Bioethics Discussion Blog: Patient Modesty: Volume 42





Wednesday, June 29, 2011

Patient Modesty: Volume 42

I am awaiting the essay of a former second year female medical student to place on this Volume's front page. She had her future hopes of obtaining an M.D. and PhD degree dashed when her medical school allegedly refused to accommodate her request to avoid performing male genitalia, rectal and female pelvic exams later in her second year as part of physical exam teaching and to avoid the OB-Gyn clerkship in the 3rd year. Her requests were based on her own personal anxiety but also for her personal philosophic reasons against performing these intrusive procedures which also challenged her own and the patient's modesty and sexual concerns. I will write nothing further and await her presentation. I think her story will be particularly pertinent to this thread. ..Maurice.

ADDENDUM: FROM THE MODERATOR-- The medical student's writing has been received as of today July 11 2011. Two apologies to the writer: 1) In my above note, I wasn't fully accurate regarding her concerns. She will explain them in her writing 2) I decided, as an ethical decision, to delete frank identification of her medical school. Please also note that one internet link was inoperative as written but the others work.

I want to wish who we have called our "stressed student" many thanks for allowing her writings to be published here and we wish her the very best in developing an upcoming career. ..Maurice.

July 11,2011

I was a [Moderator: school name deleted] medical student. Like many teenagers and young adults, I had never visited a gynecologist or proctologist. I did not come from a medical family either. And because pelvic and prostate exams are not mentioned in the premedical curriculum nor explained to medical school applicants and incoming [My Medical School] students, I did not know about these exams when I first moved to [Moderator: city name deleted] to begin my medical education.

My faculty did not bother to explain what bimanual exams were my entire first year of medical school. I only learned about them from classmates cracking jokes, and from receiving e-mails from students selling T-shirts that compared the exams to sexual activities, making light of the way we must complete the exam once on an actor as part of our Essentials in Clinical Medicine (ECM) course in our second year [Moderator: Link is in error and cannot be completed]. You can see from the link how insensitive and immature my classmates are to sell such T-shirts.

I immediately had problems with pelvic and rectal exams. I found them violating in concept. I believed it had to be wrong for my school not to explain to applicants beforehand that there was more to examining men than testicular exams and more to examining women than breast exams and catching babies. I thought that training students to lubricate and insert their fingers into male and female sexual organs was much more taboo than what many young students would creatively imagine on their own before matriculating. I thought it was not right to assume that every student must agree with digitally penetrative exams just because they are widely accepted as valid medical procedures, at least in this country. After describing these exams to my younger sister and a few friends from college, I was confident I was not the only human being who viewed these exams as more than just a little uncomfortable, but also violating.

There was ample support at my school for students with academic problems regarding written exams. But there was nobody to speak with for students who had personal, cultural, or ethical conflicts regarding clinical procedures. I did speak with a school psychologist who specialized in stress management because she gave students her contact information during orientation week, but all she did was invalidate my perspective by repeating "There is nothing sexual or violating about these exams." Realizing that a broken-record psychologist could not alleviate my stress, I decided to complete the first year curriculum and resolve my issues directly with faculty over the summertime.

I started reading Dr. Bernstein's Blog as a medical student, and contacted him back when I was trying to resolve my concerns with faculty. He bought to my awareness today that the essay I wrote for the Blog does not mention my personal career aspirations, which is something I told him about last summer. I realize this is a pertinent detail that several readers have asked about in their responses.

I entered the program at my school to prepare for a career in translational services between medicine and investigational science. I wanted to focus on pathologies of the brain and nervous system. So I was looking to develop into the capacity of a pathologist or maybe a neurologist who conducted translational research on that organ system. I was not aspiring for a career in a field like family medicine, emergency medicine, internal medicine, and obviously gynecology.

When I learned about these invasive genital exams, I found them violating enough to refuse when unnecessary. Realizing they were not part of my future responsibilities, I thought the most professional and honest approach would be to discuss all of this with faculty

Over the summer, I confided in faculty that even though I understood many people saw these exams as being just another part of the physical exam, I saw pelvic and rectal exams as being violating procedures, and that unless I went through some psychological change where I could perform them without feeling violated, I would decline to perform them, especially in non-emergency scenarios such as practicing on an actor in an artificial environment, and especially since it was not listed as a graduation competency to students beforehand (or even at all anywhere). What happened when I said this is they withdrew my scholarship, and shunned me for asking for "special privileges". I withstood so much abuse when I brought the topic up with faculty, ridiculing me with "What? We have to tell students that doctors touch people?", guilt-tripping me with "If you cared about patients, you would do the exam", and victim-blaming me with "You knew all about these exams before you got here, you just repressed it."


Over the summer, the first person I contacted was the head instructor of ECM (the physical exam class where we must complete these exams). I vaguely told him I had "concerns" about the ECM course for second-year students. He offered to meet with me, but said most students speak with other instructors of the course first, and then with him if things are not resolved. So I spoke with all the other course instructors, and by then he knew what my issues were, and was no longer interested in meeting with me. I did learn a lot of unacceptable facts about the ECM class from the other course instructors though.

I was appalled and frustrated to realize my school has watched students suffer personal conflicts like me for decades:

1) Every single year, the instructors watch a "few" students resist these exams. One instructor told me these students say "I just can't do this" and "I don't want to do this". Some students abruptly walk out of the exam room, and some postpone their dates, all the way until summertime when they must complete it once to advance to third year.

2) Students have fainted during the exams.

3) Students have cried during the exams. The worst was a recent student who said she was a rape-survivor and had problems with the male rectal exam. My instructors still forced her to do it, and she left the room sobbing in front of the actor and instructors.

4) The instructors have a rule that one female must be in the room for the male rectal exam. The rule was established to mitigate any "homophobia" among male students, and apparently my school thinks the presence of a female neutralizes any viewpoints students might possess that the exam is a "gay thing". I thought this "rule" reeked with discrimination and hypocrisy. It seemed to me this "rule" was conjured up decades ago by the primarily male heterosexual faculty who empathized with problems male heterosexual students as a selective group would face, and made it easier for them to at least graduate, when many male students never even asked for it. The most disturbing part about this "rule" though is that the faculty EXPECT a few young students to be unable to desexualize the prostate exam when it is introduced to them. To then force students to complete the exam, knowing that some cannot desexualize it, must be sexual abuse. But not wanting to "scare students away", these instructors deliberately keep students in the dark until they have invested too much time and money into school. Because at that point, students who find these exams unacceptable must choose between getting sexually abused or crawling away with a mountain of debt as a medical school dropout. The instructor who told me about this "rule" said it was handed down to her when she took the position in 1982. In other words, this "rule" is over three decades old!

What do you think of these four points? I think they unfold like rape scenes. A self-proclaimed rape-survivor leaving the exam room sobbing? Students crying and fainting while doing "intimate exams" that were not explicitly explained beforehand? Students "resisting" and "postponing" the exams for months? One instructor assured me that I was not out of place, and said he always sees students "make horrified faces". Unfortunately, his comments did not make me feel better, they made me feel angry that my school failed to question why this is the case. It disgusted me that nobody advocated for the rape-survivor. I believe they raped a rape-survivor. And it outraged me that this student cried in front of her peers, and then felt she needed to reveal personal information about herself too. There is no justification for the fact that they did absolutely nothing after that for future students.

I was sickened by the degree instructors deny they are hurting a few students each year. They assured me "I always ask those kids who keep postponing the exam how it turned out, and they say it was not as bad as they thought." What else can these students say when their own abusers fish for an agreeable response like that? The instructors even told me matter-of-factly "Students faint during the pelvic exam because they did not eat a big breakfast." They cannot possibly be keeping tabs on 200 students breakfast schedules. It irritated me they never considered why nobody fainted during the ear exam. As of now, their "solution" to the fainting episodes is to remind students earlier in the week when they explain the pelvic exam workshop to eat a big breakfast on the morning of the workshop.


I read a book "Public Privates" by Terri Kapsalis. When I learned halfway through the book the author was a pelvic exam actor at [My Medical School], I was shocked to discover she wrote an entire chapter about [My Medical School] students having problems with pelvic exams. This book was published 20 years ago, and nothing at my school has changed. Here are some quotes from her book about my school:

1) [The author discusses a paper by a physician named Buchwald] "Students seem to find it very difficult to consider female genital display and manipulation in the medical context as entirely separate from sexual acts and their accompanying fears. Buchwald's lists of fears makes explicit the perceived connection between a pelvic examination and a sexual act. "A fear of the inability to recognize pathology" also reflects a fear of contracting a sexually transmitted disease, an actual worry expressed by some of Buchwald's student doctors. Likewise, "a fear of sexual arousal" makes explicit the connection between the pelvic exam and various sexual acts. Buchwald notes that both men and women are subject to this fear of sexual arousal. "A fear of being judged inept" signals a kind of "performance anxiety," a feeling common in both inexperienced and experienced clinical and sexual performers. "A fear of disturbance of the doctor-patient relationship" recognized the existence of a type of "incest taboo" within the pelvic exam scenario."

... "Buchwald's work deviates from most publications dealing with the topic of medical students and pelvic exams. Largely, any acknowledgment of the precarious relationship between pelvic exams and sex acts is relatively private and informal, taking place in conversations between students, residents, and doctors, sometimes leaking into private patient interactions. For example, as a student in the 1960s, a male physician was told by the male OB/GYN resident in charge, 'During your first 70 pelvic exams, the only anatomy you'll feel is your own." Cultural attitudes about women and their bodies are not checked at the hospital door."

... "In his article about medical students' six fears of pelvic exams, Buchwald accepted student fear without either questioning why young physicians-to-be would have such fears or searching for the cultural attitudes underlying them."

2) [The author discusses that schools hired prostitutes to teach the exam] "In a sense, the patriarchal medical establishment took the position of a rich uncle, paying for his nephew, the medical student, to have his first sexual experience with a prostitute. This gendered suggestion assumes that female medical students are structurally positioned as masculinized "nephew" subjects as well."

3) [The author quotes a fellow pelvic exam actor] "I think the students are afraid it's sexual. They're afraid about how they're going to react, whether they're going to be aroused, but it's so clinical."

4) "Only with the use of GTAs [pelvic exam actors] have medical schools attempted to incorporate women patients' thoughts, feelings, and ideas into pelvic exam teaching. And yet, as these feminist teachers pointed out decades ago and as my experiences have occasionally confirmed, it may be impossible to educate students properly within the medical institution given unacknowledged cultural attitudes about female bodies and female sexuality."

The author of this book is correct: There is no validation from faculty at [My Medical School] that some students suffer problems regarding these exams, and there is no effort to investigate why this is the case. I also agree there is no search for "cultural attitudes" that could underlie students perceiving these exams differently. In fact, although I have American citizenship, I was raised overseas from age four and returned to America for college at age nineteen. I retrospectively learned that in many developed nations, the thought of asymptomatic women paying strangers in white-coats to routinely penetrate their vaginas is the exception rather than the norm. In Korea, for instance, some women use vaginal swabs in the privacy of their homes. In Japan, screening for cervical cancer at all is not commonplace. In other developed countries, there are self-pap tests that some women use because they find the traditional gynecological exam to be inappropriate in the absence of symptoms. In addition, the developers of the CSA blood test cite "cultural taboos" as being a primary motivation for them inventing a non-invasive alternative to check for cervical cancer. So I think my school is very ethnocentric to believe all incoming students automatically agree not only with these exams, but also with practicing them on asymptomatic actors. It is undeniable some students discover personal clashes that might derive from cultural upbringings while learning about the most taboo aspects of physical exam for both sexes, and I find it unethical that schools would not inform students about these potential problems before they move to new cities and matriculate.

At the same time, the author conveys similar beliefs as the instructors I met at [My Medical School], hastily diagnosing students as having "anxieties" and "fears" that they can "cure" us of via "education". I think the quote the author provided from a fellow pelvic exam instructor ("Students are afraid it's sexual") is nauseatingly narrow-minded. How does this woman believe she can tell all adults that an exam, mechanically the same as digital sex, is not sexual? Why does she think she can speak her mind for all adults about human sexuality in medicine by resorting to empty buzzwords like "professional" and "clinical" to do so? In fact, she cannot define what is and is not sexual (or sexually violating) for any other adult.

This reminds me of one instructor who concluded I had an "irrational phobia". Do you think it was fair for this instructor to tell me I had a "phobia" of being forced to have digital sex with an actor without my consent? Because you could easily make the reverse argument: Students who do not want to do these exams when introduced to them (as this apparently happens each year), but still complete them have "phobias" about disobeying orders from faculty, or have "phobias" about standing up for themselves, or have "phobias" about what instructors will think of them if they admit they see a medical exam as being sexual. The same with patients too: I have seen peer-reviewed papers written by gynecologists investigating why some women have "fears" about getting exams. But the counterargument here is that women who dread the thought of being humiliated and penetrated by strangers, but force themselves to suck it up, have hypochondriac "fears" about developing a rare cancer and benefiting from a notoriously inaccurate exam. Depending on their lifestyles, some women are more likely to be harmed than benefited from the outdated pap smear, and the World Health Organization does not recommend ovarian cancer screening via bimanual exams. For these reasons, I believe smart and responsible women can decide to never submit to these exams while asymptomatic, without being diagnosed by pushy and one-sided doctors as having "curable fears".

It is too easy for instructors to label and ostracize students as having "fears". These instructors told a rape-survivor she was being irrational to "fear" the prostate exam. What is particularly evil is they knew this teenage girl or young woman likely did not know about taboo old men healthcare to decide for herself before starting school whether or not she found completing a prostate exam to be acceptable. In any case, her "fear" turned out to be a rational one because the experience did cause pain, as she expected, seeing that she left the room crying. These instructors pride themselves on walking over students and their problems, and believe that with their supremely rational minds, they can triumph over anything, when in fact they have not proven any strength unless they have all been raped themselves. So who are they to judge a rape-survivor student with long-term effects of depression? And then to boast that they gave this student such a valuable educational experience, just because they cannot relate to her suffering from traumatic life events? I thought that was just plain childish.

I do not think my instructors are very intelligent. There is more to intelligence than exercising the rational mind. The author refers to these exams as being a "first sexual experience" for many students. If it is indeed true (that medical exams can be sexual experiences), then forcing teenagers and young adults to perform them without consent using shame and blackmail, when it causes problems for a few of them each year, is institutionally-sanctioned serial sexual abuse and rape. At least that is how my intellect - both rational and emotional - sees it.


After I spoke with all physical exam instructors, they sent me to the "Associate Dean for Curriculum", who is also an OBGYN. I met with him twice, and our second conversation bothered me.

He told me he was "ignorant" medical students had problems. But really, he was anything but "ignorant" since he works with the same instructors who watch students cry and faint.

I asked him if I could bring in "evidence" that students have problems. So the second time we met, I brought detailed information about [My Medical School] students having problems, as well as news articles about students across the nation being "known to faint, cry, vomit, become hysterical and sweat" over these exams (

I also brought one article about teenagers and women getting unwanted pregnancies because they could not obtain birth control from gynecologists when they refused pelvic exams. I brought this last article because I empathized and related to the female patients, as I would also refuse the exam if I were in their positions. The article was pointing out that because the medical community does not respect and accommodate these women and their opposition to pelvic exams, it leads to bigger problems like unwanted pregnancies. And I felt that was a similar message to what I was trying to voice to my school: I think a small number of medical students can find out they disagree with exams, and they should no longer be marginalized and ignored for it because that only leads to bigger problems.

When I handed him the paper, his demeanor changed from the previous meeting, and he suddenly raised his voice at me (even though I never raised my voice at him). He actually balled up his fist like he was holding pills and growled at me "If I have something a patient needs, I withhold it until they get the exam!" He was steaming with anger, even though I never thought to question his practice at all. I had read about why it was unethical to require pelvic exams for birth control (, but I assumed the doctors who abused their power in this manner were working in private clinics out in the boonies. It never even crossed my mind that an OBYGN Dean of a medical school would fit that profile.

Shocked and creeped out, because I saw his true color, I asked "Shouldn't doctors at least tell patients they could go elsewhere and get birth control without a pelvic exam?" I thought it would be lacking informed consent not to do so. He just sneered at my comment. It was very clear to me this person went into gynecology for all the wrong reasons one might expect. It infuriated me he could not even pretend to empathize with the girls and women in the article who found pelvic exams to be intolerable, just as he could not empathize with his own students who have felt the same way for years. Any gynecologist, especially one who is training the next generation of gynecologists, should understand and respect how various patients feel about their reproductive rights and healthcare. Hurdles should never be imposed for women seeking contraception. In my opinion, this has nothing to do with health care, and everything to do with power, control, and making money.

His thinking and practice is outrageously sexist: When he was a teenager who needed a condom, he did not need to confront an old woman in a white coat who withheld what he needed until he had digital sex with her first. He presents himself as someone who cares so much for women, but then dupes them into accepting pelvic exams for birth control, even though the World Health Organization and numerous medical associations have consistently stated that the only recommendation is a blood pressure check, since hormonal contraceptives are as hazardous as Aspirin. Medically speaking, there is no greater logic to requiring pelvic exams for women who want birth control than there would be for requiring prostate exams for men who want Viagra.

You can only imagine some terrible scenarios he has exploited: An adolescent patient from a poor family shows up for birth control but does not want a pelvic exam, and does not know beforehand that she will be pressured to accept one. Once in the office, she might view doctors as authoritative figures whom she cannot question. She might be time-pressured for immediate access to birth control. She might be too scared to challenge a doctor. She might find it more embarrassing to try to resist the exam. She might be fooled that the pill will harm her body if she does not accept the exam. She might be intimidated by the medical setting, and maybe cannot speak fluent English. At that point, she can either run away from the exam room (and get undesirably pregnant), or reluctantly submit to the exam (and suffer rape-like symptoms). And I am not just speculating here, I have read about female patients who realize they were mistreated after being coerced into something they adamantly did not want but ultimately accepted because of false guidelines presented to them. I have also read about women feeling "raped" from this practice, and driving for miles to find a doctor who actually follows the law.

I wonder why no students speak up when they see him mistreat patients? Maybe their voices have no impact. Maybe they worry they are out of line to defend patients. It agitates me because I know his misogynistic attitudes have an exponentially poisonous impact, seeing that his peers actually respect his philosophies enough to bestow him the responsibility of training future gynecologists at the largest public medical school in the country.

When I was about to leave the room, I recalled a discussion I had with a kind-hearted classmate who recently drove me home. I told him I had problems with these exams, and he urged me to speak with faculty and resolve the issue. Then he told me although he did not have problems performing the exams, he did have problems the way some instructors handled them: He said he shadowed the head ECM instructor, and watched him reprimand each female patient who asked for a female to do her pelvic exam. Evidently, the instructor believes such requests are backwards and bigoted.

So when the "Associate Dean for Curriculum" asked me if I had anything else to add, I said I was concerned about the head ECM instructor teaching students to reprimand patients when they prefer one sex over another for intimate care. The Dean scolded me, and said he applauded the instructor. He believed it was sexist for me to assist these patients and their wishes. He asked me "Would you ask a black person to leave the room? Would you ask a Jewish person to leave the room? Would you ask a short person to leave the room? Probably. Because you would ask a man to leave the room!"

I thought his analogy here was meager and self-serving. Funny how he was offended by modesty in medicine to vilify it as condoning sexism, when he is the one who abuses his position of power to do such despicably sexist things as withholding birth control from girls and women who refuse pelvic exams.

Patients requesting same-or-opposite-sex care for intimate exams was legalized under the Bona Fide Occupational Qualification (BFOQ) by humanitarians who advocated for patient rights to preserve cultural and personal beliefs about sexuality and bodily modesty. There are scenarios where patients know they will experience the exam as being less sexual because of their sexual history and preferences. For instance, a heterosexual man who has only had sex with women might prefer a male to do his exams because he might experience that as being less sexual. But another heterosexual man who has only had sex with women might prefer a female to do his exams because he might experience that as being more natural. And yet another might have no preference. So really, all individuals have unique sexualities both in and out of medicine. For these reasons, I believe my instructors are the ones who pass judgements on their patients and their sexual values and identities.

Some patients might find it more logical to speak with a provider who has experienced physical problems, like a female patient talking about cramps. And some patients might prefer same or opposite intimate care to protect the intimacy between their partners and spouses. How can a health provider admonish a patient and his or her relationship values?

In all honesty, I do not believe that a woman asking for another woman to do her pelvic exam is sexist. Many women perceive the act of getting naked and spreading into the lithotomy position as being sexually vulnerable and submissive. Even if a woman consciously believes that male and female doctors are equivalent caregivers, her natural instincts might strongly prefer a female examiner because she could not get impregnated by a strange female, as opposed to a strange male, between her naked legs strapped in stirrups. The consistent prevalence then of females requesting female intimate caregivers must have instinctive and deeply emotional roots, and must be accommodated by doctors without judgement or ridicule. Because when these women are demonized for making reasonable requests, doctors are punishing them for protecting themselves at a primitive and instinctual level. Hence, these doctors are docking points off patients for being human, known as dehumanization.

I have to say I find it troubling that these male providers harasses female patients for requesting same-sex care. The power differential is too unfair. Most (American) female patients are very young when they have their first pelvic exams and are too often pressured by biased propaganda and brainwashed mothers to get them without the opportunity to judge for themselves whether it is really necessary or whether they are candidates for less invasive alternatives routinely offered in other developed countries. The pelvic exam is also longer in duration and so much more visually exposing than the prostate exam. Women also face additional hurdles since our society is still a very patriarchal one, where women are sexually abused by men at much higher rates than any other combination of sexes. Even if a woman has not been directly sexually abused, she has certainly been emotionally abused from a very young age, knowing female friends who have been sexually abused (often by men), reading newspaper articles about women being raped (often by men), reading history books about villages of women being raped (often by men), receiving catcalls and verbal sexual abuses (often by men), and knowing about pornography and prostitution and late night clubs where women are sexually belittled (often by men). She has been surrounded with evidence her whole life that some men might view sexual parts of female bodies differently. Unfortunately, OBGYN is not much different than these phenomena anyway, as it is a field that has abused the sexual organs of women for decades and was created primarily by male minds. And so when a female patient requests same-sex care, it may be because she has read books such as "Women and Doctors" by John M. Smith, MD, which revealed frightening statistics such as how much more likely it is for male gynecologists to recommended unnecessary hysterectomies, and how much more prevalent it is for male gynecologists to be reported as sexually abusive.

