff our ethical acorns into the tree trunk in anticipation of what comes next? And is that always fair? ..Maurice.

Graphic: Photograph taken by me 1-31-2009 of acorns stuffed into a tree trunk, Lopez Lake in Central California.

Monday, February 02, 2009

Science to Solve Moral Problems: fMRI and Michael Vick

Read this article in the Stanford Center for Law and the Bioethics Blog

The article is all about the use of the so-called functional magnetic resonance imaging (fMRI) as called for by PETA (People for the Ethical Treatment of Animals) to determine if Michael Vick, former professional football player, who will complete a prison sentence this year for conspiracy related to his treatment of pit-bull dogs in his dog gaming activities, persists as a psychopath or sociopath before being allowed to return to professional football.

As it turns out, Michael would be considered to be a candidate to return to professional football if he could demonstrate remorse for what he had done. According to the Stanford article “ Officials from PETA sent a letter to the NFL commissioner today saying that Vick should be checked to see if he is a psychopath or sociopath before he can return to the NFL. And the method that they specifically suggested? Brain scans. PETA wants Vick to undergo a full psychiatric evaluation and a brain scan to determine whether he has anti-social personality disorder or psychopathy.” The problem is that fMRI cannot detect, as yet, psychopathology.

The issue for our blog thread here is whether what appears to be a moral decision: should a technique of science be used by society or a particular segment of society to establish whether or not a person has violated a moral boundary and has been rehabilitated? After all, maltreatment of dogs and conspiracy are moral statements set into law. Can conflicts regarding ethics and morality be settled by some scientific device or should they be resolved by law and philosophic principles? Any thoughts on this fascinating subject? ..Maurice.