So how can this Dean, who holds birth control hostage from girls and women until they submit to stirrups, relate to patients who ask for modesty accommodations anyway? Any physician or nurse, male or female, should be open-minded and accommodating with all patients and their valid and legal requests for same or opposite intimate health care, as well as their legal right to refuse degrading exams for contraception. Unfortunately, instead of accepting his patients as human beings with modesty concerns, he exploits their situations to elevate his own status as the heroic physician who is educating students to end what he conveniently believes to be sexual discrimination in medicine.

Even if these instructors are so black-and-white in their thinking to believe they are being discriminated against, they still hold responsibility to follow the law and teach students to do so as well. If they dislike the law, they can always orchestrate their own rallies to advocate for fewer patient rights. But I wonder how honest and humanistic they would feel about their pursuits. All they would be doing is transferring the alleged target of discrimination to the group of people who are in the much more vulnerable position, the patients.


The OBGYN "Associate Dean for Curriculum" said he did not support my conflicts with the curriculum, and sent me to the "Senior Associate Dean for Educational Affairs". This Dean gave me an unhelpful psychotherapeutic session the moment I walked into his room. Before I could explain in my own words what I came to speak about, he asked me "Do you remember anything happening to you that would make you see an ear exam differently than a pelvic exam?"

I thought it was unprofessional for him to ask me personal details about my life, but I told him I have never been sexually abused. I told him some students might find the exam itself to be violating if they are not told about it beforehand. He shook his head like I was a child trying to convince him Santa Claus was real, and told me the only explanation for a person to feel angry over medical exams was if he or she had been abused. Even when I reiterated this was not my case, he told me to seek help from a psychiatrist and "connect the dots" to my abusive upbringing. He went so far to ask if I had siblings, and suggested they also seek help.

I did not think this Dean seemed like an intelligent person to preach about sexual abuse inside or outside of medicine, seeing that he gave no exemption to the student who did admit to an abusive past, and maybe even believed the prostate exam granted her the ability to stop overreacting to whatever caused her to cry.

When searching for criticism of modern gynecology, I came across a popular book "(Male)Practice" by Dr. Robert Mendehlson, who was a pediatrician at [My Medical School]. The author stated:

"I will never forget a student of mine who wanted to specialize in obstetrics but couldn't swallow all of the ridiculous obstetrical intervention that he was being taught. He began to ask questions of the obstetricians: Why were the mothers' feet up in stirrups? Why were they giving the women analgesia and anesthesia? Why were they inducing labor at such an early stage? Why were they performing Caesarean sections when there was no clear indication of need? Did he get answers? No, but he got action. He was referred by the chairman of the department for a psychiatric examination, because any student who asks a hostile question in medical school is presumed to be 'disturbed.'"

This book was written in 1982, and still thirty years later at the same school, when students disagree with sensitive medical procedures, the Deans immediately send them in for psychological evaluation. I whole-heartedly concur with the author: Instructors at [My Medical School] stubbornly maintain there is something wrong with individual students each year, and never with the system itself.

Even worse, this Dean promotes a philosophy to his students that as long as nudity, touching, and penetration occur in the medical setting, then no sane person could possibly feel violated. This is far from the truth, and patients are beginning to speak up about their rights to refuse, request accommodations, and seek alternatives for "intimate" procedures.

For instance, I read the term "birth rape" has been coined. While I understand the term may be legally problematic, I find it conceivable that some women can only describe it this way after what was done to their bodies without permission. And I do not think these women are upset having life-saving C-sections, instead of natural dreamy births. They are upset having unnecessary and aggressive interventions without consent. Can it really be true that so many women must have their labor induced (a known risk factor for pelvic floor damage, perineal tears, epidurals, and C-sections)? Do so many women need episiotomies, when there is no evidence that artificial tears are safer than natural tears, which are rare anyway? Large studies of home births with trained birth attendants show that the majority of women can give birth without interventions, with less injury to mothers and babies, and no increased risk of mortality to either.

There is an unfair rule from doctors that all women automatically accept fingers and instruments in their vaginas if they wish to deliver a baby, even when births are proceeding smoothly. Doctors have an obsession with "checking progress" and recording numbers, with no respect for women who feel the procedures are barbaric. Some insurance providers cash in $250 per bimanual exam, which generates big bucks when doctors perform multiple "cervical checks". There are less demeaning maneuvers that cause less vaginal infections, but these alternatives are never offered. Instead, women who decline pelvic exams and episiotomies receive them against their wills! The baby needs an emotionally healthy mother, and that does not happen when she leaves the experience with so much trauma to call it "birth rape".

As for cancer screening, women are kept in the dark about less intrusive methods to test for cervical cancer (CSA blood tests, urine tests, vaginal swabs, and self-pap tests). Unlike this Dean, I strongly believe patients could feel mistreated by undergoing traditional pap smears should they discover that alternatives, which could have preserved their dignities, were not fairly discussed with them, or should they discover they were not even candidates for cervical testing in the first place.

A report released by Dr. Angela Raffles (cervical cancer screening expert from the UK) demystifies pap smear risks - 1000 women need to be annually tested for 35 years to save one woman from cervical cancer. Meanwhile, 95% of them (950) will require one or more biopsies that can be harmful (emotional stress, sexual problems, cervical stenosis, pregnancy complications, and even infertility). Another article by pathologist Dr. Richard DeMay "Should we abandon pap smear testing?" exposes the fact that cervical cancer mortality was trending downward before the application of pap smear testing, and that when malpractice suits led to higher false-positive rates (and hence more biopsies) cervical cancer mortality actually increased. Hence, the widely proclaimed association between the introduction of the pap smear and decline of cervical cancer might be more casual than causal.

Most doctors do not tell women that "the best kept secret of cervical cancer prevention" is through practicing safe sex and avoiding smoking, not through pap smears. Some women have microscopically slim chances of benefiting from the pap smear, such as virgins, women who only have sex with women, and long-term monogamous women. The same is true with ovarian cancer screening via pelvic exams: The American Cancer Society recommends against it. Why should doctors keep sticking their fingers in places they do not belong when there are no proven benefits?

It is clear to me that dishonesty surrounds much of these "preventative" gynecological exams. Doctors established these tests (money or fear of being sued), and the individual was disregarded. It became: Every Woman must have these exams with No Alternatives.

I can say with confidence that medical students are trained to think this way. In fact, in our first year of medical school, all students practiced interviewing patients with a standardized list of important questions. We asked ALL women: "When was your last pap smear?". But we asked NO men: "When was your last prostate exam?" It would almost make more sense to assume all older men are candidates for prostate exams, than to assume all women are candidates for pap smears since cervical cancer is an STD and so some women are not eligible. Also, the incidence and death rates of prostate cancer are much higher than those of cervical cancer, so it must not be about the numbers. In addition, cervical screening can be a more vulnerable process than prostate screening, because men often have the option of the PSA test (while the CSA test is never offered to women). So really, our first lesson was that female patients do not mind being humiliated in the medical setting, and that we should assume all women accept traditional gynecological exams, even the ones who could only be harmed by them in the first place!

The tunneled vision that this Dean holds (that doctors and nurses are above human modesty) will lead to suboptimal care for many patients outside of gynecology as well. I respect Dr. Joel Sherman and Dr. Maurice Bernstein, and the medical modesty issues for which they are raising awareness for male patients as well. In many ways, it can be a world more difficult for male patients to request and receive modesty accommodations because it is an overlooked topic without enough attention to draw any intelligent conclusions. In addition, people often view modesty as an unmanly characteristic, which might contribute to the ignorance about men having modesty, as well as the silence that fuels this ignorance because when they know to expect ridicule, men do not want to voice their modesty concerns. And I feel very sorry when I read comments from boys and men who have been traumatized by icy nurses and doctors who stereotype males as having no modesty. Unfortunately, I worry this stereotype will die hard, unless male modesty rightfully becomes a component of medical training and education.

I believe most of this ignorance stems from the way doctors are trained. When medical students learn to take sexual histories, we are trained to ask: "Do you have sex with men, women, or both?" (As a side note, I always thought the question should also include "or none" to represent all patients). Before the gay rights movement, this question was systematically swept under the rug to favor the heterosexual population, and hence made gay and bisexual patients less comfortable to openly discuss their sexual histories. Doctors now know not to assume all patients only have straight sex, and this is something that was strongly enforced at my school. I cannot imagine any of my classmates forgetting this simple question, because we are trained and repetitively graded to ask it verbatim from the very beginning. I think many medical students would feel confident to question one of their superiors if they did notice he or she was discriminating against sexual minorities this way, since it is a highly-valued aspect of our training.

On the other hand, when medical students conduct intimate physical exams, we are not trained to ask: "Do you prefer intimate care from a male or female provider, or do you have no preference?" Currently, this question is sidetracked to favor time-pressed doctors and patients who have no preferences, despite it being a legal request unknown to some patients. Obviously this setup makes patients feel ashamed if they do hold strong preferences and values whether a man or woman does their intimate exams. Perhaps then there needs to be a patient modesty movement that might be as successful as the gay patient rights movement by training and grading students to exercise the sexual rights of their patients in this manner as well.

Unfortunately, medical students know they will be shunned if they advocate for patients this way, since sex preference for intimate exams is not an official part of the curriculum. Not only that, but as I mentioned earlier, the instructors at my school reprimand students who bring the topic up for discussion. Therefore, I think dishonesty and silence are fostered in medical school, because I suspect some medical students make their own requests when they are in the vulnerable position as patients. And so they must empathize with patients, but at the same time they must sell their integrity by not questioning their superiors and fitting into what is expected of them, which is to work toward becoming competent physicians who possess minds too perfectly rational to see anything sexual about the exams, and hence too rational to understand why patients might seek modesty accommodations. In other words, doctors pretend not to "see an ear exam differently than a pelvic exam" since they fear admitting so would be a transgression of their medical conduct, and unfortunately this means distancing themselves from patients who do have modesty concerns about exams due to their sexual nature.

I think many medical students sacrifice their integrity subtly at first, and then succumb to the Domino Effect. At first, maybe a student knows he cannot desexualize the pelvic exam, but fearing how his instructors will react, he says nothing, and performs it poorly at the expense of the patient. Next, he might watch an instructor reprimand a female patient when she admits she is not comfortable surrounded by male medical students for her pelvic exam, and he does not stand up for her even though he believes she should not be reprimanded for her request. Now that he has grown more desensitized and dependent on fitting into what instructors expect of him, he might watch an instructor misinform a patient (out of conflict of interest) that pelvic exams are always necessary to obtain birth control, and even though the patient seems weary about the procedure, he does not question the ethics of his instructor. After all, he cannot express his concerns without implying that the instructor is sexually abusing his patient, which would certainly label him as a whistle-blower.

After that, an instructor tells the student that if he admits he is a medical student, then no patients will not allow him to practice sensitive exams on them, and so he follows the advice to flat-out lie to patients about already being a doctor. Ultimately, he agrees to practice pelvic exams on anesthetized patients who have not consented to it, because his instructor tells him these women would have adamantly refused students using their bodies for didactic purposes, and so it is a great opportunity for them to practice their exam skills on unconscious bodies that cannot protect themselves. The student believes the most important skill with a pelvic exam is to obtain informed consent. He sees this "educational" setup as being no different than gang rape. But he has already jeopardized his ethics so many times in the past in relation to sensitive exams. So he does what apparently many medical students do in this country, and gang rapes his own patients: (

Gang raping anesthetized patients is apparently a "time-honored tradition" in medical schools, an ethical problem that has garnered media attention for decades, but has never provoked enough frenzy to encourage change. I never witnessed this practice as a first-year student, but I bet my life it is something I would have encountered had I graduated from [My Medical School]. I strongly suspect this because when I was sent to the OBGYN "Associate Dean for Curriculum", he cautioned that I would face additional dilemmas if I refused to perform pelvic and rectal exams during clinical rotations, and said "You might also have a hard time with... Never mind, we do consent all our patients here." It was patronizing he thought I was gullible enough to believe in his statement when he had to "correct" himself. In any case, I already knew this person was not sincere because he had already lied to me earlier in the conversation. (One of the news articles I brought was about Muslim male medical students refusing certain exams on female patients. When I handed it to him, he casually commented "Oh yes, I have read about this before," when the very reason I brought him articles was because he had told me in our first meeting he was "ignorant" students had problems with aspects of physical exam).

The way he corrected himself mid-sentence told me that in fact [My Medical School] has not enforced any policy to end the gang rape of patients, which according to the press, still routinely occurs in most medical schools. This is a topic that was never officially discussed at my school, and I only learned about it through my own research. Hence, students at my school are not prepared to challenge medical gang rape because they will be branded as trouble-makers for suggesting their instructors are gang rapists. This is why I believe most medical students trade in their ethical tenets to complete school, because otherwise repulsively unethical practices like gang raping patients would have died long ago had students followed their hearts, refused to participate, and reported their instructors for legal action.

Two other quotes from Dr. Robert Mendehlson, the pediatrician at [My Medical School]:

"The tragedy of this dogmatic approach to medical education is not only that it screens out the most thoughtful, intelligent, and ethical students, or that is perpetrates traditional idiocies, but also that it virtually forestalls the application of creative noninterventionist approaches to medical practice. Dr. Roger J. Williams put it well in his book, Nutrition Against Disease: Medical schools in this country are standardized (if not homogenized). A strong orthodoxy has developed that has without a doubt put a damper on the generation of challenging ideas. Since we all have one kind of medicine now - established medicine - all medical schools teach essentially the same things. The curricula are so full of supposedly necessary things that there is too little time or inclination to explore new approaches. It then becomes easy to drift into the convention that what is accepted is really and unalterably true. When science become orthodoxy, it ceases to be science. It ceases to search for the truth. It also becomes liable to error."

"My colleagues who head the nation's medical schools boast that this process of "survival of the fittest" assures Americans of the finest medical care in the world. My observation is that doctors are taught to provide a lot of medical and surgical intervention, but I don't see evidence of very much 'care.' The fittest do survive, but what are they fit for? They are the survivors of a heartless system that too often weeds out the best and the bravest - the students with compassion, integrity, intelligence, creativity, and the courage to resist the destruction of their own moral and ethical codes."


When they withdrew my scholarship, faculty told me they "firmly believed" future doctors must competently perform these exams. But this obviously is not the case at all, otherwise they would not graduate students who did not complete the exams objectively. All the students who cry and faint and make horrified faces certainly are not demonstrating objective behavior. Moreover, the school does not even give all students the opportunity to prove they have desexualized any type of medical exam, since they enforce their "rule" that one female must be present during the male rectal exam. When problems like this are marginalized, it inevitably translates to a small number of students advancing to clinical rotations ready to hurt patients expecting adequate exams, since these students feel too much pressure to act competent as future doctors, they cannot admit the exam is something they never desexualized (and they cannot admit they might faint or cry on a real patient, like they did on the actors). Students like this avoid pelvic exams as much as possible, and write "pelvic deferred" in patient charts, because they cannot be honest enough about their shortcomings to ask another provider who feels more comfortable to perform the exams instead (Article: "Managing Emotions in Medical School").

So by trivializing something important, like the inevitable cultural and personal attitudes and barriers about human sexuality in medicine, my school is hurting patients by exposing them to students who are too busy hiding their inadequacies. I thought I was more professional than these students to admit I had visceral problems over these exams, than to not admit so and make an already unpleasant exam even more unpleasant for patients. It is blatant that the only thing faculty "firmly believed" was that students never stand up for themselves if they cannot find peace with a small component of the curriculum.

Before I left, I recommended to several faculty members to start screening students. It is unprofessional and unethical to not explain these taboo exams to students before matriculation. When I suggested this to the OBGYN "Associate Dean for Curriculum", he nonchalantly replied that they "might consider it." He said this in a very condescending and indifferent tone of voice, even though as a physician, he should respect and practice full informed consent. The only person who ever got back to me was one of the ECM instructors who sent me an e-mail saying she would voice my concerns for future students but she "can't promise that there will be a change."


I am not angry I did not graduate from medical school: I do not want to work in such a hostile and uninspiring environment. But I am angry I moved to a new city to start school without knowing that the same problems that mistreated students in the past would mistreat me because my school will not clean up their system. I am angry I had to arrange so many embarrassing conversations with faculty, only to be told I was "too immature", "too sheltered", "too squeamish", and sexually abused as a child. I am angry my school ostracizes a minority of students each year over something personal like their sexualities, and believes they should all have to change their views to assimilate to those of the majority. That is something that has always bothered me.

I hope Dr. Sherman and Dr. Bernstein continue to raise awareness for patients to know and exercise their options and legal rights regarding sensitive medical exams. And as a woman, I hope American girls and women start to explore alternative practices and philosophies about their bodies and reproductive healthcare outside of the rigid setup traditional modern gynecology has to offer. I could never accept non-emergency care from OBGYNs now that I know how they are trained. If I ever wish to have a baby, I will not think twice about home-birthing with midwives because I do not want to be a woman who receives demeaning and dangerous interventions when unnecessary and often harmful to both her and her baby. And I am ecstatic to see that American women are becoming more informed about their birthing options, thanks to documentaries like "The Business of Being Born" by Ricki Lake.

Much of what I wrote here ties into various medical modesty and ethical concerns discussed on Dr. Bernstein's Blog. That is why I agreed to publicize all of it here on his Blog. I also do not mind publicizing this story further anywhere else if it might prompt a change in some of the problems I detailed.

I wanted to end by saying that I believe there should be a requirement at the national level that students are explicitly told about these exams when they apply to medical schools, which should not be laborious to implement because students all use the same application website. I contacted several individuals last fall, told them my story, provided them with news articles about students fainting and crying, and none of them took me seriously. Some of the people I contacted included the "Senior Director of Student Affairs and Student Programs at AAMC" and the "LCME Assistant Secretary". These people told me they thought most students knew about these exams beforehand. First, I have never believed that "most" is ever enough; it does not validate the fact that the system currently tramples over a minority of young students. Second, I do not know where they got their flimsy statistic that "most" know about these exams anyway, since most students have never visited the proctologist, and at least half have never visited the gynecologist. These people also told me different students face different "challenges", and so they cannot cater to one "challenge" over another. I do not believe these intimate exams are "challenges". I believe any exam that could be construed as sexual (and sexually violating) must be fully explained and consented. Otherwise, it could be serial sexual abuse and rape.

I also want to report the OBGYN "Associate Dean for Curriculum" for not following the law that women can get birth control without pelvic exams, as well as report both him and the head ECM instructor for not properly educating students about the BFOQ patient modesty law. These individuals are teaching and encouraging hundreds of future physicians each year how to be insensitive about sensitive exams, and I want to do something about that. The problem is I do not know how to report these authoritative figures, unless there are freelance lawyers any readers out there might know about who advocate for patient rights.

I look forward to reading any comments and suggestions from readers.



At Wednesday, June 29, 2011 9:37:00 AM, Anonymous Anonymous said...

What if you call for a plumber for a clogged drain.You open your door and he's standing there with muddy boots and smoking a big cigar.His first words are "you called for a f!/?in plumber.Do you tell him to leave his filty mouth,boots, and cigar outside ,or moan about it later.What if in the process of fixing the problem,he barged into the bathroom while your 15 year old daughter is taking a shower.You challenge him and he say's, lady I have a license and I'm a professional.Besides,she ain't got nuttin i haven't seen before.What if you took your $90,000 sports car in to the shop for a tune-up.How would you feel if the mechanic let the 16 year old take it for a test drive because he never drove stick before? Couldn't you consider opposite gender nudity a fear or phobia.Why do some people scream like a baby and jump onto a chair,when a mouse runs past them.Why are others afraid of spiders,snakes, or confined spaces.Would the medical field suggest(for good care)you put those people into a 4 foot square box,dump in some spiders,snakes,and mice and tell them to suck it up.We're just trying to help you.Of course not.That would be ridiculous.But that is axactly what you do to the modest.You constantly hear not to let modesty get in the way of good care.Where we disagree is who provides the intimate good care.Who decides if it will be male or female.That choice should be the patients to make,not anyone else's. In regards to bathroom privacy.For those who have never been in the service,they have what they call a 1000 man latrine.There are 1000 toilets,sinks, and urinals all in the open.No partitions.The toilets are 2 feet apart,with nothing between them.Speaking from experience,modesty was not your biggest concern.What was your biggest concern,was if the guy on the throne next to you had a double bean burrito for lunch. Have a nice day AL

At Wednesday, June 29, 2011 10:26:00 AM, Anonymous Anonymous said...

Dr. Bernstein:
Comparing a situation of superficial unease to reap the benefit of convenience to a moral stripping of one’s ethics to reap the benefit of survival is understating what a person would feel when asked to give up as much as they do to another person for bestowal of medical care. Only an analogy of like/similar humiliation and possible future psychological repercussions with like/similar sacrifice for the benefit of safety, health, or survival could associate that feeling of trading ones moral compass for benefit of fitness and survival.
One can quickly get over someone seeing their messy house, but some people never get over the degradation of being reduced to a body who must sacrifice all beliefs to receive the benefit of the skills a fellow human being possesses.


At Wednesday, June 29, 2011 10:49:00 AM, Anonymous Anonymous said...

I will also await, but it seems to me that if this is part of the training for the particular degree she's trying to obtain then she should have to do it. There is an expectation that physicians (or others with a particular degree) will know certain basic information or techniques. If one is not prepared to learn these techniques then perhaps it's not the appropriate field. Let's say I wanted to become a police officer, but I simply knew that I could not look down the barrel of a gun and pull the trigger on another human being. I can pass the shooting requirement with targets, but knew I couldn't do it with people. Is that not a disservice for people who call the police? Their situation might require an officer who needs to perform just that action. What I should do in that situation is choose a different professional path. -Onion

At Wednesday, June 29, 2011 1:10:00 PM, Blogger Maurice Bernstein, M.D. said...

Onion, yes, await her story. She wrote me today that she will have it ready in a couple of days and then you will have a chance to look at all the facts of her case and her view of what has been happening to her. ..Maurice.

At Wednesday, June 29, 2011 7:52:00 PM, Anonymous Anonymous said...

Al, that was pretty entertaining but to the point. SWF you took the words out of my mouth, while the analogy may be made, it ignores the intensity of the emotion. Dr. Bernstein, while I agree putting ones health at risk for modesty where we depart is I feel providers use this principle to justify not doing everything they can to accomodate the modesty of patients. I can handle can't accomodate, I am embarassed, and uncomfortable but i understand there is only so much providers can do. I had a lump removed from a testicle, there is only so much they could do, I know that. However, as I related before, before the surgery I had to have a ultrasound, and while they had male techs they assigned a female tech, that was a choice by them, not that they could not, they made a concious decision to to even ask. If they had said, we know this is uncomfortable, but all we have is female tech's, would have been uncomfortable but would have been ok, but they did not make that effort. How can that be justified, how can anyone say they had my best interest emotionally when they had males available but did not make the effort. I realize providers will claim they do not know, but sorry I do not buy it, they know for mamograms, they know when it is them, so I know they have to at least have a hint that opposite gender for something like a scrotal ultrasound at least has some concern for the patient. I feel to some degree providers use the principle that compromising ones modesty for their health is smart to justify not doing everything they can for their own benefit and claim ignorance to justify it. Please don't take that as a personal attack because I honestly feel you are being honest with us, but I would be surprised if other posters did not feel the same. The question is, do, would providers recognize or admit this...alan

At Thursday, June 30, 2011 5:08:00 AM, Anonymous Anonymous said...

Now I face serious medical testing and possibly surgery of some sort.
My answer will be NO if I don't get the same gender team. However, by the time I get done with the hospital if necessary and only if necessary, you may see this one on your evening news.

At Thursday, June 30, 2011 7:57:00 AM, Anonymous Anonymous said...

I will look forward to reading the story. However, unless she plans on going entirely into research (which sounds possible) I think a physician needs to complete all the training, in case he/she is the only one available, and the exam is what a patient needs.
And even if she does go into research, she will be granted a MD, and could choose to leave research and go into patient care with a part of her education missing.
So my initial impression (subject to possible change) is that she made a poor choice.

At Thursday, June 30, 2011 10:56:00 AM, Anonymous Anonymous said...

TAM - You make an excellent point, as regards to research. An MD is not a degree that only implies knowledge. It also implies an ability to practice. One may choose not to, but there is an implication that the option exists. A PhD in human physiology, as an example, might have similar knowledge, but does not imply that someone is allowed to practice medicine. So, I'm confused why she wouldn't have decided on the PhD.

At Thursday, June 30, 2011 11:49:00 AM, Blogger Maurice Bernstein, M.D. said...

First, to Onion and TAM and others: patience. To make the best ethics decisions on issues is to have available as much facts as possible and an understanding of how they are presented. We must await the facts from our student.

However, I can inform you a rationale for why a medical student working for a M.D. degree might be working into his or her education study for a PhD degree. It all has to do with the recent concept and professional activity called "translational medical research" or research "from bench to bedside".. but also "from bedside to bench" since physicians "at the bedside" will be directly interacting with scientists "at the bench" to facilitate a more rapid movement of the results of scientific experiments to useful tools for the diagnosis and treatment of disease.
Nowadays, this integration has stimulated students to prepare themselves to work in both the "bench" and "bedside" environment (a yet novel but important approach) and thus look forward to attaining both an M.D. and PhD degree. The way the two degrees may be used is by limiting the research and practice to narrow areas of specialty in both media. (For more on the topic, look up in Wikipedia "translational medicine" or "translational medical science")

I hope this explanation has been helpful to understand a possible "why". But now let's wait. ..Maurice.

At Thursday, June 30, 2011 1:55:00 PM, Blogger BJTNT said...

Dr. Bernstein,
Just a personal note to you saying thanks for all your time in keeping this blog going.

At Thursday, June 30, 2011 7:33:00 PM, Anonymous Anonymous said...

Out of curiosity I would like to throw out a question to those on this blog who express serious concerns about medical examinations/procedures involving intimate parts by opposite gender professionals or, for that matter, same gender professionals.
In a clinical situation I can appreciate that some may be nervous that the doctors/staff are in a dominant position and might feel intimidated when informed about what they should undergo. How do those people feel about exposure of their intimate parts in situations where there is no inequality, perceived or real, as, for example, in a same-sex locker room and its unshielded showers? Have they ever skinny-dipped? Would they do so in circumstances where there is no risk of legal problems? In mixed-gender company? Or only with the same gender? Do they/would they use a hot tub naked? In other words, do they have a generalized extreme modesty position, or is their aversion to intimate inspection in a medical context only? MLX.

At Friday, July 01, 2011 12:28:00 AM, Anonymous Colin said...


I have what you describe as "Serious concerns" or "an aversion' about cross gender medical care.

I have used male changing rooms for many years without any thought.

I have to have prostate brachytherapy shortly, they have organised an all male team for me, I have absolutely no qualms whatsoever about having male nursing students, or male medical students present.

I will be unconscious while my procedure is carried out over a 3 or 4 hour period, i have placed complete trust in the Anaesthetist that he will be my advocate for all male care in the OR.

I will be at the very least, devastated if he lets me down.

I would not use an of the shared facilities you describe unless i was wearing the usual swimming shorts.

I have no "double standards", I am completely consistent, no females about while i am fully undressed.

At Friday, July 01, 2011 4:18:00 AM, Anonymous Anonymous said...

for me I have a certain level of being uncomfortable it those situations but I assume many of the others are as well. I think part of it is we were raised to feel it was OK in these situations. I have heard some women put forth the argument that many women are more comfortable/accepting of exposure in the medical arena because they were "forced" to for gyn exams at a young age. I am old enough that I grew up when showers after gym class were mandatory so perhaps that factors in. I do think the fact that we are the only one exposed makes a big difference. I am curious, would you feel comfortable in a setting where everyone, 15-20 people who were not nudist were all clothed and you were the only one nude if they didn't care? Have you ever been in this type of environment to any degree. It was indicated earlier it was uncomfortable when groups of clothed people were present at naturist gathers but if I recall was attributed to something other than the fact they were clothed. This is an interesting exchange of experiences and ideas.

At Friday, July 01, 2011 4:26:00 AM, Anonymous Anonymous said...

I'm not very modest personally. I've skinny dipped - I even went to a nudist camp once (accidentally actually, but that's another story). I don't really mind anyone seeing me unclothed, if I'm not lying on an exam table.
I wouldn't like an intimate exam with multiple people looking down at me - one doctor, that's ok with me, when necessary.
Where I think I am unusual is, I don't want to be touched intimately by someone of the same gender. It just feels unnatural to me, and I am uncomfortable. Has to do with childhood experiences I'm sure, but that is just how I feel.

At Friday, July 01, 2011 6:11:00 AM, Anonymous Anonymous said...

In response to MLX's question about modesty in situations other than medical. I, for one, do not feel comfortable being nude in ANY situation, either with same gender or opposite gender individuals. The only exception would be my husband and I do feel comfortable being unclothed in front of him. I have skinny dipped, etc. with my husband only. So, for me, modesty is pretty much a part of me no matter what setting I am in. I must say, though, that medically it does seem to have another dimension as the party(ies) viewing me are themselves fully clothed. Maybe a weird way to feel to a lot of people but that's just me. Like I have said before, modesty is a very complicated thing and definitely varies from person to person. I think, then, that is part of the problem. The medical world tends to treat all patients the same obviously assuming that we all feel the same about our bodily modesty. In their defense I think they do some standarized things to address modesty but they are unwilling to deviate from those protocols (i.e. by providing same gender care, better garments, modifying procedures to prevent unecessary exposure, etc.). Jean

At Friday, July 01, 2011 9:31:00 PM, Blogger Maurice Bernstein, M.D. said...

I thought my visitors would be interested in reading postings on the ClothesFree Forum which, from 3 naturists, gives some insight into the fact that there are some women in medicine who appear apprehensive about fully examining a man. Now, one could argue that two of the women were from cultures where this might be expected. On the other hand two were physicians and the other a physician-assistant (PA) and the need to complete an examination meeting professional standards would be the argument already noted here in response to my brief description of the 2nd year female medical student’s decisions. What I am getting at is perhaps, hopefully not too obtuse, is the med student’s reaction to a “full intimate examination” may not be so unique, even among professionals. ..Maurice.

“Yesterday was the first time I received a psychical exam from a PA. She went out of her way to make sure I was covered from head to toe by a gown, my underpants and a paper blanket. While I was laying down, she would move everything around to examine me. I told her all the covering wasn't necessary and it was making me warm. She smiled, apologized and kept me covered. Last but not least, she didn't check for hernia, skin or testicle problems, but did check my prostate. She was out the door in a flash. I intend to call the office manager next week and ask why the lack of exam. As for all the covering, I did sense she was uncomfortable. She was 22 to 25 years old.”

“I have a bit of sympathy for my doctor. I am not sure if it comes from her culture or training, but it appears that she is the one uneasy with the nudity. She is a second year resident from India in family practice. I know nothing of her religion, but she does wear western clothing and the traditional white coat. When in the exam room I don't bother with the gown, but will wear my briefs. She has made the effort to examine me for evidence of skin cancer but put a drape over my shorts when examining my legs and lower back. I have not been checked for hernia, testicular lumps, nor given the classic prostate exam. When my primary care physician was a male resident from the middle east I received these exams.”
“My female GP is, I believe, Iranian and she seems to be uneasy with nudity. She will do all the test, including prostate, but always give me a paper "gown" to wear. These things are very awkward and uncomfortable, so I left it of. She was very tense and when we finished our conversation she couldn't wait to get out of the room. When the next time I saw her and left the gown on, she was a totally different woman. In contrast, my previous GP, also a woman, never bothered with gowns. "There are no secrets in a doctor's office" she would say. We used to have a conversation about health issue; I would sit and talk to her fully nude and never think twice about it. I also get regular colonoscopies done by a female specialist whose attitude seems to be somewhere in the middle; she seems to be more concerned about my possible discomfort.
I feel sorry for those people who are so hung up on nudity that they can not even tolerate a female doctor examining them.”

At Saturday, July 02, 2011 12:26:00 AM, Blogger Doug Capra said...

What you're pointing out, Maurice, is that this issue of medical modesty goes both ways. The myth is that all doctors get over their embarrassment and modesty. The repetition of the exams becomes routine. Most do, probably. But some don't. Maybe a significant number. And with the young, new doctors it may be quite noticeable to the patients. The myth promoted in medicine is that's it's all just natural, that we should not be ashamed ("There's nothing to be embarrassed about."). If that's the case, they why don't we talk about it? Why is it so much under the radar in conversation? As I've said on past posts -- it's the great, giant elephant in the room. The patient may be greatly embarrassed, even humiliated, but the doctor and/or team pretends it's not happening, or that "They'll get over it" or that, "It's for the patients own good." The doctor or nurse may be embarrassed, and the patient notices it and that may make him or her more embarrassed. But the patient doesn't say anything. Or,how about this -- both the doctor/nurse and the patient are embarrassed -- so the caregiver barely speaks, barely makes eye contact, skips parts of the exam, does other parts too quickly, and briskly leaves the room. Can't see how the patient doesn't notice that.
Who was it on this blog who said that there's really no such thing as patient modesty. We're all patients. It's just human modesty.
Yes. What you've point out is probably more common than we think.

At Sunday, July 03, 2011 2:10:00 AM, Anonymous kate said...

Why should we have any sympathy for doctors/nurses/whoever who show embarassment around the naked body? They have all gone out of their way to become 'health (don't)care professionals'. No one forced them to undertake years of study for the right to practise medicine. The student who does not want to be exposed to other people's genitalia should find another line of work. She does not have the right to rewrite the curriculum to suit herself. Patients should always be the focus of medical work. If hcps are so modest they can get a job in an office or shop like the rest of us. Maybe these poor dears just want the status of being a doctor but don't want the hard work that comes with it. Tell the student and other hcps to get over themselves. We, as patients, have enough to deal with i.e. being ill without having to pander to them and their never ending self regard.

At Sunday, July 03, 2011 10:03:00 AM, Blogger Maurice Bernstein, M.D. said...

Again, although Kate's and the others comments seem reasonable responses to what I had written about the student, I can tell you that all the facts are not out including explanations of motivations and philosophy and as in a court trial with regard to an individual's actions, we should not make a premature final judgment.

I, too, am awaiting a response to be publish here by the student. ..Maurice.

At Sunday, July 03, 2011 7:26:00 PM, Anonymous Anonymous said...

kate, it could be the case the provider was fed the same line as we patients. It is no big deal, you get used to it, in the medical setting it's different..all the things patients are told. Maybe they got into it and then found out, guess what, it wasn't like any other body part, they didn't get used to it, maybe they underestimated how uncomfortable the patients where which made them feel uncomfortable. Judging them is littl different than them judging out modesty. I understnad your point, I had one of my daughters friends tell me she dropped out of nursing school because she couldn't stand the site of blood...really, sort of like someone who is afraid of the water and can't swim buying a boat. But, people a complex, I wouldn;t want to judge without knowing..

At Monday, July 04, 2011 12:22:00 PM, Anonymous Anonymous said...

I don't want to comment on opinions in an article that is not even posted yet. But regarding kate's comment:
Let's consider that we do not know whether this person is embarrassed by nudity, trying to find a way to fit nudity and intimate touching into her belief system, trying to find a way to give all people dignity or respect, or maybe all three. In any form....not a bad assortment of theories to have on a patient's/persons/clients side.


At Monday, July 04, 2011 2:01:00 PM, Blogger Maurice Bernstein, M.D. said...

You know, based on what I know and hopefully correctly summarized at the outset of this Volume, I tend to side with swf's last comment. In fact, I think there has been a general expression on this thread over the years that physicians have an entirely different personal and intimate modesty structure than their patients--- entirely different! But is that generalization really true? I don't think so. Just because probably most physicians assume that relief of symptoms, cure and life trumps physical modesty issues particularly in a critical medical/surgical situation, that does not mean that personally are devoid of physical modesty. I think that the comments of those naturists from the ClothesFree Forum, which I recorded here previously, as they describe some of their healthcare providers reactions, supports my belief.

Of course, I too, with eagerness,am awaiting the student's writings to my blog but I think that the concept that all students entering medical school, all medical resident physicians in their training and all practicing physicians---are ALL--some other kind of creature, with no self-interest in their modesty and a total blank space in their mind regarding that physical modesty might exist at times to various degrees (from the naturists to those who insist on degrees of cover) is just a wrong concept and wrong thinking.

Yes, it could well be, as swf wrote, that it could be that "this person is embarrassed by nudity, trying to find a way to fit nudity and intimate touching into her belief system, trying to find a way to give all people dignity or respect, or maybe all three."

By the way, I am not a naturist despite my perusing the ClothesFree Forum as a resource for my blog. I definitely would feel uncomfortable exposing myself in general but I never have felt, despite a number of personal experiences, uncomfortable being exposed, as necessary, as a patient. ..Maurice.

At Tuesday, July 05, 2011 8:33:00 PM, Anonymous Anonymous said...

I'm deviating from the current thread a bit but I would like opinions about why the nursing profession has changed so slowly. First, note that the percentage of female PHYSICIANS in the US has been the following: 1970 (8%), 1980 (12%), 1990 (17%), 2000 (24%), 2010 (32%). So for over the last 40 years women have had a better chance of finding a female physician if they so desired, than men have had of NOT having female nursing care if they so desired. And additionally since 2002 the total enrollment in US medical schools has been just about 50/50 male/female.

Contrast this with nursing schools. I think everyone reading this blog knows the percentage of males enrolled in nursing schools has been consistently less than 4-5% until recently. And in addition, I throw out that in 1980, 88% of nurses where white, well above the distribution in the US population. That trend continues even today. So to me this suggests that there have been active and intentional processes in the nursing program selection process, in spite of all of the discrimination laws in the US.

But the question is why haven't NURSING programs changed the composition of their enrollment as quickly as medical schools the past 40 years? Why haven't males been recruited and/or allowed into nursing. Why not more minorities? I postulate, but don't know, that it has to do with nursing programs affiliation with teaching hospitals (the nursing students rotate to these hospitals and do externships there and often get jobs there). Since the hospitals have had no motivation to date to have significant numbers of male nurses the female nursing leadership at hospitals doesn't give feedback to the nursing programs that they need more males. So I postulate the system is fairly closed and thus change occurs slowly. Does this seem reasonable? If so, some external force would be needed to accelerate change (one force of course is the nursing shortage). Anyway, this is part of the reason I think the use of regulatory and accrediting agencies could be helpful. Shake up hospitals, and it creates changes in nursing schools faster. Ultimately it would create a more diverse nursing work force. Well - just a thought. - Compliance PhD

At Wednesday, July 06, 2011 5:34:00 AM, Blogger Doug Capra said...

Compliance PhD
I agree with everything you say about the difference between nursing school enrollment and medical school enrollment. But, we need to add this:
Doctors get better pay and better status than nurses. Since modern nursing came into being during wars -- Crimean, Civil War, Franco-Prussian, Spanish-American, WW1 and WW2 -- men were needed to fight -- since that is true, culturally, nursing has been seen as primarily a female occupation. Since nursing was one of the few professions available to women, their leadership especially tended to be very protective about it. Add to that that frankly, women have been healers and mid-wives historically for thousands of years. They are primary caregivers for the young and the family. In other words, there are many cultural and social obstacles to men entering the profession -- still.
When you add the truth of what you've said to what I've added, you see that getting men into nursing is still a difficult profess. But you're right, there needs to be more proactive steps taken by society and the nursing profession to recruit more men.

At Wednesday, July 06, 2011 5:35:00 AM, Blogger Doug Capra said...

Compliance PhD
I agree with everything you say about the difference between nursing school enrollment and medical school enrollment. But, we need to add this:
Doctors get better pay and better status than nurses. Since modern nursing came into being during wars -- Crimean, Civil War, Franco-Prussian, Spanish-American, WW1 and WW2 -- men were needed to fight -- since that is true, culturally, nursing has been seen as primarily a female occupation. Since nursing was one of the few professions available to women, their leadership especially tended to be very protective about it. Add to that that frankly, women have been healers and mid-wives historically for thousands of years. They are primary caregivers for the young and the family. In other words, there are many cultural and social obstacles to men entering the profession -- still.
When you add the truth of what you've said to what I've added, you see that getting men into nursing is still a difficult profess. But you're right, there needs to be more proactive steps taken by society and the nursing profession to recruit more men.

At Wednesday, July 06, 2011 6:46:00 AM, Anonymous Anonymous said...

One of the problems that many have understanding why women accept male doctors vs. male nurses has to do with two different reasons.

First, people are more accepting to those they know and trust for intimate procedures.

Second, the tasks that nurse perform are sometimes far more intimate than a doctor's exam.

Third, the lack of the medical profession in policing deviants of both sexes allowing for responsibility and accountability is poor.

When opposite gender care is involved and because of statistical numbers of assaults, you will find more women upset at having opposite gender care in the "preaviously assaulted population). Some feel that a chaperone is another pair of eyes further eroding their privacy.

Men have an even harder time because some don't want the female provider nor do they want the male provider. That is a difficult position and an individual position for those who have these issues.

The bottom line is this....everyone has a right to feel safe and protected, free from degradation and having their dignity in tact.

Improving the numbers of employment with male nurse is something I support. However, with that support comes the issue that instead of making things better for everyone, now the female population is a risk. Some might say they are now on more equal footing and they would be correct. However, for those of us who are female, this is an issue if the medical profession doen't take their wonderful new asset (male nurses) and place them in the most meaningful way; same with the females.

At Wednesday, July 06, 2011 7:16:00 AM, Blogger ~Charlotte said...

And, let me add to the comments about nursing; if any of you have been hospitalized recently you may have experienced that the registered nurse has been largely assigned the role of record keeper. It seems that most of his/her job is sitting at the computer and entering data. The actual hands-on job of caring for the patient is pieced-out to different techs or LPNs so that patients are treated in an assembly-line fashion. One nurse or tech will rotate through each of the rooms to take blood-pressure, another will come through to check something else. Sometimes you can have 5 people in the patient's room with 5 different jobs to do including taking your lunch order. And, yes, these are mostly women but I think the predominantly low pay and low level of responsibility make it less appealing to those who want to be the main wage-earner. On the other hand, my impression is that in nursing homes and extended-care facilities, many of the health-care workers are men who can lift and adjust the patients. The current hospital paradigm is high on tech but low on actual patient caring and sensitivity. Maybe with the interest in alternative medicines, traditional medicine will be able to grasp the concept that people are more than a body and that their emotions and feelings have much to do with healing and wellness (although I doubt it as medicine is all about the bottom line now and will only get so, so much worse if it becomes socialized.)

At Wednesday, July 06, 2011 2:30:00 PM, Anonymous Anonymous said...

The comment re. the profession's self-policing of deviants brought to mind an issue I've been thinking about for a while, although perhaps it should be a separate topic:

Police officers, firemen, etc. have to have psychological evaluation prior to being accepted into the profession. Often (or always?), before getting each new job.

Is/should the same be true for medical professionals? People are at least as vulnerable to them as they are to police/fire personnel.

At Wednesday, July 06, 2011 4:07:00 PM, Blogger Maurice Bernstein, M.D. said...

TAM, you may have forgotten that each medical student has 4 years of psychological analysis on a virtual daily basis by a number of observers in the medical school and hospital environments. This not an hour or two sit across the desk or fill out a form type of evaluation but an ongoing critical evaluation of the student's thinking but also behavior in both interaction with colleagues, teachers and patients. All of this is done before the MD degree is presented at the end of the 4 years. Hopefully those few students who are in unhealthy professional shape will be filtered out. But unfortunately it may be otherwise: a study published in 2005 in the New England Journal of Medicine from Univ. of California, San Francisco found that doctors who were disciplined by state medical boards were three times more likely to have exhibited unprofessional behavior while in medical school. It may be that some of the students we identify showing unprofessional behaviors in medical school are yet not adequately managed by the school administration. But also there are still policemen and firemen despite their psychological evaluations end up as behavioral outliers that make the news. ..Maurice.

At Wednesday, July 06, 2011 4:24:00 PM, Anonymous Anonymous said...

It's not the medical students that are the problem. The problem are the low level employees.

At Wednesday, July 06, 2011 5:47:00 PM, Blogger BJTNT said...

I totally agree with July 6, 4:24 PM Anonymous' comment, but where are the adults? Where is the leadership in medical operations?

At Wednesday, July 06, 2011 10:07:00 PM, Anonymous Anonymous said...

Thank you for the insightful feedback. Per Doug’s comment I researched today and clearly see how pervasive the stereotypical belief is that feminine qualities (“nurturing and caring”) are more aligned with traditional “nursing”.
Gail’s comment about a nurse’s role currently is exactly what I observe daily. Nurses have so many documentation tasks, so many scheduled drug administrations, and other activities that I see the characteristics essential for the modern nurse as 1) competent, 2) detail oriented, 3) respectful. There is no time for a nurse to be nurturing in the current adult population. No hand holding and mopping the brow anymore – the hospital wants to discharge you asap. Sure to be able to show empathy is important and I think males can do that. But keeping track of all the tasks and at the same time being respectful of the patient seem most important. I don’t see that either sex has an advantage in this skill set. And if you couple that with the fact that the median salary of a nurse is more than the median salary of a family of four in the US I don’t see why more men are not going for nursing jobs.
Searching the web I find most hospitals in the UK recognize that hospital patients may prefer nurses of the same sex. At this randomly selected site ( their patient privacy and rights states: “6. That you may ask to be cared for by a nurse of the same sex and that every effort will be made to meet your request”. What is interesting about this is today men represent only 10.21% of the nursing workforce in the UK. 10.21% is just a slightly higher percentage of men in nursing than in the US. Yet – in the UK hospitals have found a way to commit to their patients to provide them, in most cases, same sex providers if they request it. This suggests that many hospitals in the US SHOULD be able to accommodate modesty requests. – Compliance PhD

At Wednesday, July 06, 2011 11:19:00 PM, Blogger Maurice Bernstein, M.D. said...

Compliance PhD, I know that I speak for the majority of the frequent and long term visitors (those visiting here for a year or years) to this blog thread that we most appreciate your presence and participation. As I have noted previously I have been looking for some representation from the "other side" of the healthcare provider-patient interaction. Yes, we have had a doctor or two write but just briefly and certainly not as extensively as you have. I have tried to get a hospital administrator and one said he would visit but never did. So.. I am most appreciative of your presentation of facts as you have experienced them and your suggestion. Thanks. ..Maurice.

At Thursday, July 07, 2011 4:39:00 AM, Anonymous Anonymous said...

Maurice, I do realize that doctors in training are observed during their training. However, most of the people observing them are not trained psychologists, and the profession does tend to "stick together". So I do view that as a different thing than a formal psychological evaluation, with objective instruments such as an MMPI-2 rather than just subjective opinions.
Also, I agree with the other poster, than many problems occur not with physicians, but also nurses or lower-level personnel.
And of course, firemen and policemen have issues also, no screening process is perfect.
I'm not even necessarily saying that such evaluations should be done - but it is an interesting consideration. Especially in the view of privacy/sexual misbehavior issues - which people in training would be unlikely to display in front of supervisors.

At Thursday, July 07, 2011 9:16:00 PM, Anonymous Anonymous said...

I think there are several points of interest, I don't think I ever felt Dr's lacked personal modesty, quite the opposite, I think many providers have personal modesty and it is multi facited one for their own nudity, one for their patients which breaks into two areas one for their patients being uncomfortable and one for them being uncomfortable with their patients nudity. I have observed the later two and assume the first. Where I have an issue is I feel providers downplay patients modesty desires for the systems status quo. Accomodating patient modesty for same gender is ignored or relegating to the patient "demanding it" vs addressing it proactively and honestly. That being the case, is it any wonder patients would be oblvious or perhaps uncaring about how the fully dressed provider feels in their familiar work environment vs a patient who is in a strange facility exposed? It does however provide a possible connection to some providers to connect with them on the issue,

On the professional aspect, I have a family member who with very minimal training possibly a CNA maybe not, but very little training, mainly a few night classes at a local small college/junior college and now works in the local hospital including a urology clinic affiliated and does all sorts of intimate procedures. The Dr's allow this, use her, and therefore to me are partly responsible. The Dr may have a lot of training and observation, the RN maybe, the "nurse" or tech assisting and present for all of the exposure...very little to none. So, if I am to consider the Dr in charge, the buck for using these people lands on their desk as well as the hospitals etc....especially when they are used for convenence and time management vs need....alan

At Thursday, July 07, 2011 10:04:00 PM, Anonymous Anonymous said...

I feel that the reason many of us have been traumatized in medical settings is because of the lack of power and control over our bodies and the attitude of the providers...I have had medical experiences where I have been exposed...and it hasn't bothered me because I was ASKED first by the doc or nurse if it was OK; their attitude was caring and warm and so I felt in CONTROL. It's always when I wasn't asked and was treated like a slab of meat that I ended up feeling violated. BTW, medical visits are supposed to be about the patient and what makes them comfortable, not the providers!

At Thursday, July 07, 2011 10:29:00 PM, Anonymous Anonymous said...

Article on privacy glass:

With all the money hospitals charge us, why can't US hospitals buy these?

At Friday, July 08, 2011 2:08:00 AM, Anonymous Anonymous said...

when i was 12 i was in a group home and was told i needed a physical.i was chaperoned by an unfamiliar female and i was a male.we talked and listened and to the radio on the way there.i thought she was just going to take me to the appointment and wait outside.we filled out some questions and both went into the exam room.i thought she would leave when the doctor came in.the doctor arrived for my exam and she was a woman.she came in and the two of them talked then she said to me take off my i was in front of two woman i had never met before and removing my clothes.i was almost 13 and just started getting pubes.when she said that i must have looked scared and she said to leave my underwear it wasnt that bad.there were two chairs i was sitting on one the lady on the other.i had put my clothes on the chair next to her.then i got up on the exam table.i was sitting on the table and my legs were facing the lady in the chair.the doctor was doing her normal things.then she said lay down.the two women were talking and she started pressing on my stomach and in one quick movement my underwear were around my ankles.i was in shock.she was standing at my chest talking to this lady who could see everything in full view.she now took my underwear off completely and put them on the chair with my other clothes.there i was completely naked in front of two women i didnt even know.and they were both getting a great show of seemed to last a long time but i was probably over in a minute or two.then she said ok and i leaped up to get to my underwear jumped off the table and almost fell. the lady sitting in the chair caught me.yes i was still completely naked.she actually helped me put my underwear back on and my stuff was just inches from her face.on the ride home it was very quiet and we didnt talk about what happened.i never saw either of them again.

At Friday, July 08, 2011 5:43:00 AM, Blogger ~Charlotte said...

I agree with Alan as to where responsibility lies concerning what goes on in a medical setting and I addressed this specifically in a lengthy letter that I wrote our hospital administration concerning patient violations. I believe and stated that it is the administration and leadership (i.e. in this case, a specific administrator and the doctors) who were responsible for creating a culture of insensitivity in their radiation oncology center. They call the shots and set the tone.
For example; a surgeon is in charge of his/her Operating Room. It is up to him/her to direct that the patient be draped and prepped quickly so that his/her OR staff get the message. Over the course of this doctor's career, his/her patients are then treated humanely and everyone knows it. Residents and students learn from this and continue this tradition in their own practices because they know it is the right way to treat people and the physician is respected for it.

At Friday, July 08, 2011 5:44:00 AM, Anonymous Anonymous said...

Anne, you are correct. The reason behind this is that without your acknowledgement and consent, what happens is against your will and creates all the negative feelings most of us feel.

With information comes consent or decline all within our legal rights.

This attitude of entitlement and what amounts to public stripping if done in a room full of people without your consent, carries with it extreme psychological damage.

At Friday, July 08, 2011 9:55:00 AM, Blogger Maurice Bernstein, M.D. said...

Good(?) news today from an ethicist writing on a bioethics listserv:

"A historical note.

Physicians have not always done physical exams. Plato observed (in Republic) that the physician healed the patient by use of his mind, not his body, which made medicine one of the “ruling arts”. The physician’s mind (with patient consent and cooperation) assumed command of the patient’s body, ordering and directing it during the course of the illness. This was not necessarily pleasant for the patient, as Plato points out in Gorgias.

And for several centuries, physicians got their information mostly by interrogatories (including the patient and family). Somewhere along, there began the examination of bodily output (for smell and appearance) and later came the actual touching and listening.

There’s now literature commenting on the demise of the physical exam – e.g., notwithstanding the omnipresent “flea collar,” that physicians are no longer competent at auscultation, that ultrasound is the new stethoscope. Occasionally, articles appear in JGIM insisting on the importance of the physical exam, bemoaning its decline, etc.

I can’t recall where I saw it, but this week, there was a story (somewhere) that the pelvic exam may also be going away, supplanted by imaging and other technology…

So, perhaps full circle…with a resulting niche for “touch therapy” as clinical skill."

So it may be that the physical exam and the physical modesty issues in the doctor's office will turn out to be an anachronism. ..Maurice.

At Friday, July 08, 2011 11:01:00 AM, Anonymous Anonymous said...

What exactly is the purpose/motivation for those
naturists visiting this blog. Should we expect to
be enlightened or a sudden epiphany of sorts.

Am I to accept their behavior and expressions
and somehow integrate their beliefs into mine.

My first question is why this blog? After all there
are thousands of mammography clinics across
the united states as well as thousands of labor
& delivery wards.

I recently surveyed perhaps 60 local mammo clinics in
my state and not one clinic was ever questioned as
to why men don't work there. Are there not female
naturists in your group.

Google mammography forums and you will find a few
mammography forums,however,they are listed under
radiology forums and are resources for mammo techs,
not patients.

If it's anyone with modesty issues I would think women
seeking a male free environment would be your first
choice of getting your personal expression and beliefs
out since on this blog we only talk about privacy concerns
whereas those clinics actually have it down 100 percent!

Why haven't you approached those facilities? I realize
my sampling is low,yet it certainly is representative. What
would you think some responses might be? I would be
willing to bet it wouldn't be anywhere near as tame as the
responses you see on this blog.


At Friday, July 08, 2011 12:51:00 PM, Anonymous StayingFit said...

Anne said "...I have had medical experiences where I have been exposed...and it hasn't bothered me because I was ASKED first by the doc or nurse if it was OK".

I couldn't agree with you more, Anne. For me, it all comes down to respect. The provider needs to respect me enough to let me know what is going to happen, why, and to offer me the opportunity to decline.

For instance, I would never, ever permit a chaperone to be present during an intimate procedure, because I find this to be disrespectful. This is especially true if I am not asked if this is OK, or if the person's real purpose is not made plain to me. Try to sneak one in as an "assistant", when no assistance is necessary, and that will definitely not be well received!

At the same time, I have often allowed students to examine me, or to be present during an examination. At my recent colonoscopy, I had the GE and his resident (both male), along with 4 nurses (2 students) and a tech, all of whom were female.

In all of these cases, I was asked first, so I had no issue with the presence of the students. Not only did I not feel violated, I felt a bit of pride in knowing that I helped with their education.

A little respect goes a long way.

At Friday, July 08, 2011 3:45:00 PM, Blogger Maurice Bernstein, M.D. said...

PT, I not quite clear as to what you would have me do on this "Patient Modesty" thread as moderator. First of all, I started with the first postings in "Naked" in August 2005 and as moderator I had nothing to do with directing the conversation except to insist on civility and sticking to the basic topic as set out by doctor Atui Gawande's theme dealing with patient modesty issues and physician responses as he wrote about it in the New England Journal of Medicine article. That's all: civility and sticking to the basic topic. How the twists and turns of the discussion were made were set by the visitors though I would try to light up a turn with some question or something of my own view or experience.

Almost from the outset, I have been looking for responses both from physicians or the medical system but generally without luck. But I also wanted feedback about personal modesty issues in the medical care context, if any, by those who intentionally live a life where they have their naked bodies exposed to others as part of a self-interest or an occupation and thus we got one male nude model but no porn movie actors or prostitutes. We have had commentaries from a naturist in the past and a couple naturists recently. The purpose: I wanted to discover whether modesty in the context of medical diagnosis and treatment is separate from apparent diminished physical modesty concerns in other contexts.

PT, if you are aware of other resources that would be willing to write here, please inform them of our existence. They would be welcome. ..Maurice.

At Friday, July 08, 2011 3:53:00 PM, Blogger Maurice Bernstein, M.D. said...

Anonymous wrote the following today erroneously to now closed Volume 38.

when i was in the hospital for a week blood sugar 1000.i asked if they had a shower.they sent in a girl to bath me.after alot of arguing they let me take a shower myself.they wanted her to bath me.they had a shower for a wheelchair that i used.she had to stand there and watch me shower i guess in case i fell.there was a stall like a small elevator 5x5 ft.there was no where to change or curtains.she was very was just us two alone.later found out she was 16.there were no problems.i was just shocked that she was that young. i thought she was a nurse.she told me she was a volunteer.

At Friday, July 08, 2011 6:11:00 PM, Blogger Doug Capra said...

StayingFit and Anne -- You make a good point, one I've been saying in many posts. For most people, I think, this modesty issue is as much or more about being treated with respect as it is with personal modesty. I've talked about how context plays such an important role and that those with no patient experience in this area can't really know how they will feel until they're confronted with a specific situation. When that happens, if the patient feels safe and respected, that his or her dignity is being protected, that he or she has some control, some say in what's going to happen. Being asked about how one feels about one's modesty and about one's choice in gender care is part of that respect, I believe. Not asking often translates as not caring which easily translates into disrespect.

At Friday, July 08, 2011 8:05:00 PM, Anonymous Anonymous said...

Here is a link to the same sex privacy law, Title 7 that I've spoken so much about. It says volumes.

At Friday, July 08, 2011 8:43:00 PM, Anonymous Anonymous said...

it didnt matter that she was a girl.i am more comfortable with woman seeing me naked than was the fact that she was only 16 and a volunteer.i mean if it was the other way around and what if i would of let her bathe me? im sure she would have washed everything including my privates.being 30 at the time should a sixteen year old volunteer be given total power over you?

At Friday, July 08, 2011 8:58:00 PM, Anonymous Anonymous said...

i am the one that posted about being 12 and examined by two women.let me be more clear the woman that took me there was unrelated and not a nurse. she was a staff member at the group you think she should have come in and stayed for my physical?also the doctor was standing at my chest blocking my view with my private parts facing the woman in the chair so she had full view of everything.

At Friday, July 08, 2011 9:02:00 PM, Blogger Maurice Bernstein, M.D. said...

Another reminder: To establish and maintain continuity of discussion which is essential to any discussion where a point is made by one discussant and then may be countered by another, it is imperative that each discussant be identified in some way. On this blog, anonymity of the writer can be preserved but I urge that some pseudonym should be applied to the commentary and consistently used by each visitor writing to these threads. OK? ..Maurice.

At Saturday, July 09, 2011 9:51:00 AM, Anonymous Anonymous said...

To anonymous who was 30 y/o when he had to shower with a 16 y/or volunteer observing. If you were a fall risk no hospital in their right mind, nor hospital Risk Manager would allow the use an untrained 16 y/o female volunteer alone to prevent a fall. In the event of a patient injury a plaintiff attorney would easily crush the hospital for this act. And similarly, if you had fallen and injured the girl her parents would be compensated without contest. Also, no hospital has in their falls prevention policy “minor volunteers may be used to assist fall risk patients in toileting and showering activities”. Simply absurd. If this really was the reason the volunteer was used than complaints to your State hospital licensing agency, the Joint Commission, and the Board of Nursing would be substantiated.

So let’s assume you actually were not a fall risk at that time. And for reasons we won’t know your nurse decided to have the minor volunteer bath you or observe you bathing. Please realize volunteers are NOT PART OF THE HEALTH CARE TEAM. You had a right to refuse them observing you and bathing you. Your rights for respect, privacy and dignity were violated. Using a minor for this is also inappropriate. Also please realize there are doors on bathrooms and pull cords in the bathroom. Bathroom doors open both ways so you could have been allowed to sit in the shower on your own with the door closed and with the volunteer waiting outside the door in case help was needed. The doors are not sound proof so any commotion would have been heard. But at least you would have been treated with dignity (regardless of whether you are comfortable naked in front of women or not).

Finally – more often than not the people entering your hospital room are unlicensed lower level staff/aides. Hospitals are supposed to identify clearly for the patient the job position for all people (done via ID badge usually). Some do a better job of this than others. But you have a right to know what type of individual is in your room. Usually you only have one nurse assigned to your care every shift. Everyone else is not a nurse. - Compliance PhD

At Saturday, July 09, 2011 10:20:00 AM, Anonymous Anonymous said...


For you to seek responses from other groups was
never in question. My comments were directed to the
naturists directly and as I expected they have made no
comments on any other medical blogs or forums that I
can find.

Certainly, they have every right and every means to
communicate their ideals. Why just this forum? Is it more
of a social gathering for them than anything else.

Personally,to me it seems like a big waste of time
to be a nudist with all the traveling and so forth when
all one has to do is wait for your next emergency room
visit. You get to actually be a nudist with all the unnecessary exposure.


At Saturday, July 09, 2011 10:51:00 AM, Anonymous Anonymous said...

Is everyone aware of the “voluntary” submission of quality of care data by hospitals to CMS? Since 2004 hospitals have been submitting data to be eligible for higher reimbursement from CMS. Any consumer can review hospital performance info that has been submitted at One category of performance data is patient satisfaction. That hospital survey you get either called about or in the mail after you were discharged is actually used for this performance indicator and gets publically reported. You can see the standard set of survey questions all patients should get at by selecting the “Survey Instruments” tab. There are a couple questions about being treated with courtesy and respect too.

However in May of this year CMS has taken another step. A final rule was passed that starting October 1, 2012 acute care hospitals will have a fledgling pay for performance system called Value Based Purchasing. There will be many clinical indicators of course, but there also will be a patient satisfaction indicator (called the “Patient Experience of Care Measures”). Whether the hospital gets paid an incentive payment or not depends on the weighted scores of all the indicators. Under Patient Experience of Care Measures 10 of the survey questions from HCAHPS (see link above) were selected. Those where privacy/dignity/respect issues could be scored include questions rating: 1) communication with Nurses, 2) communication with Doctors, 3) Responsiveness of Hospital Staff, and 10) Overall Rating of Hospital.

So by next year not only will these ratings continue to be publically available but they will start to affect hospital reimbursement. And it is inevitable that the government pay for performance programs will evolve further. So there is another factor in the future that may motivate hospitals to address patient preferences (and of course improve the quality of care also).

So don't ignore those post-discharge hospital surveys, especially if your privacy issues were not addressed. FYI. – Compliance PhD

At Saturday, July 09, 2011 1:38:00 PM, Anonymous Anonymous said...

To anonymous who was 30 y/o when he had to shower with a 16 y/or volunteer observing.

well i guess i was a major pain in the butt to them.they said i was the only one taking a shower on the floor.i was in the bed 24 hours a day and that was my only time up.i had to fight them to let me take a shower.i think it was a old closet converted to a shower.this wasnt a brand new hospital.there was just a big heavy door a couple of feet in and then the nicest shower i ever was a fiberglass stall about 5x5 with a small ramp in front.there was no chairs or nothing inside to sit on.right inside the door was a small doctors chair and a small plastic hamper.the door was just a big door with no sign on it.i remember a call nurse cord in there.but i dont know if it worked or not.they were dead set against me taking a shower.once they said there were no towels on the whole floor.i think that they had to dry the whole shower when i was done or something.i dont know they kept making far a badges my eyesight had gone as far as reading anything.i think they had badges cliped to there sides of the top of there pants.two days in they asked me to read stuff and sign it and i noticed i couldnt see to read.and the nurse said thats just what happens when you get older.but it was because my blood sugar had dropped rapidly.i was talking to the nurses alot because i was in a room by myself.they kept switching my room everyday.until they put me in a room with a guy on a respirator lung machine.i was only in there an hour or two.he was hooked up to two big very loud machines.they moved me right at like 10 pm so after about an hour i went out and sat in the hallway for about an hour.i got a private room that night and stayed there until i i would talk to the nurses every time they came in.i asked her how long she had been working there and thats when she told me.she had on a uniform like them but maybe a little different.i think hers was dark blue.she never claimed to be a nurse.i didnt know she wasnt a nurse until the end of my stay.most of the nurses i had where tiny and skinny so she looked like them.she couldnt have caught me im 5'11 200lbs.i wasnt about to be bathed in bed by her or any other nurse.because thats what they really wanted to do.


At Saturday, July 09, 2011 2:03:00 PM, Anonymous Anonymous said...

To anonymous from a group home that had a physical exam at age 12 with a female chaperone - your female group home staff member in all likelihood qualified as your guardian for that trip to the physician. Now she and the female physician could have decided to have her wait outside and any finding could have been discussed after the exam (best practice would have been to ask YOU your preference!). Sounds like that would have been more comfortable for you. Unfortunately such consideration of male modesty/privacy never enters the mind for many chaperones and physicians in these situations. Was it inappropriate she attended your physical exam - probably not since you were a minor and she your guardian. Was it optimal or best practice - no. Hopefully your unsettling experience at age 12 will help you insist on your rights as you experience health care throughout adulthood. - Compliance PhD

At Saturday, July 09, 2011 7:04:00 PM, Anonymous Anonymous said...

even though i was a minor and she my legal guardian i had only known her for the half hour ride seems that they were more comfortable with my complete nudity in front of them than me.i only had on underwear and she took them off completely and put them on the chair next to the staff she stood in front of my chest so i couldnt see but the lady in the chair had full view of what was going on.did she do this for legal reasons or was she giving the lady a free why would she put my underwear on the chair next to her she knew i would have to get up and get them right.i wonder if they were just having fun at my expense.are young males and females normally completely naked for physicals esp when others are present?

at 12

At Saturday, July 09, 2011 7:41:00 PM, Blogger Maurice Bernstein, M.D. said...

With regard to the previous discussion about whether medical students should learn about the personal and emotional reactions on both sides of the speculum (in addition to the learning of the anatomy and pathology and technique) of the pelvic or other intimate physical exams, you may find the link to the following brief article very pertinent. The title is "Examining Ourselves: Exploring Assumptions about
Teaching Pelvic Examinations in Midwifery Education" Read it and return to give your opinion. ..Maurice.

At Saturday, July 09, 2011 9:05:00 PM, Blogger Doug Capra said...

Compliance PhD -- You write: "Unfortunately such consideration of male modesty/privacy never enters the mind for many chaperones and physicians in these situations."
Sorry, Compliance PhD -- I can't believe that caregivers in those situations are not aware of the embarrassment they cause patients in such cases. They're aware. They may rationalize the "good" they're doing as justifying that embarrassment -- but they notice. After years of this they may avoid eye contact and/or utilize other defense mechanisms to convince themselves that it's not that bad, or that the patient will get over it, or that it's all for the best, or that, I've got a job to do, etc.
If you are correct, and they are that obtuse -- then they need serious reeducation. They may need to be reeducated in this area, but it's not because they don't notice.

At Saturday, July 09, 2011 9:23:00 PM, Blogger Doug Capra said...

Interesting article, Maurice. The sentence that stood out for me was this one:
" How do students who would prefer not to participate because of a history of sexual abuse, transgender surgery, or other legitimate
reasons for wanting privacy about their bodies register their concerns without drawing attention to a matter of personal privacy."
A few points:
The word "patient" could easily be substituted for "student" -- but it doesn't fit into the schema of medical education. This is interesting because in this situation the "student" is being asked to play the "patient." But when the student confronts the same kinds of obstacles and pressures patients face in similar situations -- the student doesn't want to become the patient. Understandable. Who really wants to become the patient? Not even "patients" the will face every day wants to become the "patient."
"legitimate reasons" -- We see this expression come up in this debate often. Pray tell, what distinguishes "legitimate" from "illegitimate" reasons -- and who gets to decide, and based upon what criteria?
But, it's a good article as far as it goes. It doesn't go far enough, though. The "student" needs to analyze why he/she doesn't want to become the patient. What are the reasons? Specifically. What's so special about the pelvic or any genital exam? Why the fear? Why the embarrassment? Students need to discuss this, journal about this. Eventually, they may begin to see that their feelings are not much different from the ordinary, everyday patients they will see every day.

At Saturday, July 09, 2011 10:08:00 PM, Blogger Maurice Bernstein, M.D. said...

Doug, hopefully when my stressed ex-medical student comes up with her description of her concerns and philosophy for this thread you should get one student's answers to your last questions. ..Maurice.

At Sunday, July 10, 2011 9:31:00 AM, Anonymous StayingFit said...

Compliance Phd, in responding to the post by the gentleman who was forced to shower in the presence of a 16 year old volunteer, you said:

"...more often than not the people entering your hospital room are unlicensed lower level staff/aides. Hospitals are supposed to identify clearly for the patient the job position for all people (done via ID badge usually)."

The poster responded that he was having trouble seeing, so differentiated badges would do him little good. I would find myself similarly disadvantaged, if I was in a hospital without my glasses.

You have mentioned previously that the more facts that one has, the better. So, names, dates, places, etc, would be good to know, if some issue should arise. However, if one cannot see the badges, how could one know the identity, or job title, of the caregiver involved?

Are these people required to identify themselves verbally, if the patient is not able to see very well? Are they required simply to give their name, or must they also include their job title?

I would think that a patient must be made aware of a person's role as a volunteer before that volunteer could perform any sort of care. In fact, I am surprised that a volunteer is allowed to perform any patient care, period. But, perhaps I am wrong about that.

I am also curious as to your advice on how the poster could have handled his situation. It seems that he argued with the nursing staff, in order to avoid being bathed by the volunteer. Is there someone at the hospital to whom he could have requested to speak, in order to resolve this? I like to think that this person would have devised a better solution than the one he was forced to endure.

I ask, because I would like to be prepared, should I ever face a similar situation. The time to find out how to respond is before you are sick, and vulnerable. Pursuing the matter after the fact is still worthwhile, but it is better to avoid the violation of your rights before it happens. I appreciate any advice that you could give.

At Sunday, July 10, 2011 11:45:00 AM, Blogger Hexanchus said...


I agree that all medical personnel should introduce themselves to the patient by both name and job title - relying on badges is simply not sufficient for the reasons outlined.

My recommendation to patients is - if they don't adequately introduce themselves, simply ask them who they are and what their job title is.

As I've advocated many times on this thread, while we should be able to expect that health care providers will treat patients with respect, it is incumbent upon us to be proactive in making sure we receive both the care and respect we are entitled to.

At Sunday, July 10, 2011 12:13:00 PM, Anonymous Anonymous said...

Staying Fit,
I tried to post earlier and don't know if it went through so I will repeat.

First, you have the right to refuse any treatment whatsoever as long as you are mentally competent.

Second, ask questions about what they intend to do, state of undress, who will be in the room and the purpose and then make you gender needs known.

I will tell you from experience if you give them any "wiggle room" your gender needs will not be met and you will be upset afterwards.

Some people are totally comfortable explaining their previous history and some are not; you shouldn't have to but when it comes to et
hics and "to do no harm", you should win this argument every time. Good Luck! Remember...YOU ARE IN CHARGE

At Sunday, July 10, 2011 5:33:00 PM, Anonymous Anonymous said...

I'd like to post my disappointment to the majority of posters on this blog.(Compliance PhD and Doug excluded.)Here you have a 12 year old boy who writes in about his modesty violation looking for compassion.He knew at 12 his modesty had been violated.Lets change some facts.12 year old girl at group home , is taken for a physical by a male staff member.Male doctor tells her to take off all her clothes with male chaperone present.Male doctor does a GYN exam in full view of male chaperone.We all know,that would never happen.Double standard.You bet.He asks,are they having fun at my expense and mentions a free show.People comment about a 30 year old exhibitionist who prefers to be naked around women.She was 16 years old.I understand he didn't know her age at the time.Ever hear the term 16 will get you 30.(16 year old girl vs 30 years of jail.)He's a 30 year old man,not a little boy.It's his choice.Back to the 12 year old.He stated,he must have looked scared and she said to leave his underwear on.What possible reason could she have for making him sit naked for the complete physical.Did she ask the chaperone to step out or turn around before she removed his underwear?Did she ask if he would be more comfortable with a male physician?NO.It was their playground and they were going to do what they wanted to do.No concern for male modesty here.If you don't speakup as a adult,that's on you.Who was speaking up for the 12 year old boy?Kind of like putting the fox in charge of the hen house.If someone would have treated my 12 year old this way,there would have been hell to pay. Have a nice day. AL

At Sunday, July 10, 2011 6:35:00 PM, Anonymous Anonymous said...

Doug – your replied: “I can't believe that caregivers in those situations are not aware of the embarrassment they cause patients in such cases” wrt a 12 y/o boy being examined by a female physician with a female “chaperone” present. This is one of the key concepts and one of the very reasons I ended up on this blog. This will take me two posts to give you my perspective on this.

If one carefully measures particular human traits, like modesty and level of respect one finds a continuum of values. Some humans are extremely modest. Some have no modesty and feel more comfortable being nude. And many people fall in between. There usually is a bell shaped curve (“normal distribution”) that reflects the continuum of values. Similarly if you measure one gender’s perception of the other genders modesty, there will be a continuum of values. I am fairly convinced that a good portion of the female gender believes: a) men are less modest and equally important b) men do not need considerations for modesty. That is, that bell shaped curve has a mean value that is pretty far towards the side of the graph where men have little to no modesty according to the female gender’s perception.

Why do I believe this? First, a woman’s social history plays a big role in this mental bias. For example, many females grow up in households with male siblings. Mothers teach and involve their daughters in the childcare and child rearing duties. Daughters help bathe their little brothers, they see how their mother treats the males and how she protects and encourages female modesty, etc. Society for years has been consistent at reinforcing at almost every turn that women have more modesty and should have more consideration for their privacy and that men have less privacy. This prejudices the female attitude toward male modesty.

Now you overlay on top of that those women who go to nursing school or medical school where they learn about examining and treating “The Patient”. They receive scant training on issues like modesty and almost no training on regulatory requirements and privacy requirements. They are trained to perform certain tasks, like inserting a catheter or performing a physical exam organ-by-organ system. Most of that training is not about reinforcing concepts of patient modesty, but to get to a diagnosis and a treatment. And yes, I believe their training does reinforce ignoring patient “discomfort” during the exam/treatment. And when other women are doing the training I’m sure the concept that men a) are less modest and b) men don’t need the same modesty consideration does either intentionally or unwittingly come into play. Finally I have repeatedly observed nurses and physicians who believe they have rights to treat and perform procedures to “The Patient” because s/he has presented to their hospital domain. That is, they are so disconnected from the person in room 17, they believe “The Patient” in room 17 has relinquished most of his/her rights and they have authority to do many things to “The Patient”. This of course couldn’t be further from the truth.

So to conclude part 1 of my response I personally think it is MORE probable that a female pediatrician who has practiced for some time simply is disconnected from the concept of modesty for 12 y/o boys. This doesn’t make it right - I just think this is the more probable explanation. We need to get the health profession to recognize that all patients may have modesty concerns and that for no additional cost they can modify their practices and leave less emotional scars. Part 2 to follow. - Compliance PhD

At Sunday, July 10, 2011 6:39:00 PM, Anonymous Anonymous said...

Part 2 to Doug. There are many reasons to address providing dignified and respectful healthcare to all patients. Aside from the obvious benefit to the patient, there are financial, regulatory, and legal reasons for this too. So I’ve been puzzled why the gross double standard in the provision of care that is discussed in this blog. Since I work with mostly females I’ve taken the opportunity for many months now to try and understand the female perspective and why we don’t accommodate the male patient’s preferences more. I’ll be the first to admit what I write next is anecdotal and not scientifically rigorous study but it is suggestive.

I’ve actually discussed with many (~15) female (and reputable) nurses and non-nurses alike the exact same situation of this 12 y/o boy, the full physician exam (PE) with a chaperone present. This is a situation that is very common and many of us have experienced it. When I ask the females about the breast/pelvic exam with chaperone they all relate the chaperone is female. When I inquire about the use of the male observer as chaperone all that I talked to find that unsuitable, and some find it very offensive. Than when I mention that many males actually get exams from female physicians, but in this situation when the physician insists on a chaperone it always is a female. Now here is the interesting part – the females that are not Nurses see the analogy to their situation having a male observer present as chaperone and can verbalize how that might be uncomfortable (although not with the same vigor as their situation). The Nurses however don’t see any issue with two females being present for the PE although they intellectually realize it is the analogous situation to the male observer present for a female PE. When I ask why is it acceptable for a male to have two females present but not a female to have one or two males present for the PE I have actually heard “males are less modest”, and “some men actually prefer it”. Some can’t articulate well why it is okay. But isn’t it curious they have acquired a belief that males have less need for modesty considerations?

Certainly not all women believe this. There is a continuum in beliefs. But for me now I’m thinking the average female nurse and physician thinks the male patient on average has little modesty and little need for modesty consideration. Doug – your assertion is possible too – but more depressing and for everyone’s sake I hope you are wrong. Regardless – I hope we can help change professional attitudes toward modesty and their practice habits. –Compliance PhD

At Sunday, July 10, 2011 8:54:00 PM, Anonymous Anonymous said...


Previously,you mentioned about hospital surveys.Many hospitals
don't send surveys out to patients.
Are they required to send a survey
to every patient? I don't think so
and it certainly works to their


At Sunday, July 10, 2011 11:20:00 PM, Blogger Doug Capra said...

To Compliance PhD:
I don't disagree with some of what you say. I've said as much on past posts on two blogs. But I stand by my original point. You have to be blind to (1) notice that males, the young boy in this case, is embarrassed, perhaps humiliated, and then (2) believe men are not as modest as women. See the discrepancy? The conflict -- is seeing believing, or is believing seeing? If seeing is believing than the experience of what they see will influence what the believe. Believing is seeing is as much a rationalization as anything else. I wrote about this extensively on past posts -- the elephant in the room syndrom. Different professions are socialized to "see" certain things and "not see" other things. "Not seeing" doesn't mean they don't see that elephant -- it means they don't regard what they see as relevant. But when theory bangs up agains the reality -- i.e. they see and realize men are embarrassed, modest, humiliated -- how does one deal with that? Deep down one knows the truth. They know.
Now, is what you say possible for some caregivers? Certainly. For all? Certainly not. How many in each category? Who knows? But I've interviewed nurse, too. And most have honestly acknowledged they know the men are embarrassed and that some would rather have same gender care. Some of these nurses didn't have a choice. No males were available. Others didn't what to appear wimpy, afraid or unwilling to do what was expected of them. A few said they would catch hell from their supervisors if they requested a male nurse instead of doing the job themselves.
So -- I thing you're right to some extent, but not all the way or perhaps even most of the way.

At Monday, July 11, 2011 5:03:00 AM, Anonymous Anonymous said...

Al, my post was specifically for someone who was asking how to handle a situation as an adult.

Complianc, Ph.D, you are so right. have posted a before and after version of myself. The first was before I was sexually abused in a hospital and the second was after.
Before, I never even asked the gender of a provider. Now, based on my experience, I ask lots of questions and legally found a way to protect myself and get what I want. I also know if the payment ever meets the pound, while I may change my mind, legally they will have to do what I say. That is my right as a competent adult.

At Monday, July 11, 2011 8:35:00 AM, Blogger Hexanchus said...

Ditto what belinda said...... my post was specifically in response to the same question.

At Monday, July 11, 2011 11:54:00 AM, Blogger Maurice Bernstein, M.D. said...

As you can now see in the Introduction to this Volume 42, the writings of our "stressed student" has been published. I want to publicly thank her for writing on my blog about her personal experiences and including her research on the subject. She has a lot to say and much of it does follow many of the views which has been expressed repeatedly throughout this thread by others.
She would like further discussion of the issues she raised. I fully support her in her attempts to publicize these important aspects of medical education and finally medical practice. Thanks! ..Maurice.

At Monday, July 11, 2011 12:53:00 PM, Blogger Joel Sherman MD said...

Compliance PhD,
Doug and I have been greatly impressed by your comments and knowledge on this board. We'd like to invite you to contribute an article to our mutual blog.
You have much to add to the conversation. An article on our blog would make it permanently accessible and searchable to all.
Please email me ( ) if you are interested or would like to discuss it.

At Monday, July 11, 2011 4:00:00 PM, Blogger Maurice Bernstein, M.D. said...

3 days ago I posted this comment from an ethicist on a bioethics listserv:

"A historical note.

Physicians have not always done physical exams. Plato observed (in Republic) that the physician healed the patient by use of his mind, not his body, which made medicine one of the “ruling arts”. The physician’s mind (with patient consent and cooperation) assumed command of the patient’s body, ordering and directing it during the course of the illness. This was not necessarily pleasant for the patient, as Plato points out in Gorgias.

And for several centuries, physicians got their information mostly by interrogatories (including the patient and family). Somewhere along, there began the examination of bodily output (for smell and appearance) and later came the actual touching and listening.

There’s now literature commenting on the demise of the physical exam – e.g., notwithstanding the omnipresent “flea collar,” that physicians are no longer competent at auscultation, that ultrasound is the new stethoscope. Occasionally, articles appear in JGIM insisting on the importance of the physical exam, bemoaning its decline, etc.

I can’t recall where I saw it, but this week, there was a story (somewhere) that the pelvic exam may also be going away, supplanted by imaging and other technology…

So, perhaps full circle…with a resulting niche for “touch therapy” as clinical skill."

A physician-ethicist responded there with the following:

"Just one perspective from the patient point of view, but many of our imaging procedures are still invasive, as every woman whose ever experienced a pelvic ultrasound knows, or any colon imaging procedure, etc. There is still bodily invasion of many private orifices, with less personal attention and decorum and even trust than may exist with one's provider.

I share this, as the issues of who invades the body, how and where learning occurs (often the exam is partially repeated by radiologist, after the technician, adding to the dignity discomfort for the patient), still have elements of ethical concern. Are ultrasound and radiology techs gaining consent from patients to do the exam more than once?

I do feel the provider -pt relationship is suffering a tremendous distancing, that at times, the physical exam is the only contact, connection w/ the person, as Electronic records, and electronic email get the provider further from seeing, hearing AND touching the patient.

these elements of change have not yet been fully evaluated as to their nature in the healing relationship. If anyone is aware of studies evaluating the impact of the further distancing of actual contact in the provider-pt relationship and its effects on outcomes, I would love to be directed toward them."

How do you feel about the values for the doctor-patient relationship beyond the diagnostic value comparing the physical examination vs procedures. ..Maurice.

At Monday, July 11, 2011 4:46:00 PM, Anonymous StayingFit said...

To AL: I share your outrage, concerning the exam of the 12 year old boy. I am sure that we are both pleased to see the comments that were written after yours. Certainly that story merits attention.

However, I disagree with you, concerning the gentleman who was assigned a volunteer to watch him as he showered. It would seem that your disappointment in the responses to the first item colored your comments on the second.

I won't repeat your statements, since they are abusive. I will simply say that the person who posted that story deserves better than to be ridiculed, and to have his character questioned. Especially when such accusations are not supported by the contents of his post. Frankly, that portion of your comments should never have been allowed to be published.

To Belinda and Hexanchus:

My sincere thanks for your advice and comments. It is because of folks like you that I continue to return to this blog.

At Monday, July 11, 2011 6:54:00 PM, Blogger Maurice Bernstein, M.D. said...

I am about to write the obvious. Unlike those of us who participate in hospital ethics committees who must base our decisions regarding the ethics of a situation based on known stakeholders and verifiable facts, all of us who are attempting to interpret the "good" vs "bad" behaviors within the medical system on a blog like this where those presenting the case are mostly totally anonymous and there is no proof whether the stories presented are real experiences or simply devised scenarios are significantly disadvantaged.

Don't get me wrong: analyzing the possible ethical interpretations and consequences of devised scenarios is still a worthy activity to make some theoretical conclusions. But those doing the analysis should be aware that unless they know the validity of the facts and the validity of those presenting them, their conclusions cannot represent support or rejection of any advocacy for any specific but anonymous writer to this blog. ..Maurice.

At Monday, July 11, 2011 9:09:00 PM, Anonymous Anonymous said...

I too would like to thank Compliance PhD for contributing to this blog. I appreciate the details of the inner working of healthcare you provide and especially the attitudes of doctors and nurses. Although I don’t fully understand why they have these attitude, apparently neither do they. But it is rare to encounter those in the healthcare industry that are willing to talk about it, to tell it like it is. It confirms what many of us believe exists is healthcare, the double standard in mixed gender intimate care (female pt, male nurse = bad but male pt, female nurse = perfectly ok) that sites like allnurses repeatedly refuse to allow to be discussed. How the healthcare industry deals or doesn’t deal with those patients that have modesty issues and what we can do to change it is why we are all here.

I also want to thank “stressed student” for her fantastic and detailed explanation how she personally felt violated by what she was required to do and how she was far from the only one who felt this way. Just as patients have a right to their modesty boundaries I believe that doctors also have a right to their modesty boundaries. It’s a two way street or at least it should be. The condescending attitudes of some of the instructors at her medical school are truly disturbing. I wonder if all the power hasn’t gone to their heads and the old adage about absolute power rings true once again. Although you spend most of your time about the abuse of women by medicine, thank you for at least mentioning that men get mistreated too. As a married man with 3 daughters, I am especially concerned for them. SWF was right on again, stressed student” was fed the line “It is no big deal, you get used to it, in the medical setting it's different.”

Dr Mo, can you explain the reason for removing the name of the medical school? Why protect them and the horrible attitude of the Dean and some instructors? I will say one thing though, I do appreciate you publishing peoples posts verbatim, even the angry ones, anger that seems justified when abuse and exploitation is revealed. ~Anon52~

At Monday, July 11, 2011 9:36:00 PM, Anonymous Anonymous said...

To Staying Fit - Each shift when the new nurse comes on duty s/he should be introducing themselves (by their first name) to each patient. Many hospitals have info boards in the rooms where they write your current nurse’s name and that of an aide that might be assigned to your room and other info. There is a call button by your bed that rings to the nurse’s station. You can use that to ask the names of your nurse. Any patient has an absolute right to know who all caregivers are. As you only have one nurse assigned to you per shift a good rule is everyone else coming in the room is not a nurse. Some visiting your room may have different types of licenses (e.g., social workers, radiology techs, etc.) and many will be unlicensed aides, food service personnel, house cleaning, etc. If you are unsure who they are ASK that they show you their ID badge or ring the nurse’s station to verify who they are. This is not only for privacy and modesty reasons but also for SAFETY reasons.

If staff/physicians are placing you in an uncomfortable position, or being abusive or refusing reasonable requests than ask to speak to the Unit supervisor and/or Unit Manager. If that doesn’t work ask to speak to a House Manager. Higher up the hierarchy are the hospital Risk Manager and the Administrator-on-Call, both of which can be reached by using your telephone and dialing “0” and asking to be connected to these individuals. You can also ask to speak with the Compliance Officer. Generally there is a Risk/Compliance type person on call 24 x 7 (generally the House Manager or Operator knows how to reach this person). Also, at admission you are given your Patient Rights in written form. In those rights will be spelled how to file a grievance with the hospital, with the Joint Commission and with CMS and possibly with State licensing. Grievance is a specific CMS term and means more work for the hospital and potentially more negative consequences. So be sure to assert you wish to file a grievance when you reach Manager, House Manager, Risk Manager, etc.

As for the shower/bathing situation I would have asked to take a shower. I would have insisted on privacy (no one else in the shower). I would have followed their instructions (hold onto hand rails at all times, use the shower seat, use the pull cord for emergencies, let the assistant know when I’m done and dressed, etc.). The assistant/aide could wait outside the closed door for goodness sakes. It is highly unusual a minor was sent to do this and we do not allow volunteers to perform clinical duties at my institution.

To PT - Currently it is “voluntary” for hospitals to conduct patient satisfaction surveys. If they do conduct them they are eligible for full CMS reimbursement and conversely they lose some reimbursement if they don’t participate. Next year the scores (and not just participating) will factor into CMS reimbursement. (If the hospital you went to does not participate in Medicare, e.g., a VA hospital, than they may not care to survey, no incentive for them). Not all patients have to be surveyed but there is a minimum number that must be surveyed per unit time. Surveys can be phone calls or via mailing. Mailing has a low rate of return so institutions that use the mail system usually send surveys to all patients discharged (to get enough responses back). Phone surveys have their own problems and can be more expensive. Surveys should be done with days to up to 6 weeks post discharge. – Compliance PhD

At Monday, July 11, 2011 9:36:00 PM, Blogger Maurice Bernstein, M.D. said...

Anon52, though I suspect the policy exhibited by "stressed student's" medical school is probably generic in the United States and initially I told her that I would publish the name. When it came to a final decision, I was concerned about the identification of the various faculty through their positions in the medical school and whether it was ethically fair (what ethically I would term "just") to have her critique of their alleged faculty misbehavior without contacting them myself and presenting them with her writings and give them a chance to defend their position on my blog at a minimum. I decided I did not want to engage in that process and hold up publication of her writing.. so..I decided to withhold direct disclosure of the medical school name. ..Maurice.

At Monday, July 11, 2011 9:47:00 PM, Anonymous Anonymous said...

OK, thanks for the explanation Dr Mo. Also, an apology to SWF and Anon of 7-3-11 @ 7:26pm for mixing up the "fed the same line" quote. ~Anon52~

At Monday, July 11, 2011 11:35:00 PM, Blogger Doug Capra said...

Stressed student is giving us the inside of what I've brought up a few times on these threads -- the hidden curriculum. The hidden curriculum is much more powerful than the formal, academic curriculum. You can teach all you want in the classroom about draping, patient dignity and respect -- but what really counts is the behavior, the attitudes, the culture of an institution and its leaders. It's rare to get such an in-depth, insiders view of what goes on in some medical schools. The attitudes and world views of the medical staff she describes matches what we've been talking about here -- the gender neutral position; a program to resocialize patients toward the prevailing medical view on modesty; the attitude that what the patient doesn't know won't hurt him/her. With stressed student's essay, we see how this behind the scenes culture affects not only patients, but medical students as well.

At Tuesday, July 12, 2011 6:12:00 AM, Anonymous Anonymous said...

As for the shower/bathing situation I would have asked to take a shower.

i had to ask repeatedly everyday the one day they told me there were no towels on the whole floor even though i was the only one taking a shower.

I would have insisted on privacy (no one else in the shower).

they wanted to give me a bath in bed.

I would have followed their instructions (hold onto hand rails at all times, use the shower seat,

there were no hand rails in the shower and no seat.i think it was meant for a wheelchair.there was a little metal doctors stool that the girl would sit on in the corner.the shower was a good distance from my room and there was really no place to change and no cutain. i had to get undressed ,dry off and get redressed in the stall.

use the pull cord for emergencies, let the assistant know when I’m done and dressed, etc.). The assistant/aide could wait outside the closed door for goodness sakes.

i think that they did this for their enjoyment or as a game of power.

It is highly unusual a minor was sent to do this and we do not allow volunteers to perform clinical duties at my institution.

i had just been diagnosed with diabetes and my blood sugar was 1000 i told them i had dizzy spells.i was very tired but otherwise alright.there had been a lot of people running in and out of my room.nurses and their assistants in training,nutritionists,and cleaning they were moving me everyday to a new nurse introduced me to her and her assistant she said she was training her.i had several nurses a day but mostly saw those two. i hardly saw anyone at night.there were different people on the weekends too.the 16 year old came in alot and talked to me thats why i thought she was a nurse.they all had badges but they were just blurry rectangles to me.i told them that i couldnt see to read 2 days in.there were several people coming in and out of my room all day they would talk to me but not really say what their position was. i had never had trouble seeing before sight got better two months
later.the hospital closed down around 8 months later.

At Wednesday, July 13, 2011 12:04:00 AM, Anonymous Colin said...

My first hip replacement 4 years ago, I was like a lamb to the slaughter, I went along with most things the hospital wanted to impose on me, I did however refuse point blank to allow a female nurse watch me shower, this caused a lot of argument.

My hip replacement a few months back, a totally different story, BEFORE i was admitted, i addressed all dignity issues up front. When I was actually admitted, they allocated a male nurse to look after me and I had absolutely no problems allowing him to support me when I showered the day after my procedure.

Recovery time for this procedure was less than half for last time.I cannot say anything scientific based on such a small sample size, just that my general well being was MUCH better when I had taken control of things and stated in advance, what considerations I would be wanting.

I even had an all male OR team.

I am now back at work and feeling good, contrast with last time when I suffered PTSD.

At Wednesday, July 13, 2011 8:16:00 AM, Blogger Hexanchus said...


I agree. While stressed student's essay gives us a valuable in depth view of the situation from another perspective, I can't say I'm really surprised at what she had to say.

What I find very disturbing is the overt suppression and outright castigation of those students like her that have the courage to ask "WHY?". It saddens me that those who would have the courage to effect needed change in the profession are, as a result of this type of mistreatment, driven from it.

In the words of Kahlil Gibran:
"The teacher who is indeed wise does not bid you to enter the house of his wisdom but rather leads you to the threshold of your own mind."

IMHO, the instructors she describes don't even come close, and by their dismissive attitudes do both their profession and humankind a disservice.

At Wednesday, July 13, 2011 9:20:00 AM, Blogger ~Charlotte said...

"Stressed student" brings up many excellent points and issues. I am unsure though where or how we can respond to her? I am also wondering if there is a more private way than this blog to respond to her about some of the issues she brings up?

At Wednesday, July 13, 2011 9:32:00 AM, Anonymous Anonymous said...


Congratulations!!!! I'm so happy that you got what you needed and a great result. Continued good health and again, Congratulations! Well done for all of us!!

At Wednesday, July 13, 2011 11:23:00 AM, Anonymous Anonymous said...

I appreciate the candidness and effort put into the essay by this medical student. She certainly brings to light some troubling attitudes at medical with regard to how students are treated. However, bearing all that in mind, there is nothing even remotely convincing as to why an MD should be conferred upon any medical student unwilling to perform these tasks, if indeed these have been established by the medical community as necessary skills; and it appear that they have.

I understand that she may have been given a "false bill of goods" prior to entering medical school and was not treated with respect and so forth. Those are problems with the medical school, but they should not impose a change on the profession itself or the expected skills of the profession. There is no line of correlation.

I feel for her and all of the moral twisting and judgment she's had to endure. But all of those wrongs put upon her do not address my primary issue...that a physician must be able to perform the skills necessary for a physician to perform. It doesn't mean they ever will, but who really wants a physician who is qualified in all of the procedures they personally felt were necessary or ethical while in medical school? This is becoming an even more important issue as medicine moves more and more toward evidence-based treatment.

I brought up the example of a policeman (at least in the US) earlier. I applaud someone who refuses to take a human life. But certainly to take the job of a policeman, one must be willing to draw their firearm and point it at a target and fire...with full knowledge it may result in death. Yes, they want to be a peace keeper and want to save lives, not take them...all admirable positions, but there is an expectation by the citizenry that if they are in immediate danger a policeman will be able to take the action to take an assailant's life to save a victim. Similarly, there is an expectation by the citizenry that their physician will be competent in all of the procedures (highly specialized skills an obvious exception) that a patient might require.

- Onion

At Wednesday, July 13, 2011 1:31:00 PM, Blogger Maurice Bernstein, M.D. said...

On reading the "stressed student's" essay, I found missing was what she had told me previously about her intent to go into translational research by getting both a PhD and MD degree. When I reminded her that this was a significant missing part of her essay, she realized her error and has written me the following which I have inserted into her original essay as she directed. Here is the part of the essay that she originally left out. ..Maurice.

"I started reading Dr. Bernstein's Blog as a medical student, and contacted him back when I was trying to resolve my concerns with faculty. He bought to my awareness today that the essay I wrote for the Blog does not mention my personal career aspirations, which is something I told him about last summer. I realize this is a pertinent detail that several readers have asked about in their responses.

I entered the program at my school to prepare for a career in translational services between medicine and investigational science. I wanted to focus on pathologies of the brain and nervous system. So I was looking to develop into the capacity of a pathologist or maybe a neurologist who conducted translational research on that organ system. I was not aspiring for a career in a field like family medicine, emergency medicine, internal medicine, and obviously gynecology.

When I learned about these invasive genital exams, I found them violating enough to refuse when unnecessary. Realizing they were not part of my future responsibilities, I thought the most professional and honest approach would be to discuss all of this with faculty"

At Wednesday, July 13, 2011 1:44:00 PM, Blogger Maurice Bernstein, M.D. said...

To respond directly to Charlotte and her question "I am also wondering if there is a more private way than this blog to respond to her about some of the issues she brings up? "

The "stressed student" has given me her permission to publish here her e-mail address since she anticipated that some visitors might like to communicate with her directly and she would find value for that to happen.

Her e-mail address is:

However, I am sure myself and others would also encourage your continued communications about her issues on this blog thread. ..Maurice.

At Wednesday, July 13, 2011 2:08:00 PM, Blogger Maurice Bernstein, M.D. said...

Onion, perhaps after you have read the missing portion of "stressed studen's" essay which I posted above, you might find it helpful in reconsidering your views.

Consider that in medicine and medical education there are many possible examples in which the dictums, habits and procedures have virtually become anachronistic. It is possible and maybe even likely that the need for teaching invasive genital/rectal exams to every medical student regardless of their planned final career may be unnecessary in these days of translational research where in many cases as in the case of the "stressed student", in no way will the researcher be handicapped by failure to have learned and performed genital/rectal examinations. Not only "unnecessary for the future career" but also "unnecessarily traumatizing" to certain students such as our student writing to this blog.

We can present other medical anachronisms and discuss it on another thread. By the way, many of these outdated philosophies and behaviors are presented (actually "passed on") by the elderly attending physicians to the fresh students, interns and residents and constitute part of the so-called "hidden curriculum". ..Maurice.

At Wednesday, July 13, 2011 4:39:00 PM, Anonymous Anonymous said...

I have a hard time reading Stressed Students revelations regarding the gang raping of anesthetized patients. In an earlier response to me by Dr. Bernstein he related that the medical community basically doesn’t agree with this behavior and made me believe that it was a thing of the past; yet, Stressed Students indicates that Gang raping (Through digital pelvic and anal examination of patients without their consent) of anesthetized patients is apparently a "time-honored tradition" in medical schools, and is still regularly occurring. If the sheriff’s office of the county in which this occurred would send in undercover techs (Don’t put it passed them to send ucos to training for this purpose) into the operating rooms to witness and record these obvious violations of criminal and civil law, then maybe some prosecutions could raise the issue to law makers and laws could be established to lessen the chance of such an outrageous crime. I personally hate these people and would love to see them rot in prison. I encourage you to mention it to law enforcement as I will.

Compliance PhD: Thanks for your input. It has been the most constructive and helpful information to date. How do women protect themselves from a team of hungry medical students waiting for them to fall asleep as described by medical student Hilary Gerber in The article the unnecesarean? Is there any way that a husband can suit up and go with his wife into surgery to protect her? Or pay for a same gendered medical professional not affiliated with the hospital to witness the pre op through the recovery operation? Can the whole process be filmed with sound for the patient‘s future reference? This whole thing is shocking, morally unacceptable and far beyond what is considered reasonable.

Compliance PhD: Regarding the post with the following excerpt: Women who decline pelvic exams and episiotomies receive them against their wills! How can that be when the law indicates that patients must consent to medical procedures. Medical procedures may not be undertaken without a patient's consent, absent unusual circumstances. Why can’t the patient refuse in these cases? Fire the doctor on the spot! Incidentally, where are the fathers of the children being born?

Compliance PhD: Regarding your post with the following excerpt: If staff/physicians are placing you in an uncomfortable position, or being abusive or refusing reasonable requests” That was very useful information and I appreciate it. I would like to ask you though how that would play out in a situation where the patient is being told that an opposite gender tech or nurse is all that is available for an intimate procedure and if the patient refuses indicating that he or she will wait and try their luck on the next shift. I’ve heard of doctors trying to discharge them from the hospital or emergency room due to their failure to allow invasive opposite gender exams. If they’re threatened with discharge what should they do?


At Wednesday, July 13, 2011 4:40:00 PM, Anonymous Anonymous said...

AL: Regarding the 12 year old, I agree with you. There would have been hell to pay. A twelve year old is way too old to expose in that way without causing psychological damage. This doctor was obviously a sadistic pervert who enjoyed what she did and the power she wielded over a child. The chaperone is just as guilty because she should have put a stop to it. It sounds like they both were in it together. They’re clearly pedophiles.

Regarding the 16 year old assigned to wash the adult, I would have made it plain That I did not want her to wash me (No consent) and raised hell citing the health need to be cleaned. Then file a formal complaint with local law enforcement regarding child abuse, neglect and child exploitation. You went on record that you did not want to be humiliated this way but the only way that you could maintain your health and sanitation after days without bathing was to allow a child to bath you. At least you would make a point.


At Wednesday, July 13, 2011 5:26:00 PM, Anonymous Anonymous said...

Dr. Bernstein: Your points are well taken and I am not unsympathetic to this individual. But we're talking about a degree that has a meaning and value beyond just the academic. To the vast majority of people in this country an MD connotes one who deals with patients, a healer. If there were a track for MD wishing to only do research (and I know a few myself) then perhaps a new designation is needed (such as AMD, Academic MD) to indicate someone with all the knowledge of an MD, but who does not treat patients and can never be eligible for a license to practice medicine. And that is my concern.

JD has done the same thing. There are AJD (or similarly themed) degrees that are essentially for those wishing to go into law but not wanting to take the bar and not able to represent someone in legal matters. This makes sense, as a JD connotes that someone is eligible for the Bar and qualified to fully represent you as an attorney.

She is not interested in practicing medicine. Understood. But the degree being conferred upon allows her to do just that. Should she be allowed to, without the full training that other physicians had, if she happens to change her mind? I don't feel she should, and thus should not be given the degree that allows her to do so. I know many successful translational medicine researchers that are not MDs.

PS - I'm not an MD or a JD or a PhD. This is not about my personal standing.


At Thursday, July 14, 2011 7:44:00 AM, Blogger Maurice Bernstein, M.D. said...

Oops!I erroneously rejected belinda's posting from today. But here it is with my response. ..Maurice.

"It is very interesting that the same themes of mistrust and deception are present during medical training as we experience as consumers especially during hospitalization.

What does this say about the ethics of the medical care?

I personally have seen someone lied to about what a nurse was putting in the IV. The patient instructed this nurse not to put a specific medicine in the IV in the a.m. as this medication made her sick and would be tolerated better in the afternoon. The medication was a tranquilizer.

Later that day she became ill, asked to see the records and sure enough the medication was administered against her will and she was lied to. There was no doubt she needed the medication (it was a tranquilizer) but at 84 was overwhelmed and never filed a complaint. This is just one of thousands of horror stories.

Maurice, do you feel that the medical community is accountable and responsible for having "punishments fit the crime" for such egregious behavior?
belinda "

I think that the medical community must be accountable for behaviors such as what you described. After all, the current thinking and hopefully actions to prevent the huge numbers of medical errors from occurring is that the patient should as fully as possible participate in the error prevention. This means, in one example, the patient should be made aware of the name and action of all medications administered and to avoid errors by refusing to take a medication which had not been discussed by the nursing staff or physician with the patient. In the case you noted, if the patient was not made aware she would be unable to perform this requirement. Even if the patient was made aware of the nature of the medications to be administered, a patient with capacity for making her own medical decisions, has the right to reject taking that medication. What happens next depends on a professional/social interaction. The nurse must follow the doctor's orders unless the nurse is aware of other circumstances (such as the patient's rejection ). In that case the nurse must call the doctor and discuss the future management. It may be necessary for the doctor to take time and discuss the matter with the patient. The problem is that some doctors have a "don't bother me now" response and the nurse may be left with no further instructions. The nurse may also resist calling doctors who repeatedly give the nurse "a hard time" (with "bad" talk) when the doctor is disturbed by the call. So the nurse may just go ahead and follow the doctor's orders in the chart. Notwithstanding that excuse, yes, the medical team is responsible for ignoring a patient's request. I am sure Compliance PhD could speak to this issue in more detail. ..Maurice.

At Thursday, July 14, 2011 9:08:00 AM, Anonymous Anonymous said...

AT 12: I was a house parent in a boy’s group home right out of college. I had never seen a nude male. Looking back, I know my concern was to avoid ME being embarrassed. Some boys would streak out of the shower to get their pajamas on so they could have a snack. We never embarrassed them or shamed them but focused on teaching appropriate behavior. The showers were supervised by male staff – and they needed supervision! Amazing the things you can do w/ soap except actually use it to wash the body. Whenever I had to enter the boys bathrooms or bedrooms I would announce myself first to give the time to cover. In a living situation like that there was exposure; zippers get stuck, boys get tangled in their swim suits, rashes need checked. I’d like to think I treated them most respectfully.
If my employer had assigned me as staff to take you to the doctor, the same thing would have happened. I did not know how to protect myself in medical situations, still don’t, how would I protect you? At that age, I would have “followed dr’s orders”. We both would have been traumatized. Me for witnessing your trauma and not knowing how to protect you. I would not have known to ask for a male dr for you or that you would even want one. I would have not known about draping or any of the things I’ve only recently learned by following this blog. Most children were taken by their county social worker to dr apts and most social workers were women.
However, in the car ride back, I would have said something to you. I would have provided a safe way for you to vent your feelings. Like, “I hate it when I step in gum!” and follow your response to see if we continue with I hate statements. I am sorry for your experience. I hope this perspective from an inexperienced chaperone with good intentions will help you. ~tear

At Thursday, July 14, 2011 3:12:00 PM, Anonymous Anonymous said...

Thanks Maurice for answering my question. I will say that this woman needed the tranquilizer very badly and can almost understand why they did it. Not only was she upset with the staff and could have taken legal action, for me, a trauma survivor, is just added to the mistrust that I already feel whenever I'm in a similar situation.

This same patient was sent by helicopter to a major hospital after hitting her head and needing emergency. Even though she was competent and didn't want the surgery, they waited until she was in a coma and then called a distant family member to ok the surgery even when she said that she didn't want to take the chance of ending up handicapped (having had many relatives that suffered from stroke). They operated anyway and the good news for her is that she is fine.

At Friday, July 15, 2011 4:56:00 AM, Anonymous Anonymous said...

It was very interesting reading the student's story. While I am sorry that she did not get to realize her ambitions, I think my original impression stands.
My believe is, if you want an MD, you have to complete the training. Once you have an MD, you are allowed to practice medicine, not just do research. I don't want an MD who has not completed all the training.
I believe that medical school is a very rough thing. I'm sure the professors are not always nice and considerate people. I'm sure I can find many things to dislike about how they treat the students. Re. the treatment of patients, that's been addressed frequently in this blog, I don't feel the need to comment further.
But - re. this student - I have to side somewhat with the medical school. To think that you have to tell students just what sort of exams they will have to perform before entering medical school doesn't seem reasonable to me. People are generally aware that physical exams occur.
This student seems to see these exams as sexual. Having had both consensual sex, and medical exams, while both may involve a finger, they are certainly not the same. I am certain that some students are very uncomfortable with learning to perform the exams, I'm sure I probably would be. But to characterize them as sexual, I don't believe that is correct.
This may not be a popular opinion, but my impresison is that the way the school handled it was probably not good, but I can see some validity to their opinions that this student was not psychologically ready to be a physician.

At Friday, July 15, 2011 9:04:00 AM, Blogger Maurice Bernstein, M.D. said...

Mandy wrote the following today. She gave a link which only showed comments but not the original posting. The link I exchanged below shows both the original posting and the comments.

By the way, I was writing about anachronisms in medicine (remember?).. well, Mandy picked up another one: performing a cervical exam for cervical cancer when there was no cervix present. ..Maurice.

Many opinions and comments about this story and the student here:


At Friday, July 15, 2011 9:17:00 AM, Blogger Maurice Bernstein, M.D. said...

To go to the most recent portion of the discussion where Hexanchus describes our "stressed student" essay and comment by others follow, here is the original link by Mandy:


At Friday, July 15, 2011 1:41:00 PM, Anonymous Anonymous said...

Just to be clear (and I may have read it wrong) but does "stressed student" perceive penetrative exams as sexual and not testicular, genital, and breast exams?
Is it the act of entering the body (either gender) as opposed to genital viewing and touching that defines the sexual opinion?
This is not a judgment, but rather: a point of interest as to where a student might draw the line of benign vs. sexual.
I am not discounting all of the fine and valid points of the article, which I would like to comment on later, but was looking for clarification of this point.

At Friday, July 15, 2011 3:15:00 PM, Anonymous Anonymous said...

I had a couple additional thoughts after re-reading that NY Times article that "stressed student" quoted, talking about students fainting, crying, etc. at having to do the genital exams. I had read that article in the past. Actually, it was quite positive, talking about how the teaching got the students over their fears, so that when they got to actual patients, they would be more comfortable and skilled.
So, in my opinion, just because someone finds something stressful doesn't make it bad. I've read of how stressed students are the first time they use a scalpel on a live human. Or, for that matter, how incredibly difficult dissection in the anatomy lab can be. I would think that there are probably quite a few stressful parts of medical training - but does that make them wrong? I don't think so.

At Friday, July 15, 2011 3:43:00 PM, Blogger Maurice Bernstein, M.D. said...

On review, it appears to me that the "stressed student" finds that the entry itself of the rectum or vagina is to her the traumatic act which also may have sexual connotations. This would be in contrast to visualization or touching of the genitalia or anus. I even suppose that the invagination of the scrotum ( folded back on itself to form a cavity) to reach the inguinal ring which we routinely do to check for hernia would be acceptable to her since that is not entering the body cavity.

Hopefully, our "stressed student" will write further to the thread to respond to the comments and questions. ..Maurice.

At Friday, July 15, 2011 7:10:00 PM, Blogger Doug Capra said...

As I see it, there are several separate issues relative to the stressed student account. The one we seem to be focusing on is whether a medical student should have to learn to do these kinds of intimate exams. Another is how necessary some of these intimate exams really are. These two, of course, are closely connected. A third is the bullying and unhealthy atmosphere that exists in the culture of some medical schools -- a part of that hidden or underground curriculum.
To what extent these kinds of exams is an important issue. The possibility that they are not as necessary as the medical community says, is one thing. That should be corrected. But that doesn't mean that they never have to be done. My sense is that if a medical student gets a degree that allows them to actually practice medicine as a doctor, then they need to know how to do these exams and that means clinical experience. If they could go through medical school without that expectation of practicing medicine, that would be different.
What disturbs me most about stressed student's account is the unhealthy atmosphere, the bullying, the holier than thou and patient as object attitude, the negative hidden curriculum. She has really exposed that.

At Saturday, July 16, 2011 5:33:00 AM, Anonymous Anonymous said...

Whether or not these exams are necessary on a routine basis certainly is a topic for debate. But I believe that, under some circumstances, they are necessary. A rectal exam is performed if there is suspicion of bleeding for example. So I do believe that people who have a degree that allows them to practice must be able to fully examine a patient.
As far as the atmosphere in medical school, sadly it does not surprise me. Because, I believe often patients are treated the same way. To me, more than just privacy, the issue of the power imbalance and often lack of respectful or even kind treatment is a more widespread issue of concern to me.

At Saturday, July 16, 2011 11:47:00 AM, Anonymous Anonymous said...

Thank you Dr. Bernstein.

So with that being said, it appears that "SS" was not exactly trying to turn the medical arena on its heels with multiple and extreme modesty issues. "SS" didn't shun any and all issues dealing with nudity and intimate patient care. She did seem to have a concern that admittedly many other students had.
While I understand the point some posters have made that a curriculum cannot be tailor made to the student, neither should educators be able to pick and choose what they are and are not willing to openly and honestly discuss. Whether there was a dignified solution to her issues may now never be known, but certainly a challenge of unique opportunity lost that the institution should have embraced.
By instead berating and humiliating a student we see that some in the medical arena want to continue the culture of leaving these issues in the dark. One could easily see that as a focused agenda to keep the status quo of the medical mentality.
Discourage the source: dissuade anyone who wants to make changes and these issues can remain unspoken.
A year or so ago we were discussing students (I believe on this blog) and how they felt about these issues. How they may have either been eased into the system or just educated into silence. We see here at least one answer to our question. No wonder it is so difficult to make changes on the 'outside' when it is so protected 'within'.


At Saturday, July 16, 2011 12:35:00 PM, Anonymous Anonymous said...

Under nursing news on all nurses it is suggested that
the nursing industry constitutes a "CULT". Now I can
certainly see that and all the negative definitions that
describe that industry.


At Tuesday, July 19, 2011 5:49:00 AM, Anonymous Anonymous said...

In regards to the stressed medical student: personally I do not see the need for medical students to be taught pelvic and rectal exams if they have already decided on a speciality that would never require the need for these exams. For instance, a ear, nose and throat doctor or a podiatrist. It just doesn't make sense to use instuction time on something that the individual will never use in their practice. I think intimate exams are usually reserved for either specialists in that field or for primary care physicians, ER doctors and such. I do believe that the culture of medical school would probably be slow to change but that doesn't mean that change would not be for the better. Long established institutions should be open to change; just because things have always been done a certain way doesn't mean there isn't room for improvement. Even though stressed student was only intending on going into research, I still wish she would have found a way to stay in the system because she would have made a valuable addition to the medical field with her viewpoint and committment to her morals/integrity. Jean

At Tuesday, July 19, 2011 9:01:00 AM, Anonymous SS said...

Thank you so much for reading the article and commenting. I will try to respond to individual comments. But I noticed the last several comments were all centered around the same topic of my school withdrawing my scholarship, so I will respond to that topic with one collective comment.


Thank you for recognizing that I am not likely the only student who is mortified to learn that digital penetration of sexual organs on both men and women are not only valid exams but also part of my graduation competencies, albeit it not being explained anywhere beforehand (or even at all).

I agree I certainly focused more on women being abused in medicine. It is probably because male modesty in medicine is an "overlooked topic without enough attention to draw any intelligent conclusions". So naturally, after I learned about pelvic and prostate exams, I searched for criticism and found more on medical abuse of women - including two books penned by faculty at my school, several more books and documentaries, and forums where women describe the exams as "violating", "barbaric", "rape", and "birth rape". In addition, I was sent to the OBGYN "Associate Dean for Curriculum", and hence much of my article stems from his obvious mistreatment of women, whereas had I been sent to a faculty proctologist, I might have had more to write about mistreatment of men.

The first time I saw boys/men voicing modesty concerns as loudly as girls/women was on Dr. Sherman's Blog. I was disgusted to read what some of these patients had been through. It was obvious many of them were silenced and oppressed, unable to make modesty requests lest they be branded unmanly and sexist to prefer same or opposite intimate care. It was also evident the shortage of male nurses contributes to the problem. Because of this, I was puzzled my school enforced the "one female in the male rectal exam" policy because many male patients blogged about feeling traumatized to have females present during their exams. Another sloppy gap between what students learn and what patients want.

At Tuesday, July 19, 2011 9:02:00 AM, Anonymous SS said...


Your remark about the formal versus hidden curriculum holds water. Part of the reason is that students will alter their behavior throughout the curriculum to obtain good grades and approval from faculty. For instance, at the end of second year, students are formally graded on a final "head-to-toe exam" (excludes genital exams). Students must demonstrate knowledge of the clinical basics for each organ system to advance to third year. An instruction sheet warns students will have points deducted if they do not respect patient modesty (appropriate draping, informed consent, explaining before doing - even though genitals are not included), and I am certain students meticulously follow the sheet. But just a few months later, when students enter third year, they are bombarded with the hidden curriculum, and witness faculty stripping patients of all their human rights in some of the most horrific ways imaginable. In this new context, students can no longer support patient rights, knowing their rotation grades will suffer should they question faculty. How baffling students are expected to practice informed consent on actors, only to be expected to violate patients months later.

However, I believe there are parts of formal curriculum that do not have analogous underground hidden curriculum. An example is when medical students learn to take sexual histories. We are trained to ask: "Do you have sex with men, women, or both?" I believe faulty do follow this guideline. They have no hidden curriculum because discriminating against sexual minorities today carries a huge stigma for any professional. In contrast, when medical students conduct intimate physical exams, we are not trained to ask: "Do you prefer intimate care from a male or female provider, or do you have no preference?" Initiating that into the formal curriculum would be difficult because the "Associate Dean for Curriculum" is a male gynecologist with his own agenda. And so most students are entirely oblivious to the BFOQ laws. With that said, though, even if it were introduced into the formal curriculum, I worry there would be analogous negative hidden curriculum, since faculty have conflict of interests with having to lose patients to health providers of one preferred sex, and since faculty face little stigma being ignorant about patient modesty, like they would being ignorant about gay sexuality.

Maybe in the formal curriculum, faculty could explain to first-year students that the school is trying to abolish a persistent hidden curriculum, which has included activities as terrible as gang raping patients. They could tell students they are responsible to look out for it, and have a safe and easy way to report faculty who teach hidden curriculum, such as ignoring BFOQ laws, pushing pelvic exams for birth control, and gang raping anesthetized patients. Once it can no longer hide, the hidden curriculum might yield to the formal curriculum.

At Tuesday, July 19, 2011 9:02:00 AM, Anonymous SS said...


Thank you for your comments. Definitely the atmosphere of my school was full of "overt suppression" like you said, and the instructors showed "dismissive attitudes". The head instructor of ECM (physical exam course) dismissed my problems entirely and did not seem interested in meeting with me - Despite the fact that he has always watched a minority of students have similar issues in his course, including the sexually-abused student who recently cried during the prostate exam. While he ignored my issues, he was promoted to deanship, and sent out a campus-wide email stating that he desired to use his new position to focus more on student feedback to improve curriculum. Why then would he show no effort to personally meet with a student who was actually leaving school due to disagreements with his own class? Because of "dismissive attitudes", the same problems will happen to future students for sure as they have always happened to a minority of students in the past.

At Tuesday, July 19, 2011 9:03:00 AM, Anonymous SS said...


Thank you for asking to post my contact information. And thank you to those "ghost readers" who wrote me insightful e-mails.

At Tuesday, July 19, 2011 9:03:00 AM, Anonymous SS said...


Thank you for your comment. I am in line with you calling gang rape of patients an "outrageous crime". And I too would love to see faculty and students who participate in these "educational activities" prisoned. If traditional rapists go to jail, then white-coat rapists should as well.

As I stated in the article, I never directly witnessed this horror at my school since I never reached clinical rotations. However, I know it most likely occurs at my school. Terri Kapsalis, the pelvic exam actor at my school, wrote in her book about the practice of gang raping anesthetized women in medical school. And the OBGYN "Associate Dean for Curriculum" inadvertently raised my suspicion that lack of consent routinely occurs at my school when he corrected himself mid-sentence. In addition, before I left the city, I had dinner with a friend who shadowed an OBGYN as a first-year student. She told me her mentor introduced her as a "doctor" to practice a pelvic exam on a patient. She said she felt like she was "just fingering" the patient because she was had never performed the exam before (There is a rule - obviously not followed - that students cannot perform genital exams on patients until third year). The OBGYN taught my friend that informed consent can slide, and that medical students can have the arrogance to believe their right to learn takes precedence over the right of the patient to know the truth. What if this patient did not want her body used for pedagogical purposes without consent? Or have a pelvic exam done by someone with zero experience without consent? Deceive patients so you can get in their pants - I thought that was a creepy lesson for my friend. If faculty at my school lie to practice pelvic exams, then they might abuse and rape to practice pelvic and rectal exams.

Google the topic, and you will unfortunately find a plethora of frightening statistics about the current prevalence of gang raping patients. Maybe Dr. Bernstein was correct to say that (some of) the medical community does not agree with this behavior. But they do not disagree with it enough to overhaul it.

At Tuesday, July 19, 2011 9:04:00 AM, Anonymous SS said...


Thank you for the question. I should clarify this since the introduction by Dr. Bernstein was not quite right. I answered a similar question to Dr. Bernstein in an e-mail but it was over one year ago.

I find pelvic exams and rectal exams to be "sexually violating" - These are the exams I refused to learn on actors. Between the two, I find the pelvic exam to be worse.

I find other genital exams to be "sexually uncomfortable". I understood the mechanics of these exams before moving to the city. They were what I expected to be the most "uncomfortable" aspects of physical exam. I use the term "sexual" because they involve manipulation of sexual organs, and from my perspective, that makes them sexual in human nature.

I find breast exams to be simply "intimate" (which is the euphemism my school uses to describe all these exams for all students).

I do not believe my thinking is very idiosyncratic since from most legal definitions, forced penetration of sexual organs can be rape, while anything else can be sexual abuse. Since many humans feel sexual penetration can be more violating than sexual touching, then pelvic and rectal exams are generally more taboo than testicular and breast exams. And so incoming students are less likely to know about the more invasive aspects of so-called "intimate" care since they are rarely discussed in detail anywhere.

I just grabbed from my old e-mails what I originally wrote to instructors:

"I knew I would need to touch patients on the surface for any biological system that needed examination. But I feel that a line is crossed when it comes to these intrusive exams where I am putting my fingers inside people. They should not be treated like blood pressure checks. And I just think that when these exams are being performed, neither the examiner nor the patient should feel unhealthy to be a part of it. I feel that incoming students, just like patients, should be fully consented about what they are getting involved with, especially as they do not all come from medical families and since these clinical topics are not even discussed as part of the premedical courses and requirements."

So I did explain this to them. But as the one Dean smugly told me: A pelvic exam is an ear exam.

The possibility that medical exams can be perceived as sexual by some people is by all means denied by my school. Because if they would start showing genuine empathy for the few students who do face problems each year, they would have to knock down that wall that made them so harsh to force a rape-survivor to complete a prostate exam on an actor. They would have to admit that forcing invasive "intimate" medical procedures without consent on students who clearly try to resist might be more like rape and therefore unacceptable. And then they would need to start screening students, which would be admitting they might have done wrong things in the past.

At Tuesday, July 19, 2011 10:02:00 AM, Blogger Maurice Bernstein, M.D. said...

I want to give a bundle of thanks to our "stressed student" (SS) for her replies to the specific comments made by our other visitors to this thread.
I hope she continues to find time to return and continue to participate here.

I think one of the contributions of our "stressed student" has been opening a new view of the physical modesty issue by presenting the aspect from at least one and perhaps other medical students who have not yet moved on into the deeply invasive "hidden curriculum" and have not yet become "changed".

Again thanks and keep it up! ..Maurice.

At Tuesday, July 19, 2011 11:34:00 AM, Anonymous Anonymous said...


Nurses "gang rape" their patients as well,something
documented on a number of nursing sites.


At Tuesday, July 19, 2011 11:41:00 AM, Anonymous SS said...

General response to Onion and TAM:

Although I did not want to solely focus on whether readers agreed or disagreed with my school deciding to withdraw my scholarship, I should say I believe it was hypocritical. I never argued there would not be an aspect of my skills that was "incompetent". But what bothered me about some of the responses from readers was the way they zoomed in on me as the sole "incompetent" student, without remarking about the other students who are "incompetent" over the same exams but still graduate to practice medicine.

In my opinion, performing a "competent" exam means gaining full consent, and then performing the exam with at least objective behavior. As I indicated countless times in the article, I am not the only student who is by that definition "incompetent" since many students graduate without practicing informed consent and/or without performing the exams objectively.

The students who lie and call themselves "doctors", the students who watch faculty withhold birth control for pelvic exams, and the students who condone raping anesthetized patients, for instance, are not any more "competent" than myself. Although they may have desexualized the exams (something I could not do), they have dehumanized the patients behind it (something I could not do), and their "incompetence" to consent and respect patient autonomy and rights will hurt and violate many more people down the road than would my "incompetence" for refusing the exams when I know my visceral reaction would make them even more unpleasant for patients in a field where performing them is not my responsibility in the first place. In the article I attached, one out of four medical students does not think it is unethical to gang rape anesthetized patients. Therefore, it is only fair that if I am thrown away as an "incompetent" student, then 25% of my classmates should also be thrown away, and some of my faculty should be fired as well, since these people are just as, if not even more, "incompetent" over the same medical procedures.

The students who cry, faint, and make "horrified faces" are unable to perform the exams with objective behavior, and hence are also "incompetent". By failing to admit their shortcomings, they will cause more humiliation and pain for patients who deserve a provider professional enough to admit it when they are ill-prepared for a sensitive exam. Therefore, it would only be fair then that these students are thrown away as well.

I wanted to point all that out because I was asked to leave for being "incompetent" when everywhere I looked many other students and faculty were also "incompetent". For that reason, I felt ostracized and treated unfairly in comparison to these people. It was obvious to me that the decision of my school was not really because they believed I was the only "incompetent" one, but because they are too intimidated by any student who question authority.

At Tuesday, July 19, 2011 11:42:00 AM, Anonymous SS said...


"However, bearing all that in mind, there is nothing even remotely convincing as to why an MD should be conferred upon any medical student unwilling to perform these tasks, if indeed these have been established by the medical community as necessary skills; and it appear that they have."

There is no established list of necessary graduation skills from the medical community. Even the LCME and AAMC have no specifications for what clinical skills are required for future doctors. When I said I had problems with pelvic and rectal exams, my school did not have a list to show me either. Apparently they do not even know what they officially require. What is deemed necessary varies across schools, and Dr. Bernstein told me last summer that practicing rectal exams on actors is precluded at his school.

My school does mail a list of clinical competencies to students before they matriculate. I initialized everything on the list. It included only vague statements. Things like "I am culturally tolerant to coworkers and patients", "I can work with mentally ill patients", and physical capabilities like being able to lift objects.

"I understand that she may have been given a "false bill of goods" prior to entering medical school and was not treated with respect and so forth. Those are problems with the medical school, but they should not impose a change on the profession itself or the expected skills of the profession. There is no line of correlation."

There is a bold line of correlation between problems in medical schools and the profession. After all, each person who practices the profession was shaped by the medical school he or she attended. When we read stories of doctors (and nurses) abusing patient rights during intimate exams, some of it is because of behaviors fostered in schools.

"I brought up the example of a policeman (at least in the US) earlier. I applaud someone who refuses to take a human life. But certainly to take the job of a policeman, one must be willing to draw their firearm and point it at a target and fire...with full knowledge it may result in death. Yes, they want to be a peace keeper and want to save lives, not take them...all admirable positions, but there is an expectation by the citizenry that if they are in immediate danger a policeman will be able to take the action to take an assailant's life to save a victim. Similarly, there is an expectation by the citizenry that their physician will be competent in all of the procedures (highly specialized skills an obvious exception) that a patient might require."

I understand your analogizing physicians to police officers, but please complete the entire analogy out of fairness. What do you think of a police officer who can use a gun but then goes trigger-happy shooting innocent people for practice (This would be like doctors gang raping patients for practice)? What do you think of a police officer who obeys and fires on demand when she knows her skills are so poor to make the situation worse by killing the victim instead of the assailant (This would be like students fainting and crying and making "horrified faces" and traumatizing the situation for patients by not admitting their problems)? What do you think of a police officer who enjoys getting money and power-trips by abusing citizens (This would be like doctors who lure innocent girls and women into unnecessary pelvic exams for birth control)? What do you think of a police school that allows incompetent and corrupt police officers like this to graduate but throws out a police officer who refuses to practice firing since it is not a responsibility for the branch of the profession she is entering (This would be like my school)?

At Tuesday, July 19, 2011 11:44:00 AM, Anonymous SS said...


"My believe is, if you want an MD, you have to complete the training... I don't want an MD who has not completed all the training."

The training is different between students because they have different experiences when rotating in different hospitals. In some cases, training includes gang raping patients. In this case, would you still prefer the MD who completed all the training?

"This student seems to see these exams as sexual. Having had both consensual sex, and medical exams, while both may involve a finger, they are certainly not the same. I am certain that some students are very uncomfortable with learning to perform the exams, I'm sure I probably would be. But to characterize them as sexual, I don't believe that is correct."

Please, and I ask you respectfully and kindly, do not tell me that what I think is sexual (or sexually violating) is not "correct", and I will hold the same basic respect for you and your viewpoints. It is never constructive to invalidate how another person feels about sensitive topics, and label them as holding "incorrect" perspectives, simply because they differ from your own. I understand that many patients and medical students do not view these exams as sexual or sexually violating, and I would never tell them they are "incorrect" for that.

I do not understand your argument that because you have consented to sex and invasive genital exams in your own life that no students could "correctly" characterize these medical exams as being sexual or sexually violating. What about the student who told faculty she was recovering from history of sexual abuse? Do you believe you could tell her that since you have only experienced consented physical intimacy that her viewpoints are false? You have had consensual sex and consensual medical exams - How does that justify non-consensual medical exams for thousands of incoming medical students?

At Tuesday, July 19, 2011 11:45:00 AM, Anonymous SS said...


"I had a couple additional thoughts after re-reading that NY Times article that "stressed student" quoted, talking about students fainting, crying, etc. at having to do the genital exams. I had read that article in the past. Actually, it was quite positive, talking about how the teaching got the students over their fears, so that when they got to actual patients, they would be more comfortable and skilled."

Do you agree with every article you read when it covers a topic from a blatantly biased perspective? I think the fact that students faint and cry while penetrating sexual organs speaks for itself, and that of course the teachers featured in the article will boast about how much they "empowered" students. The instructors in the article present no less of a one-tracked bigotry than the instructors at my school who believe they did such a noble thing to force the prostate exam on the crying student who said she was still recovering from previous sexual abuse.

Do you believe that all students who show such strong and natural resistance to perform these exams waltz off to third year ready to comfortably perform them? As far as I know, the students who faint and cry leave the practice workshop and are not asked to return to prove more objective behavior before they are sent off to work with real patients. Once in clinical rotations, the students who never objectified the exams still hold negative attitudes about them enough to avoid them as much as possible, even when they might be necessary to patients. I refer you to the article ""Managing Emotions in Medical School" where you can read quotes from students themselves about avoiding pelvic exams by writing "pelvic deferred" in charts. And I refer you to the book quote from the pelvic exam instructor at my school who said "it may be impossible to educate students properly within the medical institution given unacknowledged cultural attitudes about female bodies and female sexuality." For these reasons, I believe it does no good for medical schools to continue ignoring problems, because it hurts not only the students but also the patients who they work with.

While I understand your argument that the technique of introducing students to trained actors can act as exposure therapy for those students who do only have "fears", I do not think you can hastily assume the visceral reactions of all students are necessarily "fears" that can be cured like any other "fear" via cognitive behavioral therapy. For instance, say you had a child who was scared of the dark, a common "fear". Each night, you could tweak his night-light to shine a few shades less bright, until eventually he could sleep in the pitch-black with no problem. Now say you wanted him to eventually go to medical school, and you wanted to help him get rid of any "fears" he might face in relation to medical training. You could force him to practice pelvic and rectal exams on trained actors for instance, and help him get rid of his silly little phobias before he even started middle school! After all, if you are to collectively label resistance to performing pelvic and rectal exams as any other curable "fear" like being scared of the dark, then you are calling it a fixable psychological quirk independent of any innate characteristics of the person (in this satirical example, age and life experience obviously).

At Tuesday, July 19, 2011 11:45:00 AM, Anonymous SS said...


"So, in my opinion, just because someone finds something stressful doesn't make it bad. I've read of how stressed students are the first time they use a scalpel on a live human… I would think that there are probably quite a few stressful parts of medical training - but does that make them wrong? I don't think so."

I am of the belief that forcing penetration of sexual organs in ways that are not explicitly described to students who show adverse reactions is rape.

Rape victims are less likely to report rape if they do not fit the stereotypical rape victim profile in the stereotypical rape scene (i.e. innocent woman who was raped by an unfamiliar man in a dark alley). This silences victims who do not fit the stereotype. Maybe they are men. Maybe they consented to some forms of sex but not to others.

It took feminists years to advocate for spousal rape to be recognized. Back then, the assumption was that husbands owned their wives (and vice versa less often). And today, humanitarians are beginning to fight for recognition that rape can occur in the medical setting. Right now, the assumption is that doctors (and nurses) own their patients (hence they can gang rape them without going to jail).

It is difficult for patients to report physicians who rape them because they do not fit the traditional victim profile. It is even more difficult for medical students to report medical schools that rape students because they do not even remotely fit the stereotypical victim profile (students should feel privileged to have this "educational" tool, students "should know what they were getting into", students must be "competent" with examining patients, and students are the inserters rather than the recipients).

I do not have a very liberal definition of rape. But I strongly believe this scenario can be rape for some students. Much more than just another "stressful" educational experience.

At Tuesday, July 19, 2011 11:46:00 AM, Anonymous SS said...


"To think that you have to tell students just what sort of exams they will have to perform before entering medical school doesn't seem reasonable to me. People are generally aware that physical exams occur."

It is not only reasonable but also logical and ethical to explain exams to incoming students.

Why is it reasonable? Because it is not a grueling task to produce a graduation requirement list that explicitly describes all aspects of physical exam of both sexes.
Why is it logical? Because if a taboo aspect of medical training causes problems each year, it will continue to do so until somebody introduces the necessary changes.
Why is it ethical? Because non-consented, forced penetration of sexual organs achieved through coercion, blackmail, and intimidation that causes humiliation, shame, and feelings of violation is rape.

I request that you please back up your statement with evidence when you suggest that all thousands of incoming medical students are aware of prostate and pelvic exams. I have never seen a single publication about how often incoming medical students know about invasive genital exams. Please attach your evidence in your reply. I also want you to specify what you mean when you state people are "generally" aware of invasive genital exams. What does "generally" mean? And what credentials do you have to say this? I believe "all" students have the right to know what is required of them before they start a financially and resourcefully demanding process.

I think some students may not know about pelvic and prostate exams. These exams are not discussed in high school, college, or the premedical curriculum. They are taboo for a reason, and so they are not discussed outside of education either. More than half of incoming medical students have never had a pelvic exam and almost all medical students have never had a prostate exam. One could say knowing this information that it is possible a sizable minority or even majority of students do not know about one or both of these invasive genital exams. The possibility makes it even more imperative for schools to respect students with consent.

I have contacted the AAMC numerous times asking them to include more explicit information about taboo aspects of physical exam, since all medical students use their website to apply to schools. They have ignored me each time. Recently I contacted the founder of Women Against Stirrups, and she contacted a lawyer from her group who said that administrative and lobbying activities would be the best bet for me to achieve some of these goals. So I contacted staff members of AAMC (including president and vice-president) and directed them to this Blog to read the story and any comments that might hopefully persuade them to treat incoming students in this country with more respect via full informed consent.

And with that, I would like to encourage any readers of the Blog to please contribute your thoughts on this topic: Do you think it is an ethical problem that the AAMC does not explicitly describe these exams as graduation requirements for students applying to medical schools?

At Tuesday, July 19, 2011 10:13:00 PM, Blogger Joel Sherman MD said...

We are re-posting 'stressed student's article on our blog in sections. I originally referred her to Dr Bernstein and the re-publication has their permission. It is slightly modified by the author from the article on this blog in a few significant ways.
Part 1 can be found here.

At Tuesday, July 19, 2011 10:18:00 PM, Anonymous Anonymous said...

I think people know what they are
getting into when applying for
medical school. As I've said before
the problem is not so much physician
based but rather the support staff,
nurses,cna's etc.
By far the largest contributors
to hipaa violations are the support
staff.Just last month UCLA hospitals
were fined $865,000 for privacy
breeches. This was not the first
time UCLA medical centers were fined.
It was secretarial staff and
nursing peeping into medical records
of hollywood celebrities. The hipaa
violations centered around four
different well known hollywood
entertainers. Yet many people on this blog continually complain about
physicians, primarily male I might
I can't even remember the last
time I read about a male physician
violating someones privacy in regards to medical records. If any
one is curious I'll tell you the
second most likely patient aside from a celebrity guaranteed to have
their hipaa violated. That would be
a male patient presenting to the er
with a rectally inserted object.
Not 5 minutes after their arrival
everyone in the er is blabing about
this patient. I've even seen er
registration personnel asking to see
the x-ray and/or asking for a copy.
Even worse read where nurses posted a copy of the patients x-ray
on the internet,lied about it and
then fired.
Its equally notable that the females posting on this blog never
really have nursing directed complaints and why should they when
the ratio of nursing gender is 94/6.
Further proof of the real problem
and how this blog does little to
bring attention to the issue. At
almost every turn we choose the
physicians we intend to see,yet
we really don't choose the nursing
or support staff,especilly the ones
who like to be present for exams when their presence is unnecessary.
You never see comparable complaints from non medical staff
about hipaa violations on any nursing sites such as allnurses. The
posters are usually other nurses
commenting on how stupid the nurse
was for commiting the violation and
getting fired.Yea,we've heard that
story before.
Hipaa violations cross all gender
boundaries and are almost always
committed by female nurses. Perhaps
nursing schools are where the complaints should start and end at
hospitals and institutions.After all
if someone is willing to violate your hipaa rights what else are they
willing to do.


At Wednesday, July 20, 2011 6:24:00 AM, Anonymous Anonymous said...

It is quite apparent that you do not appreciate a viewpoint that does not agree with yours. I'm not going to have an argument here, I've stated my thoughts, and you have stated yours.
I do have a few thoughts though.
As far as specialties, doctors can and do change specialties. For persons such as yourself, it is a shame there is not an academic version of the degree, that does not confer the right to practice.
There are probably many people that I wish would not become physicians, or I wouldn't want to have for my physician.
I was a certified rape counselor. No, I wouldn't want people who condoned or performed exams on unconscious people without consent to be physicians either. Yes, I find that rape, or at least sexual abuse, depending upon state laws. I do not, however, consider requiring people to perform exams on consenting patients or actors rape. The students do have the choice, as you did, to not perform the exams. Yes, there are consequences to that choice, but to me, that does not make it rape. That would diminish, I believe, the pain of rape victims.
You say the New York Times article was biased... well so are your writings. So are we all biased, at least to some extent.

At Wednesday, July 20, 2011 6:46:00 AM, Anonymous Anonymous said...

I understand all the arguments here. However, telling a student they can exempt from a part of their training because it won't effect their work in the future is the same thing as telling a law student that they don't have to take math or gym in undergraduate school as a pre-requisite. The only way to fight this is a change in curriculum for different types of degrees

At Wednesday, July 20, 2011 7:35:00 AM, Blogger Maurice Bernstein, M.D. said...

It has been my decision since the beginning of this blog in 2004 that visitors writing here should avoid naming names particularly when controversial, negative or derogatory comments are being made. This decision was made in the interest of ethical fairness. The basis for that ethical decision was that the comments are usually made by usually fully anonymous individuals about persons or institutions who may not even be aware of that such comments were posted and thus may have no opportunity to respond to the anonymous visitor on this blog.

This is my own philosophy as moderator here. With regard to postings by SS, the current article by her on the "Patient Modesty and Privacy Concerns" blog discloses the name of her medical school and therefore also could identify the individuals she is writing about through their position at the school. The decision to allow the name of the school to be published is one to be made by the blog's moderators and not me. However, again, with regard to further communication on my blog, I would, independent and regardless of the merit of the statements by SS, continue the policy here against the "naming of names" in this regard. ..Maurice.

At Wednesday, July 20, 2011 7:15:00 PM, Blogger Maurice Bernstein, M.D. said...


My publication here of the stressed student's essay on her experience as a medical student within her medical school, as modified by my deletions of reference to the name of her school or location, met my criteria for an ethical exercise in the presentation, anonymously, of one student's experience and philosophy.Though I cannot and will not debate the validity of her story, I feel, as a medical educator myself, it was a worthy issue in medical education to discuss in a generalized and anonymous fashion.

Unfortunately, without my knowledge or approval, she allowed her school name to be disclosed on another blog. Her negative images of the school and faculty and dean can now be referred directly to the school and the faculty. To us, SS remains anonymous but with some Googling some of those about whom she is writing are potentially no longer strictly anonymous. To be fair
the school or the faculty or dean most likely may have a different story to present, I think it is important that they have a chance to tell their side on the blogs to which SS wrote.

The most appropriate solution to the issue now would be for SS to notify the school and the involved faculty and dean regarding what has been written on the blogs (provide them with appropriate links) and offer them the opportunity to write their rebuttal, if they desire.

Their response to this blog would certainly be welcome and appropriate now that their anonymity is gone and their side of the story would have great value in evaluating the "stressed student's" concerns.

If you have comments about my suggestion, please write me on the blog or by e-mail: ..Maurice.

At Thursday, July 21, 2011 9:09:00 AM, Anonymous SS said...


"I do believe that the culture of medical school would probably be slow to change but that doesn't mean that change would not be for the better. Long established institutions should be open to change; just because things have always been done a certain way doesn't mean there isn't room for improvement."

Thank you so much for your comments. Your comment here nails down exactly what I felt very strongly after leaving medical school, and what I tried to communicate in my article. I think there is so much room for improvement (even within such a narrow slice of medicine as "intimate" exams) both that medical students need to be respected, and that medical students need to learn to respect patients.

At Thursday, July 21, 2011 9:10:00 AM, Anonymous SS said...


Thank you for your statement about nurses also being responsible for "gang rape" of patients. It is disgusting health care providers from all areas are so viciously brutal toward their own patients. I have not seen many articles about nurses participating, but I certainly believe you when you say this has been documented on nursing sites. May I ask: Do you mean directly documented (such as the nursing profession itself admitting it needs to change), or indirectly documented (such as patients leaving angry comments on nursing sites about being "gang raped" by nurses)? Both are hopeful for change, but the first might be much more hopeful!

Again, I never witnessed "gang rape" of patients at my school, but I believe that since old habits die hard (especially in medicine), and if it does continue at any of the many hospitals near my school, rotating students will not be prepared to defend the patient or report the incident because the practice is not officially recognized as being appropriate for students to fight against in the "formal curriculum" at my school.

I can only write about negative aspects of medical training regarding "intimate" exams from a medical student perspective, but hopefully more nurses will write about similar topics from their training as well. It definitely needs to be recognized and changed as soon and completely as possible across all fields. There are no excuses for health "care" providers to do this to the people they "care" for.

At Thursday, July 21, 2011 9:12:00 AM, Anonymous SS said...


"I understand all the arguments here."

Thank you for saying this. There were a lot of arguments, that is for sure.

"The only way to fight this is a change in curriculum for different types of degrees."

Thank you for the input. Do you think these invasive genital exams should be part of the medical school curriculum?

I do not have such a strong opinion on it. I do think it is a shame if they deter people from medical school and if they really are not necessary. But I have no solid evidence on how many young people would be deterred enough from these exams and how necessary they really are in comparison to other medical skills.

What bothered me more than whether or not it is part of the curriculum was the fact that my school does not respect students enough to explain all graduation competencies to them beforehand, when they fully expect the need to "educate" a "few" upset students each year who inevitably do not view these exams with the healthy perspective they want them to.

I am wondering, do you think it is unethical for my school to continue it this way?

At Thursday, July 21, 2011 9:23:00 AM, Anonymous SS said...


"That would diminish, I believe, the pain of rape victims"

I believe it would amplify it in many cases. Some students, such as the one who cried to do a prostate exam, might be rape victims themselves. So I believe my school indeed diminishes the pain of rape victims the way they did nothing for this student or even for future ones after her.

At Thursday, July 21, 2011 9:59:00 AM, Anonymous SS said...


"As far as specialties, doctors can and do change specialties. For persons such as yourself, it is a shame there is not an academic version of the degree, that does not confer the right to practice."

Thank you for saying this. I am now in another pathway where I can still contribute to research in the health field. There are fortunately many different ways people can go about that, and I am thankful to still have a great opportunity. I also believe the environment of my new education will be more open-minded, creative, and accepting of individuality.

As a result, I did not mind not graduating from medical school. What I minded was being set up for failure in a system that has disrespected and ridiculed students like me in the past. Then when I read about patients feeling the same way regarding these exams, and learned that my faculty actively taught students to disregard patient rights in "intimate" settings, I felt even more dismayed about how medical training amplifies these problems by not respecting even more people. That is why when Dr. Bernstein asked me to publish this story on his Blog, I immediately agreed with him that it could bring positive change.

"I was a certified rape counselor. No, I wouldn't want people who condoned or performed exams on unconscious people without consent to be physicians either."

I just felt I had to defend myself from your previous comments, because I felt I was being ostracized as the "incompetent" one when there are certainly many "incompetent" students, faculty, and standardized methods regarding "intimate" exams, which I included in the article to relate it all to some of the hypocrisy and resistance to any change in medical training. Maybe the "shock value" of physicians and nurses abusing patient rights (disregarding BFOQ, withholding BC from pelvic exams, and medical "gang raping") has warn off for people, but the "shock value" of a medical student finding these exams violating even in the "safe environment" with actors is entirely new and, as far as I know, never previously admitted as publicly as this forum. Because when we put these two "shock values" side by side, the most shocking and "incompetent" attitude and behavior between the two could be as much the prior group as the later group.

But thank you mentioning this one, that physicians and nurses who condone these exams on unconscious people are not your ideal physician or nurse either.

At Thursday, July 21, 2011 10:00:00 AM, Anonymous SS said...


"I do not, however, consider requiring people to perform exams on consenting patients or actors rape. The students do have the choice, as you did, to not perform the exams. Yes, there are consequences to that choice, but to me, that does not make it rape. That would diminish, I believe, the pain of rape victims."

We can agree to disagree, whether forcing uninformed medical students who resist performing these exams each year can be rape.

I disagree with your argument though that "having a choice" while at the same time being pressured to participate in activities involving penetration of sexual organs suddenly deems it not rape. Rape victims can be given many "choices" while being coerced, blackmailed, or intimidated into doing something humiliating, violating, and unwanted. The fact that they choose rape over threats with consequences does not render it consented. In the extreme case, a victim could be told he or she will be killed (intimidation) or lose his or her job or reputation or anything else he or she values (blackmail). Similarly, medical students who perceive the exams as violating are told they must choose between performing them and suffering emotionally, or lose money, time, hard work, respect from self, respect from family, and many other conditions. For some students, it is financially impossible to "choose" to leave medical school because of the massive debt (up to $60,000/semester for some students at my school). That is why I believe students must be given the fair opportunity to decide for themselves before all these deathtraps can be used as blackmail to force them into these exams when they express resistance.

I am respect and wonder what your opinion is on all this. Not whether you would define it as rape, as you have expressed you do not believe that is the fit term. But I ask: Do you think it is unfair for my school to not update these problems?

"You say the New York Times article was biased... well so are your writings. So are we all biased, at least to some extent."

Certainly. I am writing a personal account on my medical school experience, and my writings present my own viewpoints and values. I never said to speak for any faculty, students, and patients. I wrote what I witnessed in medical school and related that to patient modesty issues with my own subjective eyes, hoping it could contribute to something more positive for the future. As the title suggests, the article is about my individual "concerns", and hence I allowed my anger and disbelief to naturally come out in my writing. Otherwise, to artificially tweak my writing to should distant and professional would introduce an element of dishonesty because I am writing from the heart about "my concerns".

This is in contrast to the NYT article that hastily claims to speak for all students, even the ones who faint and cry and hyperventilate, on a sensitive subject.

At Thursday, July 21, 2011 10:00:00 AM, Anonymous SS said...

Dr. Bernstein and All:

Thank you and Dr. Sherman both for asking me to publicize the story on your Blogs. I feel the story presents some of the medical modesty issues frequently discussed on these Blogs from a unique perspective, and have enjoyed replying to all comments and suggestions (and "ghost reader" comments on my email). I feel much less silenced and invalidated when you both recently asked me to publish my story. So thank you so much for that.

I am willing to publish the story with as many or as little details as deemed necessary by any publisher (with the exception of directly publishing personal names - both my own and faculty). When Dr. Sherman asked me to publish my story with the school name without job titles, I agreed to that format and still believe it is a terrific opportunity to tell the story to his audience in whatever way works best for his Blog.

In terms of my own anonymity, that is something that is not in the least bit protected in my writings. One could easily look between Blogs, and know the author is an MD-PhD female who entered "my school" in 2009 (There are only four people who fit that description, and the three others are still in school). With this information alone, any student or faculty from "my school" who reads these Blogs can unequivocally identify me.

Furthermore, any Blog reader can find a two-year old "Welcome New MD-PhD Students 2009" website from "my school", and compare it to the current online roster from "my school", and deduct that the missing name belongs to the author of this publication. My article also reveals that I grew up overseas between ages 4 and 19, have a younger sister, left UIC in summer 2010, and was interested in brain pathology. Not only my classmates and faculty, but any coworkers or family or friends who read these articles will know all the more that I am the author and can hence know my personal and embarrassing reasons for leaving school - as well as the fact that I actually had my scholarship withdrawn against my choice, something I do not readily tell many others.

I did not include my full name as author, not because I am ashamed of my beliefs (otherwise I would not have spoken face-to-face with dozens of faculty, a few trustworthy classmates, my sister, my college friends, and school psychologist) but because I do not need my name key-linked to sensitive material on the Internet. I cannot be widely proclaimed as a "whistle-blower" on the Internet as it will damage my future career applications and ambitions. (Although I welcome readers to determine my real name with the aid of Google if they are for some reason interested). Likewise, I did not include the full name of my instructors and key-link them to sensitive material on the Internet.

Both me and my instructors are all semi-anonymous on the same ground (i.e. A few clicks away on Google, but without direct key-linked name identification).

At Thursday, July 21, 2011 10:01:00 AM, Anonymous SS said...

Dr. Bernstein and All:

When I originally left on a "Leave of Absence", my OSA (Office of Student Affairs) advisor told me I needed to type my reasons for this to be read by a "review committee" consisting of students and faculty. I e-mailed her today, and attached a more thorough reason for withdrawing from the school to be reviewed by the same "review committee." Of course my full name is revealed to all these committee members. In my typed reason, I included the links to both Dr. Sherman and Dr. Bernstein Blogs, and invited all faculty and students of the "review committee" to contribute their thoughts to the Blogs. I also attached an alteration of the article, which included the full names of all faculty members I discuss in the article, in case the individuals in the article wish to respond to my statements.

Ten days ago, I contacted Terri Kapsalis, the author of "Public Privates", and invited her to the Blog if she wished to comment about her experiences working at my school.

I do not believe all the ECM instructors I spoke with last summer are on the "review committee" and so I will invite them all in a group e-mail to contribute their thoughts to the Blog as well.

I am very happy to have invited my school (and specific faculty members) to contribute to the Blog with their own comments. I believe an open discussion like this is very much needed, both to benefit my own beliefs that I was personally abused by their system, and also to benefit their own system in the many ways it dismisses medical modesty issues (faculty not screening students, faculty teaching students to withhold BC from patients, faculty teaching students to not respect BFOQ laws, faculty allowing students to lie and introduce themselves as "doctors" to get in patient pants). These things do not change until somebody makes a fuss.

So thank you again for supporting this discussion!

At Thursday, July 21, 2011 12:39:00 PM, Anonymous Anonymous said...

If a medical student doesn't feel comfortable with the curriculum it is a wise decision not to continue on. Best to find a field that suits your needs.

While I don't believe the school handled the matter in the most sensitive way possible they did make the right decision in keeping the curriculum intact. Once they deviate from one part of it others would want to bypass other fields as well which defeats the entire purpose of medical school. It is to give a broad and balanced view of all medical fields. You can't pick and choose what suits you as an individual.

As a medical student you need to be able to understand on an intellectual level why these exams are often necessary. Not every intimate exam is forced nor is every intimate exam the equivalent of rape. A good medical student who goes on to become a good doctor learns not just the importance of the exam but the importance of good communication in regards to them as well.


At Thursday, July 21, 2011 7:31:00 PM, Blogger Doug Capra said...

I want to reference three articles connected to this discussion -- articles I have discussed in several past posts on this and Dr. Sherman's blog.
-- "Not Just Bodies: Strategies for Desexualizing the Physical Examination of Patients" by Patti A. Giuffre and Christine L. Williams. Published in Gender and Society (2000) 14:457.
It discusses various strategies doctor use to desexualize physical exams. Assumed in this entire study is that there is a need for a significant number of doctors to desexualize these exams. As I've pointed out, these strategies are not necessarily healthy strategies -- just strategies that work for the doctor. Though they may work for the doctor, that doesn't mean they work for the patient. This study is very relevant to what "stressed student" writes about.
-- "Managing Emotions in Medical School: Students' Contacts with the Living and the Dead" by Allen C. Smith, III and Sherryl Kleinman. Published in Social Psychology Quarterly, 1989, Vol. 52, No. 1, 56-69. A few quotes:
"As several sociologists have shown, both doctor and patient use dramaturgical strategies to act "as if" the situation is neutral." Implied here is that the some of these intimate situations are not really "neutral" by we pretend that they are in order to get the job done. Patients and doctors use these strategies, but these techniques are not necessarily in sync. That is, what strategy works for one may make the other feel uncomfortable, embarrassed or humiliated.
"Clothed in multiple meanings and connected to important rituals and norms, the body demands a culturally defined respect and provokes deep feelings. Even a seemingly routine physical exam calls for a physical intimacy that would evoke strong feelings in a personal context, feelings which are unacceptable in medicine."
The issues brought up by "stressed student" are not insignificant, and have been known and addressed by medical professionals for years. This doesn't mean they have necessary been addressed successfully.
"The ideology of affective neutrality is strong in medicine; yet no courses in the medical curriculum deal directly with emotion management, specifically learning to change or eliminate inappropriate feelings."
Embedded in this statement is that inappropriate feelings are a significant issue in medicine and that medical schools do not deal with this sufficiently.
-- "The management of embarrassment and sexuality in health care" by Liz Meerabeau. Journal of Advanced Nursing, 1999, 29)6), 1507-1513.
Note "management." These feeling do exist and cause problems. From my research, the focus is more on management strategies that work -- not on whether these are healthy strategies or how they affect the patient. The research seems to mostly focus on what works for the doctor whether it's good for the patient or not.

At Thursday, July 21, 2011 8:09:00 PM, Anonymous Anonymous said...

I find the thought of non-consensual intimate bodily penetration of anaesthetized persons by multiple medical practitioners, and particularly students, to be completely abhorrent. On the other hand, I really have difficulty understanding that someone entering into an MD degree course would not comprehend, without specific spelling out, that this requires a complete familiarity, theoretical and practical, with all aspects of human anatomy including internal examination of mouth, nose, throat, ears, rectum and female genitals.
Whatever the career plans of the student, ideas or circumstances may change and if a qualification entitles a person to exercise as a general practitioner who may be faced with anything at all then they should in my view have completed the entire curriculum. Whilst I understand that certain aspects of this may be extremely uncomfortable for some individuals one has to wonder, if they cannot go through with them, whether they have been mistaken in their vocation. I am sure there are plenty of other professions where people who would love to join them have to abandon doing so because of an inability, whether physical or other, to complete the curriculum. The alternative would seem to be a series of specialist degrees which would not permit any practice outside their scope. This would open a whole bag of complications and call into question the meaning of the title “Doctor”.
Interesting that the most highly qualified consultants are known as “Mister” rather than “Doctor” (at least in the UK). MLX

At Friday, July 22, 2011 9:48:00 AM, Blogger Doug Capra said...

MLX -- "Whilst I understand that certain aspects of this may be extremely uncomfortable for some individuals one has to wonder, if they cannot go through with them, whether they have been mistaken in their vocation."

Part of me agrees with your comment. Part of me doesn't. Implied in your statement are a few possibilities:
-- Those who have gone through medical school, become doctors, and have nothing to do with these invasive medical exams (ENT's, Podiatrists, etc) -- are better doctors because they had to learn these kinds of exams. I question that and would suggest there as absolutely no evidence to support it.
-- Or, if they felt the same way that stressed student does -- then they are mistaken in their vocation.
I would suggest that there may be a significant number of doctors out there who do not do those kinds of exams, would not consider it, feel like stressed student about them -- and, are fine doctors practicing very effectively and compassionately in a speciality that is outside the scope of these kinds of exams. You're suggesting that they are really mistaken in their vocation, or, only because they forced themselves to go through with the training, they are not mistaken. I don't follow that logic.
I would like to see specialities with special training. On the other hand, i do believe that a doctor who is licensed to practice whatever kind of medicine he/she decides, must be prepared to do these kinds of exams when medically necessary

At Friday, July 22, 2011 6:53:00 PM, Anonymous Anonymous said...

Doug: Your observations are perfectly fair ones. But as I said, offering "Doctor" title with limitations as to the type of general care they are qualified to offer would open a whole bag of complications.
Attitudes, circumstances and job opportunities can change and may cause a doctor to become involved in areas they had no intention of following when they graduated. That being so, I find your final paragraph sums up perfectly. MLX

At Friday, July 22, 2011 7:19:00 PM, Anonymous Anonymous said...

I had written a response to SS regarding the exams as rape, but that response did not appear. I would be happy to write one again, but I'm not certain if that post just got lost, or was determined to be offensive in some fashion?

At Friday, July 22, 2011 8:49:00 PM, Blogger Maurice Bernstein, M.D. said...

TAM, I don't recall receiving that posting and there are no postings currently to be moderated. Go ahead and rewrite.

By the way, because we are up to over 140 comments, tomorrow or Sunday I will close down Volume 42 and begin Volume 43 using the original SS essay in the Introduction. I feel that there is still a tendency here to continue to discuss the special aspects of patient modesty and "student modesty". I presume you all don't think that this topic has been fully covered. ..Maurice.

At Saturday, July 23, 2011 8:48:00 AM, Blogger Maurice Bernstein, M.D. said...



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